Issue link: https://emsworld.epubxp.com/i/336320
CASE STUDY 21 www.ihdelivery.com July 2014 Integrated Healthcare Delivery "We're the ones who see day to day what's broken in the healthcare system—the front- line primary care docs, the EMS workers, the nurses in the emergency rooms," says Brenner. "And we all struggle with challenges that are beyond our ability to solve by ourselves." But together perhaps not. From that breakfast club emerged the Camden Coalition of Healthcare Providers. Led by Brenner— who last year received a $625,000 genius grant from the John D. and Catherine T. MacArthur Foundation for his work—the coalition became a formalized nonprofit aimed at improving healthcare delivery and lowering costs among Camden's biggest users. It's having success that's both demonstrable and potentially replicable. Community Organizers Take its Care Management Program, which employs an embedded nurse care manager/ medical home model to ease superutilizers' transitions from hospitals to outpatient care and help them avoid rehospitalization. When a patient with special medical and social needs is identified, they're visited in the hospital or wherever they are by a team that includes a nurse practitioner, a social worker and a health outreach worker/medical assistant. The team confers with doctors, reviews the pa- tient's medications and ascertains what they'll need upon discharge. Once the patient is home, they'll soon visit again and then provide con- tinued support for up to nine months. They may help the patient find primary and specialty care, go with them to appointments and arrange social services, including temporary shelter. At the con- clusion, hopefully, the patient will be equipped to better manage their affairs on their own. This appears to reduce future problems and save money too. The first 36 patients involved in the Care Management Program averaged 62 hospital/ED visits a month before care-team contact, but just 37 after. Their average monthly hospital bill went from $1.2 million to around $500,000. There's another, similar group of medically Health coaches are advocates integrated into care teams who work closely with patients to help them manage their medi- cal affairs. The Camden Coalition uses AmeriCorps volunteers pursuing careers in medicine or nursing. Initially coaches may go with patients to their medical appoint- ments. Many patients who typically seek primary care at the ER, the coalition notes, aren't used to waiting for regular doctors; the coach helps educate them to appropriate use of the system. As they wait, coaches can help patients consider their conditions and prepare questions for the doctor. This gets them more engaged in their care and results in a more effective office visit. Other common activities for health coaches include help- ing patients make and track their own appointments and find transportation to and from them, which may mean mastering public transit. Health Coaches The data that ultimately led to the Camden Coalition was initially obtained as part of a thwarted police-reform project. Brenner used hospital billing data to map where crime victims lived. Beyond that, he began studying how patients flowed through the local hospital system. Looking at ambulance transports, for instance, he found 57 falls by elderly patients in two years at one address, resulting in almost $3 million in costs. Brenner took that data to construct block-by-block maps showing Camden residents' hospital costs, looking for "hot spots." (This echoed the NYPD's successful CompStat approach to fighting crime.) The two biggest he found were one that had a large nursing home and one that had a low-income housing project. In 6½ years, people in those buildings accounted for more than 4,000 hospital visits and $200 million in bills. By intervening directly with people like that, Brenner figured, he could both help them get better care and reduce their costs. He began meeting with local ED docs and social workers and sharing the patterns. He asked to meet their biggest users. Working with the first few led to more, then more, then the coalition. Hot Spotting IHD_20-22_CaseStudy0714.indd 21 6/13/14 11:24 AM