Issue link: https://emsworld.epubxp.com/i/336320
22 Integrated Healthcare Delivery July 2014 www.ihdelivery.com CASE STUDY complex, high-cost patients with less-severe social issues and primary care that's more con- sistent but not coordinated. The Care Transition Program launched in 2011 to reduce their re- admissions uses a nurse and health coach (see sidebar). They assist patients at a pair of local fed- erally qualified health centers and are working to help those establishments become patient- centered medical homes that will use nurse care coordinators to manage care transitions. Obviously programs like this require con- nections across the healthcare and social-services spectrum. Much of the coalition's early days were spent enlisting colleagues and forging those partnerships; now they're well linked to phy- sicians, hospitalists, specialists, social workers and nurse discharge planners throughout the region. In this manner, the heart of integrated healthcare is a kind of community organizing. "We're using the skills community orga- nizers use to solve problems," Brenner says. "For example, homelessness in our city is a huge issue, and homeless patients are very difficult to deal with in a practice. They're difficult for hospitals to deal with, they cause problems for the police, and they don't do well. So how can we work together to find a better solution?" Who You See the Most Central to these efforts is the coalition's Health Information Exchange (HIE). This grew out of the early hospital data Brenner started with (see sidebar) and now contains patients' electronic health records with all their treatment history and notes. Providers, social workers and others can access these from anywhere and exchange com- munication within them as care progresses. The HIE also provides real-time alerts when tracked patients are seen at hospitals and provides aggregate clinical and utilization data to help spot trends and opportunities for intervention. All the local hospital systems participate, along with numerous other players. Data includes ad- mission, discharge and transfer actions, labo- ratory results, radiology reports, medication reconciliation and discharge summaries. To work with superutilizers on any sort of large scale, you'll need something comparable. But to get started requires nothing so elaborate. "At the beginning of it," Brenner says, "you can go to any EMS or emergency de- partment provider anywhere in the country and say, 'Name the person you see the most.' They'll tell you off the top of their heads. You don't have to have the data to get started." When you find these patients, start with their hospital billing data, obtainable if they'll sign a release. Let that lead you to the partners ap- propriate to help each patient. Their needs may differ, so don't force a template on them. Start lean. There are tools on the coalition's website ( www.camdenhealth.org ) to help you get going. A final piece to the puzzle is educating not only your patients, but the community at large to the nature of these ongoing problems. "We need to empower these patients to start telling these stories," says Brenner. "Don't hesitate to say to patients, 'The system is pretty darn broken, and we think people like you get really bad care. Let's work together to tell your story. Could you sign this release form? Then we'll have you talk to the media and tell them how hard it is to get in to see the doctors. Tell them about the struggles you're having.'" ■ Northgate II —At the troubled housing project Brenner's data identified as a hot spot, steps included a new doctor's office within the building residents can use for care needs instead of calling 9-1-1. A doctor staffs it twice a week; a medi- cal assistant covers other times. ■ Good Care Collaborative —The coalition leads the local Good Care Collaborative, a coalition focused on Medicaid reform and determining what "good care" should actually entail for under- served locals. See www.goodcarecollaborative.org . ■ New Jersey Medication Access Partnership —NJMAP helps patients who can't afford medications connect with pharmaceuti- cal company programs that provide them at low or no cost. ■ Diabetes Collaborative —The coalition works to increase local capacity to care for patients with diabetes; increase suf- ferers' self-management abilities; and improve care coordina- tion for diabetic patients across practices, hospitals and health systems. The Diabetes Collaborative is part of a greater effort to convert community-based primary care practices to patient- centered medical homes. Other Solutions IHD_20-22_CaseStudy0714.indd 22 6/13/14 11:24 AM