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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, 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.
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.
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%).
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.
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.
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.
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.
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.
We, at Baptist Memorial Hospital, have been focusing on readmissions for quite some time but for the last two years, we received the readmissions penalty. We’re higher than the national average for pneumonia readmissions rates.
Effective Jan. 1, 2016, Indiana enacted the Caregiver Advise, Record, and Enable Act, or the CARE Act. The CARE Act requires hospitals to offer each admitted patient who will be discharged home an opportunity to: (1) identify a lay caregiver, (2) communicate with the lay caregiver regarding discharge and (3) offer education and training to the lay caregiver to ensure he or she understands how to care for the patient post-discharge, among other things. This required Riverview Health to evaluate its current processes and implement strategies to ensure compliance with the CARE Act.
In 2008, Mary Washington Hospital (MWH) was ranked first in the state for having the worst 30-day Heart Failure (HF) All-Cause readmission rate. Inconsistent with our mission for improving the health status of the people in our community, MWH undertook efforts to reduce HF readmissions. With administrative support, a registered nurse (now the HF Program Coordinator) began taking steps to identify opportunities surrounding HF readmissions. From detailed chart review, it was discovered that the opportunities were multi-faceted and required an organized, comprehensive approach.
It can be difficult to ensure patients receive a warm hand-off when there are many moving parts in a complex system. Sakakawea Medical Center and Coal Country Community Health Center worked to improve their continuous care model. This model transitioned patients from the medical center to the clinic with a warm hand-off to allow for continuity of care.
Illinois Valley Community Hospital set a goal to reduce its readmissions rate for patients diagnosed with congestive heart failure, COPD and pneumonia. This rate tends to run slightly higher than the overall hospital readmissions rate (1 percent). Medicare also focuses on congestive heart failure, COPD and pneumonia for reimbursement.
Saline Memorial Hospital (SMH) has been a part of the Arkansas Hospital Association Hospital Engagement Network (HEN) since the network’s inception in 2012. Although our hospital’s multidisciplinary team has grown and changed over the years, we pride ourselves on working together to improve the safety of our patients and community. When the HEN presented readmissions as one of its quality improvement initiatives, it was an area we hadn’t thought about or believed we could make an impact. Although we didn’t think readmissions was a problem, we asked our IT department to create and send a report each morning, showing the number of readmissions from the day before. That’s when our eyes were opened! When we first started collecting readmissions data, the numbers seemed overwhelming and too big to overcome. But we remembered the story about “how to eat an elephant … just one bite at a time” and that’s how we proceeded for this initiative.
While emergency departments (ED) and hospitals are an integral part of the health care system, unnecessary ED and hospital utilization, as well as avoidable hospital readmissions, are significant challenges. As the foundation of an efficient and effective health care system, comprehensive care coordination by primary care physicians (PCPs) can help reduce excessive care, repeated tests and procedures and high rates of ED and hospital utilization. However, to do so, the primary care practices in the ACO need to be informed of the full spectrum of their patients’ care. This includes care delivered outside of their practice, and particularly when patients are admitted to or discharged from a care facility.