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Bridging Cardiac Rehab and Patient-Centered Care

Michigan Medicine is an Academic Medical Center and Patient is Partner is a small LLC that collaborates with health care to solve challenging problems utilizing the patient voice and experience.

In spite of the positive outcomes over the many years, cardiac rehab continues to face challenges such as lack of awareness and underutilization by providers and patients. Studies show that only 20 percent of eligible patients are referred and of those, only 50 percent participate. We wanted to address the following questions:

  • How might we increase understanding, enrollment, persistence, graduation?
  • What could the new commitment to patient partnerships do to help?


Rolling Out the 4Ms for Age-Friendly Care Across the Care Continuum

When determining how to pilot new approaches for enhancing health outcomes for older patients, Kaiser Permanente leaders decided to focus initial efforts at Woodland Hills Medical Center in Woodland Hills, Calif. Twenty-two percent of Kaiser Permanente members who visit Woodland Hills are age 65 or older, which is the highest density of older people in the health system’s Southern California service area. Our goal is to test strategies that can be adapted and scaled across the care continuum.


Structuring Medicare Wellness Exams and Geriatric Consultations Around the “4Ms”

As part of the mission and strategic plan, Indiana-based St. Vincent is working to improve the health, quality of care and functional status of adults age 65 and older. Indiana ranks last among 51 states on a national scorecard that evaluates long-term services and support for older adults, people with disabilities and family caregivers. With the number of elderly patients increasing, St. Vincent is working to change this scenario.


Finding Out What Matters to Older Patients: A Conversation Guide

Older adults routinely receive care they do not want or that is discordant with their goals and wishes. A key reason is that providers do not consistently ask patients what matters to them. Clinicians are very good at problem-based discussions with patients, which focus on assessing symptoms and identifying treatments. But many of us need additional training in how to have conversations with patients about what matters to them versus what’s wrong with them.


Referral Process Improves Cardiac Rehabilitation Participation Rates

Despite well-documented benefits, the rate of referral to outpatient cardiac rehabilitation programs has remained low. We wanted to verify that our institution’s procedure for managing cardiac rehabilitation referrals met or exceeded the national average and if these referrals translated into outpatient participation. We aimed for 70% participation in alignment with the Million Hearts® initiative.


Deploying the 4Ms to Improve Outcomes and Health Experiences for Older Adults

More than 45 percent of patients admitted to Anne Arundel Medical Center (AAMC) are ages 65 and over, and we expect that percentage to increase as Baby Boomers age. We’re located in Annapolis, MD, near Chesapeake Bay, which attracts a lot of retirees. While AAMC has taken a number of steps to improve outcomes for older patients, including opening a geriatric inpatient unit, we believe more needs to be done. Too many older Americans suffer from falls, inappropriate medication use, delirium and other avoidable harms.


Saint Alphonsus is Becoming Age Friendly

Saint Alphonsus Health System has been making changes to be more age friendly for many years. The emergency room (ER) adopted the Senior Emergency Department (ED) initiative, making physical changes to the ER, such as softer beds, bigger clocks, a quieter environment, steps available to get in and out of the bed, closer restrooms, as well as learning how to change the providers’ approach to meet the unique needs of the older patients in a crisis setting. A case manager for the ER, Becky Beaver, concentrated on the older patients and their discharge needs. In many cases, older patients returned to the ER in a deconditioned state, confused about their medications or non-adherent to their prescribed medications.

Dr. Chad Boult, a geriatrician for Enhancing Care Initiative at Saint Alphonsus, opened three specialized clinics to address the complex care of the older population in this community. Yet, there still remains a need for improved care for older people at all levels of health care, including the community resources. Dr. Boult reminds others that “older people are the fastest-growing segment of the U.S. population – and their growth in numbers will accelerate throughout the coming decade. It’s time, past time, actually, for our health care systems to start focusing on meeting the special needs of these older patients.”


Emergency Department Partners with Community Volunteer Dental Program

In 2009, there were over 13,000 Muskegon County, Michigan, low-income residents who were uninsured or underinsured. These residents have unmet healthcare needs including the inability to pay for dental treatment. These residents are veterans, retired and working families, and people with disabilities. Once provided with access to high quality dental care and oral health education, it can decrease the number of people who utilize the hospital emergency department (ED) for dental emergencies and improve the overall health of our community.

The Muskegon County Oral Health Coalition wanted to assess how many residents were using the ED for oral health concerns. The coalition drafted a report using hospital data and sent it out to all stakeholders in the area. At the same time, the Volunteer for Dental program was created and piloting began.


Improving Patient Recovery Through Cardiac Rehab

With the help of a supportive and progressive cardiologist as our medical director, the outpatient program started in 1978, work that continues today. We wanted to provide patients with the best care by starting rehab at the right time. However, there is limited research on the ideal time to start cardiac rehab. Without research to guide action, the team decided to start rehab immediately following hospital discharge because we felt there was no benefit in waiting.


Reducing Rural Transportation Barriers

Transportation combined with poverty creates a true barrier to health care in a rural environment. In the Mt. Ascutney Hospital and Health Center (MAHHC) service area, 7% of households have no vehicle available. Compared to New Hampshire and Vermont, 5.2% and 6.6% respectively, the service area has significant disparity in available transportation. In MAHHC’s most recent community health needs assessment (CHNA), transportation ranked third in overall barriers to care. Key stakeholders in the CHNA ranked lack of transportation as the number one barrier to accessing services (72.7%).


Connecting with Families: Turning Interest into Action

University of Illinois at Chicago’s Division of Specialized Care for Children (DSCC) has a regional office in Peoria, a city that is home to a well-known children’s hospital that cares for many children eligible for DSCC’s programs. Many of these children are referred to DSCC for assistance but often not until the child is older. DSCC’s care coordination teams believe it is vital that these children are referred to our programs as soon as soon after birth as possible, especially those with critical cardiac conditions. DSCC’s Peoria staff had developed relationships with the hospital’s nurses and social workers and presented about our programs numerous times. However, they recognized that hospital staff members are busy with their own heavy workloads; therefore, we cannot rely on them as the primary referral source for these families. Our staff also recognized the need for families’ privacy during the emotional time following the birth of a child with special health care needs.


Huddling to Improve Teamwork

In DSCC’s Mokena Regional Office, each Care Coordinator is paired with a Program Coordinator Assistant to work as a team to meet a child and family’s needs. A Care Coordinator is a DSCC staff person who is a nurse, social worker, speech pathologist or audiologist. A Program Coordinator Assistant (PCA) is often a family’s first contact with DSCC. The PCA takes referrals, discusses the child’s needs and sends the application to families. The PCA also determines financial eligibility and updates this information periodically.

The Care Coordinator and PCAs’ individual responsibilities often are contingent upon the completion of specific activities from their respective partner. Upon my arrival as manager, several employees expressed multiple issues related to the lack of communication between team members. This lack of communication resulted in missed deadlines or lapses in other pertinent information required to complete a task.


Meds to Bed Program: A Medication Concierge Service

Tamblyn and colleagues found that nearly a third of patients fail to fill first-time prescriptions.1 Other studies have found that e-prescriptions are 65% more likely to be left abandoned at a retail pharmacy by patients than hand-written prescriptions. 3 Mount Sinai Hospital (MSH) recognizes that the issue of medication adherence is challenging. MSH strives to become the national model for the delivery of urban healthcare and develops innovative and effective ways to accomplish its mission.

In the communities served by MSH, the percentage of citizens living below the poverty line ranges from 14% to 45%. Ten of the 13 communities MSH serves have a poverty rate higher than the Chicago average of 22%. Three communities (East Garfield Park, North Lawndale, and West Garfield Park) have a poverty rate two times higher than the city average.

The literacy rate for MSH’s community served is another barrier to medication adherence. Nineteen percent of Chicago adults over age 25 do not have a high school diploma. In 12 of the 13 communities, the percentage of adults without a high school diploma is higher than the city average. In two communities (Gage Park and South Lawndale), over half of adults lack a high school diploma.

Another limitation of MSH’s patient population is the lack of transportation. Patients depend on family members, neighbors and friends to commute. Financial concerns and long wait times are other barriers that patients voice as concerns for filling outpatient medications.


Calvert CARES Program Reducing Readmissions: It’s All About Relationship

CalvertHealth Medical Center (CHMC) was challenged with developing an innovative plan to address high utilizer recidivism in the ED and inpatient settings. Early success with the Transitions to Home Program resulted in readmission targets being significantly decreased. To identify resource access gaps, CHMC called on its “village” (local health care coalition and their case management team of acute care and emergency department nurses and social workers) to identify opportunities for program enhancement by using a SWOT analysis. Medication and medical supply affordability, transportation access and other social determinant-related opportunities were identified.


Building a Care Coordination Program: Addressing Determinants of Health and Well-being

In 2013, Medical Center Health System, located in Odessa, Texas, embarked on a journey to create a healthier community. We knew we had a long way to go. Our county health rankings weren’t favorable according to the County Health Rankings from the Robert Wood Johnson Foundation, and we didn’t yet have a department at our hospital to address our community’s many health needs. We knew we wanted to approach the issues from the community angle but also from the hospital perspective. Our hospital understood that to build a “Culture of Health” we needed to be innovative and think beyond the traditional four hospital walls. We wanted to design a program that centered on the medical well-being of the patient but also addressed the determinants affecting our residents’ health. We also appreciated the fact that we needed to be creative to make best use of our existing resources and available health care providers.


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