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Improving Care Transitions for Socially, Medically Complex Patients

With funding from a Centers for Medicare & Medicaid (CMS) Health Care Innovation Award, Truman Medical Centers (TMC) developed a care transitions program that led to 283 fewer hospital admissions, 845 fewer emergency department (ED) visits, and more than $3 million in costs savings over the course of a year among 198 socially and medically complex patients.

The patients in this program are commonly referred to as high-cost high-utilizing patients. They suffer from multiple chronic diseases, such as diabetes and hypertension, and frequently return to the hospital or ED after discharge due to social issues, such as a lack of housing or food insecurity.

Our health care system has long struggled to improve care and reduce costs among socially and medically complex patients. This makes TMC’s work all the more remarkable and worthy of being featured in the July/August 2015 issue of the Journal for Healthcare Quality (PDF download).

Patients Are Enrolled Until They “Graduate”

TMC’s care transitions program enrolls patients age 18 or older who have two hospital admissions within the previous six months or three within the previous year, one or more chronic diseases, and have baseline data for one year prior to enrollment.

Once enrolled, patients undergo the first of two assessments developed by TMC. The Guided Chronic Care Social Intake Navigation Guide (SING) assesses the patient’s housing and social circumstances. It helps initiate the second assessment, called the Care Plan, which lists both health and social milestones, such as keeping 75 percent of appointments and demonstrating the ability to maintain adequate nutrition. (Both assessments are in the full study text.)

Unlike other programs that enroll patients for a set number of days, patients remain enrolled in TMC’s program until they demonstrate the established behavior criteria in the Care Plan and thus can self-manage their medical conditions and capably navigate the health care system. Only then are they deemed a “graduate.”

To Address Complex Issues, You Need a Multidisciplinary Team

TMC is the largest provider of uncompensated hospital care in the state of Missouri. More than half of TMC’s patients are on Medicaid or uninsured. Research shows that mental illness is a bigger problem for the poor, and TMC knew that addressing behavioral health as part of chronic care management was imperative for this population. The hospital also had to address social issues, such as transportation to routine primary care appointments.

To do this, staff formed multidisciplinary care teams:

  • licensed clinical social workers (LCSW) – one as team leader, another for case management
  • health coach registered nurses
  • client-community liaisons (CCL) – home visits
  • community health advocates (CHA) – home visits
  • psychologists – evaluate new enrollees, ongoing counseling as appropriate
  • advanced practice registered nurses – serve as primary care provider for those without one or who cannot get a timely appointment
  • administrative assistants (AA) – maintain phone contact with patients, update patient data

The CCLs and CHAs are commonly known as community health workers in other programs. The CCL has an associate’s degree or organized health care training, while the CHA generally has a high school diploma or General Educational Development (GED) and lives in the community. The majority of patients in the program have  a minority ethnic or racial background. The CCL and CHA provide culturally sensitive education on social services such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP). They also help patients budget for rent, utilities, nutrition, and medications as priorities.

TMC’s use of high functioning AAs to maintain telephone contact with patients and assist in entering and retrieving patient-related data was a program adaptation after its start. It freed up time for the health coaches and social workers to serve more patients and increased job satisfaction.

Significant Decreases in Admissions, ED Visits, Costs

As of March 31, 2014, 198 patients had enrolled in TMC’s program, and 86 of them had graduated. Additional results include the following:

  • Inpatient admissions for this group decreased by 32 percent.
  • ED visits decreased by 40 percent.
  • Charges for admissions and the ED decreased by 31 percent.
  • The average number of clinic visits went up 31 percent, which is seen as a positive shift from costly and inefficient hospital admissions and ED visits to outpatient care.

What are you and your organization doing to better serve the complex patients in your community? Please share your thoughts in the comments below!


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