A prevention-focused care management program successfully reduced hospital admissions and ED visits among a vulnerable population.

“We’re dealing with a very complex patient demographic,” says Mo’sha Myles, MSW, LSW, a social work program manager at Oak Street Health in Indianapolis. Oak Street Health treats more than 50,000 patients at 42 centers in five states. Rhode Island will be the sixth state in 2019.

Oak Street Health’s program has reduced hospital admissions by 44% and ED visits by 46% for its patient population. The organization also has a 94% patient retention rate, according to the organization’s internal data.

The population mostly is older, low-income patients who suffer multiple physical and psychosocial-behavioral health issues. The program’s underlying theme is for physicians, care managers/social workers, and others to spend time with patients, looking at their health from a holistic perspective, Myles says. (See case study showing how the program works in this issue.)

“We think about the challenges and complex needs these populations bring with them,” she says. “We look at patients from a holistic perspective; we don’t see them as just a medical concern or issue.”

The care model includes assessing patients’ mental health status, socioeconomic status, and access-to-care barriers.

Myles explains how care management works at Oak Street Health:

• Create a team. Centers can have one or more — up to six — care teams, depending on their patient population.

Each team includes care managers who are master’s-level social workers. Also included are a physician, nurse practitioner, medical assistant, nurse, and scribe. Scribes are the people who take notes as physicians talk to patients. Each clinic also employs a phlebotomist.

“That team has a high level of focus on patients’ needs,” Myles says.

Care teams meet daily in morning huddles to talk about the patients who will be seen that day.

“We have a patient dashboard every morning that shows all the patients currently in the hospital and all who are coming through the door that day,” Myles says.

The dashboard notes medical red flags and any needed health screenings.

Care teams also meet weekly to dive into their patients’ needs.

“They look at patients’ challenges and the support they need,” Myles explains. “Everyone sitting in that room is collaborating and brainstorming and seeking out ways to help patients.”

The weekly meeting focuses on finding out why certain patients are frequently hospitalized, and their new diagnoses or complex care needs. “We talk about priorities inside the patient’s complex needs and determine where our focus needs to be right now,” she says.

“Maybe the patient has two or three things going on, but one issue is very pertinent, and that’s when our team is all-hands-on-deck to help the patient with that problem,” she adds. “This meeting is carved out so there is no distraction and the time can be used specifically for patients and their needs.”

• Use scribes. Scribes typically are students enrolling or planning to enroll in medical school or a physician assistant program, Myles says.

“They come to Oak Street to get clinical hours,” she says. “They put in all the notes and anything a doctor is writing — outside of a prescription.”

The scribe program at Oak Street Health has been very successful, she notes.

When someone applies to be a scribe, the person is paired with a doctor and stays with the doctor until the scribe begins medical school. Some stay with the program for six months, and others might be scribes for a couple of years. Some are local, and others come to Oak Street Health from other states because they value the clinical hours they obtain in the job, she says.

• Coordinate and collaborate with other providers. Social workers visit patients at skilled nursing facilities (SNFs). They share information with SNF staff and collaborate to discuss patients’ issues and to bring more information back to the care team, Myles says.

Care managers/social workers stay connected to hospital transition nurses, sometimes meeting to discuss a patient’s change in a living situation — for instance, a hospitalized patient who had been living independently before suffering a stroke cannot return to independent living, she explains.

They also are involved in direct patient follow-up. Patients with the highest need return every three weeks. The social worker calls them weekly to check up on how they’re doing and to follow up on scheduled visits. “The social worker might say, ‘I know the doctor has scheduled you for this visit, are you still planning to go? Have you had any challenges since your last appointment?’” Myles says.

In some cases, the social worker might call and find out the patient experienced problems such as headaches or nausea since seeing the doctor. The social worker will ask the patient to explain what’s going on and then contact a nurse to talk about symptoms.

“A lot of case coordination happens like that,” she says.

Care managers/social workers can connect patients to home health services and hospice care as needed, she says.

“If a patient falls a lot and needs physical therapy at home, the doctor would contact the social worker here and say, ‘Mr. Jones is a fall risk, and I feel like his muscles are weak and he needs physical therapy,’” Myles says.

The social worker also can assist with a referral to a home health company.

Physicians can bring social workers into cases in which patients are deteriorating and will need hospice care. They can reinforce to the patient and family what hospice means and clear up any anxiety they might have, Myles says.

“When the patient is ready to connect with hospice, we’re the first line of defense to make that connection,” she adds.

• Attend to social determinants of health and advance care planning. Care managers/social workers handle any challenges providers have with patients. If patients say they do not have transportation to get to their specialist, a social worker can help them connect with a transportation organization.

“They can help the patient go online and fill out an application,” Myles says.

Social workers also help patients complete applications for housing and help them obtain medication when they cannot afford it. If patients need clothing, housing, and food, the care team helps out.

Sometimes, patients need behavioral health services, which Oak Street Health can provide. The centers offer individual therapy and telepsychiatry, Myles says.

But patients who need extensive behavioral health services, such as substance abuse treatment, are referred to external providers.

Care teams assist with advance care planning by helping patients understand the process, Myles says.

In 2018, Oak Street Health helped about 600 patients complete advance care planning documents. These were scanned into the medical records, shared with their loved ones, and seen by their specialists, she says.

“We think of all the challenges our families are going through, and we’re being proactive,” Myles says.