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Improving discharge without high costs? Try a CBO
AIDS group helps local hospital with DP
It's in a community's best interest to have high-quality discharge planning. This is why a community-based organization (CBO) in New York City, has formed a collaboration with a local hospital to assist when HIV/AIDS patients are being discharged.
"We understand the relationship between programs with different expertise and similar consumers to ensure a full range of services," says Sharen Duke, MPH, CEO of AIDS Service Center (ASC) in New York City.
ASC has formed numerous partnerships with hospitals and medical providers as part of its mission to ensure a full range of services for its clients, Duke says.
"We have a case management program that works with New York Presbyterian Hospital," Duke says. "It's funded through Medicaid and targets people who are living with HIV, providing both an assessment and escorts to medical appointments."
With HIV/AIDS patients' consent, Presbyterian Hospital physicians ask ASC to be part of the hospital's inpatient discharge planning team, she says.
"This is unprecedented for an outside entity to be part of inpatient discharge planning," Duke adds.
The program started in April 2006, with a single patient, says Susan Olender, MD, instructor of clinical medicine at Presbyterian Hospital.
Leaders at the hospital's AIDS Center had long observed that HIV patients were frequently readmitted to the hospital when they should be engaging in outpatient care, Olender says.
"There are a lot of AIDS-related, preventable illnesses if only people could connect to their outpatient services," Olender says. "Even if you have advanced HIV disease, if you take a daily antibiotic, you can prevent pneumonia and meningitis."
When patients failed to engage in outpatient care there were outcomes of significant morbidity, mortality, and inpatient costs, she adds.
Some leaders at the hospital already knew Duke and were familiar with ASC's services to this population. So, they hatched the idea to have ASC assist with discharge planning for patients who were considered at high risk of failing to access outpatient services.
"The formal process is, we have these rounds in the inpatient setting with the social worker, and we keep our ears out for people who might be at high risk of failing to follow up," Olender says. "We ask patients whether they'd be interested in having a case manager help them so they won't have to come back to the hospital, and when people say, 'Yes,' we call ASC."
An ASC case manager then will meet with the patient before discharge and review the patient's discharge plan. The case manager will help the patient pick up medication, make a connection with all outpatient visits, and update the hospital team in weekly conference calls, Olender says.
Before the patient leaves the hospital, the ASC case manager will work on an assessment of the patient's needs, says Kim Atkins, chief financial officer of AIDS Service Center.
"We take on the hardest cases to deal with," Atkins says. "These are the people who drop out of the system and then come back to the hospital."
These high-risk patients often have unstable housing and have mental health problems, he adds.
"We develop a plan and identify the patient's concrete needs, setting up manageable goals for the individual," Atkins says. "Then we're with the patient right after discharge to see where they're going and to make sure they're situated."
From a case manager's perspective, the work is very intense, says Cynthia Rossi, MA, senior case manager with AIDS Service Center.
"We work with a goal of stabilizing the client," Rossi says.
For example, a physician calls Rossi about a patient who will be discharged in a couple of days. Rossi will visit the patient and do an intake in the patient's hospital room and describe the program to the patient, explaining that the main goal is to help the patient make that leap from inpatient care to outpatient care.
"It's really overwhelming to the client, because there's so much information to absorb," Rossi says. "They have four to five medical appointments in the first week after they're discharged."
The hospital-CBO collaboration for transitioning patients to the community hasn't included a thorough collection of data on the program's impact, but Olender says she's certain the program has provided patients with better care.
For example, before the first patient was treated in the program, he had an alcohol abuse problem and was regularly missing medical appointments, Olender recalls.
"ASC case managers sought him out and brought him in just in time for a treatment of lymphoma," Olender says.
"The case manager tried and tried week after week and brought him in and got him into supportive counseling," she adds. "So he was treated for HIV, treated for cancer, and this resulted in remission of the cancer, and he got his own apartment."
The man occasionally still drinks, but his case is a success story, Olender adds.
ASC and Presbyterian Hospital are working on ways to make their relationship and the structure of the program stronger, Atkins says.
"We're using existing resources to do this, but we're limited by that," Atkins says. "We can't build it the way we want or make it better without additional resources, so we're partnering with others to find those resources that will make it more effective."
Benefits of collaborating with a CBO
One of the major benefits of collaborating with a CBO during the discharge process is that these outside organizations have more knowledge about resources available to patients in the community than do many hospital discharge teams, Olender notes.
"I've learned that ASC has excellent knowledge of housing resources in New York City," she says. "They also have a sense of framework, knowing what people's options are and where people can go if they're homeless or marginally housed."
Some of the issues the ASC case manager deals with are ones that occur immediately at discharge, and others are basic needs that must be met before the patient can progress to the next level of medical care, Olender adds.
While HIV disease is a good candidate for this type of discharge planning model, there are other chronic diseases for which it would work as well, Olender says.
"A whole crop of people are talking about how to create a model that's less about inpatient care and more about meeting people's outpatient needs, as well," she explains. "There appears to be some interest in trying to replicate the model to some other chronic diseases."
For instance, Olender has worked with dialysis patients, who are another group who need to be compliant with their medical treatment or they'll be readmitted to the hospital.
"I remember seeing patterns of patients coming in over and over," Olender says.
"You set up your discharge plan, and then you shrug your shoulders when they come back in with the same pattern," she adds. "But some need of these patients wasn't being met, and the idea was whether it would be possible to get someone to follow them around as outpatients, helping them help themselves."
For other chronic disease populations, the problem with the model would be finding resources, because public funding is different for HIV services, Atkins says.
The model makes sense from a holistic health care perspective, because society saves money when the high-risk patients stop being frequently admitted to the hospital.
"We've seen that preventable illnesses are taking up a lot of resources on the inpatient side, so there is definitely a need to shift care to the outpatient setting so that serious diseases can be prevented," Olender says.
"In a review of inpatient AIDS cases, physicians found that 29% of admissions on HIV service were due to preventable causes, and these admissions accounted for approximately 70% of HIV care inpatient dollars," Olender adds.
However, there also are logistical barriers to the model, such as finding time for team conference calls. "We've dealt with other medical providers who haven't figured out how to overcome barriers internally with inpatient and outpatient social work services," Atkins says.
But it's important to stay committed to collaborative models that work on preventing hospitalizations, because care coordination makes for better care, he adds.
For more information, contact:
Kim Atkins, Chief Financial Officer, AIDS Service Center NYC, 41 E. 11th St., 5th Floor, New York, NY 10003. Telephone: (212) 645-0875. Email: firstname.lastname@example.org.
Sharen Duke, MPH, Chief Executive Officer, AIDS Service Center NYC, 41 E. 11th St., 5th Floor, New York, NY 10003. Telephone: (212) 645-0875.
Susan Olender, MD, Instructor of Clinical Medicine, Presbyterian Hospital, 180 Fort Washington Ave., HP-6, New York, NY 10032. Telephone: (212) 305-3174.
Cynthia Rossi, MA, Senior Case Manager, AIDS Service Center NYC, 41 E. 11th St., 5th Floor, New York, NY 10003. Telephone: (212) 645-0875. Email: email@example.com.