Care coordination cuts hospitalizations

Nurses help uninsured at primary care sites

MetroHealth System's care coordination program for the uninsured, Partners in Care, has resulted in 34.8% fewer inpatient stays at an average cost of 15.4% less than a demographically similar group of patients who were not enrolled in the program. Patients in the program with diabetes demonstrated a 6.6% improvement in HbA1c control and a 6.8% improvement in cholesterol control and hypertensive patients had a 4.1% improvement in blood pressure control.

Located in Cleveland, OH, the health system includes MetroHealth Medical Center, a 740-bed, county-owned hospital that is the largest safety net hospital in the state of Ohio, and 17 community health clinics. Uninsured patients make up 18% of the health system's outpatient practice.

Faced with a steady increase of uninsured patients, the health system looked for ways to provide care in the most cost-effective and clinically effective way and created Partners in Care, says James Misak, MD, associate director for family medicine in the MetroHealth System Center for Community Health. "As a public hospital and provider and payer for care, we spent more than $100 million out of a total budget of $750 million on providing healthcare for the uninsured in 2011. Anything we can do to provide care in a clinically effective and cost-effective way is a win-win for us and the patients," he says.

The health system began transforming its outpatient primary care services into a patient-centered model of care in 2007 and created care teams to work with patients across the continuum. The team created Partners in Care, a program exclusively for the uninsured that connects them with a care coordinator to help them navigate the healthcare system.

In the first phase of the Partners in Care program, the health system placed nurse care coordinators at six practice sites with a goal of rolling the program out throughout the system. About 16,000 patients are enrolled in the Partners in Care program at the six primary care sites.

The health system mines its electronic medical record system that includes inpatient and outpatient services to identify uninsured patients for the program. When an uninsured patient is hospitalized or visits the emergency department or an urgent care center, the patient is automatically listed in the daily acute care registry. Patients with chronic illnesses are entered into the disease management registry.

Geneva Jones, RN, BSN, MEd, care coordinator at MetroHealth Broadway Health Center in Cleveland, says the daily acute care registry is her most active registry. She begins her day by reviewing the list of patients who have been admitted to the hospital and those who have had emergency department or urgent care visits and contacting them to find out their needs and barriers to care.

"Many of the patients who visit urgent care or the emergency department don't have a primary care provider. I talk to them about the benefits of having a primary care provider and help them sign up for one. If they are frequent users of the emergency department, I talk with them to try to identify barriers to care," she says.

After patients are discharged from the hospital, she calls them to review their discharge instructions and assess their clinical status. She helps them establish a primary care appointment if needed and lines up transportation if they don't have a way to get to the clinic. If she can't reach the patients, she sends them a letter and asks them to call her.

Misak points out that because of a lot of different barriers to care, the uninsured often put off receiving preventative services and seeing a doctor until their condition gets so serious they can't ignore it. "With this program, we want to help them understand the importance of preventative care and to encourage them to establish a relationship with the primary care team. The care coordinators do whatever is necessary to overcome what barriers exist to getting patients re-established with their primary care team and achieving their healthcare goals," he says.

Patients typically stay on the acute care registry for 21 days, Jones says. She puts patients who need extra support on her case management registry, which reminds her to check back regularly. She works closely with the clinic social workers and may make referrals if patients need help with community resources such as medication assistance or free dental care.

The program's disease management component focuses on patients with hypertension and diabetes, two diagnoses which are most prevalent in the uninsured population. Patients with chronic conditions are enrolled in disease management registry and receive telephone calls or education by mail, depending on their risk stratification. If patients do not have their chronic conditions under control, Jones enrolls them in case management and follows up as often as every day, or as infrequently as once a quarter, depending on their needs.

Jones says that she works with most of her patients over the telephone. Sometimes providers bring patient to meet Jones. In other cases, if she sees someone with whom she's been working on the appointment schedule, she'll make it a point to see them. "I ask some people to come in and meet with me because I feel like I can help them better face-to-face. A lot of my job is building relationships. Most patients know me and call if they have questions," she says.

"This program has shown good results in reducing hospitalization rates but it's an expensive intervention since it adds another clinician to the episode of care. We're analyzing the results to determine if this is the best use of resources to drive down hospitalization," he says.