It takes more than access to healthcare coverage to address the needs of vulnerable patients with multiple life challenges.
Meet Martin Sullivan. He’s fought a long battle with chronic obstructive pulmonary disease, hypertension and diabetes. His chronic illness became so severe that he’d been admitted to intensive care just a year ago and required oxygen 24/7. The normal things, like getting up to get a glass of water, became an effort.
While hospitalized, Martin Sullivan was referred to us at St. Joseph Health Queen of the Valley Medical Center’s CARE Network.
In case you’re not familiar, we’re a community-based disease management and transitional care program for low-income patients. We serve the most vulnerable patients in our community – those who are at or below 200% of the federal poverty level. They are the working poor. They have families and are having a hard time keeping a roof over their head and food in their refrigerators.
Our patients are referred from hospital inpatient and emergency services, primary and specialty care physicians and community-based organizations.
Many regularly use emergency services for care and have been hospitalized for 15 or more days due to uncontrolled medical problems and can’t be released without support. Without intervention, they’re often readmitted within 30 days.
To improve the health and quality of life for these patients and reduce healthcare costs, we focus on our social work process. We use interdisciplinary care management teams comprised of registered nurses, social workers, behavioral health therapists and care aides/navigators to get patients the resources they need to improve their health.
Last year, we served 370 patients providing 327 linkages to medical services and 900 linkages for financial benefits and basic needs (medications, housing, food, transportation).
Among our patients, there was a 72% decrease in emergency room visits, and a 62% decrease in hospitalizations compared to the year earlier. And 78% of patients demonstrated an overall increase in quality of life.
How did we do it?
The most important key to success is earning and keeping patient trust, building hopefulness and self-sufficiency where there has been hopelessness and helplessness.
Here’s what works for us:
- A holistic approach. Our model takes into account all the issues contributing to the health and quality of life of our patients, builds trust and supports development of self-sufficiency.
- The right staff. Our staff is grounded in our values to respectfully serve the poor and vulnerable and committed to working together as a team and with patients.
- Addressing urgent needs first. Patients cannot care for their medical needs if they’re homeless, hungry or lacking medications.
- Embracing cultural differences. We have bilingual, bicultural staff at all levels and in all disciplines of the program.
- Providing care in safe environments suited to the independence level of the client such as home visits.
- Breaking down language, literacy and institutional barriers by linking and accompanying clients to services and resources to ensure follow-through.
- Building robust partnerships with providers and community partners to facilitate warm hand-offs and urgent and ongoing care coordination.
- Harnessing teachable moments to build self-sufficiency and self-management.
- Ongoing attention to quality improvement through deep analysis of patient outcomes, emerging best practices, internal policies and practices and unmet patient needs.
- Persistence in patient outreach, engagement and education.
For Martin Sullivan, the CARE Network has given him a life he never knew. He no longer requires the use of oxygen during the day and has even started an exercise program.
Make sure to check out Martin’s entire story:
What the future holds…for our patients and for us
We’re deeply honored and grateful to win the 22nd annual Premier Cares Award. With the award funds we received, we plan to put them towards diagnostic screening for uninsured patients and additional navigators to facilitate access to care and resources.
We’re thrilled to continue to serve the most vulnerable patients in our community with our comprehensive approach, and to raise awareness of the needs of these patients.