SC Hospitals Push Coordinated Care

With all of the challenges facing healthcare providers under the Affordable Care Act, it's sometimes easy to forget that progress is being made on common sense care coordination strategies.

This is not to say that there aren't legitimate questions about the efficacy of "ObamaCare" or other healthcare reforms that are designed to slow healthcare cost growth, all of which will be debated for years to come.

However, across the country we are seeing a growing movement toward strategies that identify community resources and pull them together to improve population health.

Rick Foster, MD, senior vice president of quality and patient safety at the South Carolina Hospital Association, spoke with me recently about the Palmetto State's efforts to reduce readmissions and emergency room visits by improving care coordination. "We are trying to look at all the different organizations involved in care transition work," Foster says.

Some of the state's projects are in line with Center for Medicare & Medicaid Innovation care demonstration projects, including an initiative in the Spartanburg region that starts this month and that will send home health coaches into the homes of chronic care patients within 72 hours of discharge.

"Our hospitals realize that we are moving [toward] value-based reimbursements. We have been working for a number of years in a collaborative environment on how to move toward improving quality and safety and also better coordinating care. That challenging transition from volume-based to value-based won't happen overnight. You can't just flick a switch."

Instead, Foster expects to see more and more partnerships developing between hospitals and other health and healthcare organizations to improve community health, particularly for people with chronic or complex illnesses.

"Hospitals are going to be major partners in the community to improve community health," he says. "How do they work with other providers, physicians, home health and nursing homes and the community in general to reach out and keep the patients out of the hospital? This is very much new territory; the value-based approach that asks 'what are we doing for the community' and also tries to focus on those patients who do need the hospitals."

South Carolina's hospitals have been willing to work with other partners, Foster says, because they realize they can't do it alone.

"They have to work with home health agencies and long-term care facilities and primary care physicians. We also have a good relationship with the state office on aging and there are area offices where they can tap into services like Meals On Wheels that traditionally were seen as somewhat separate from the healthcare system. Now we're realizing that they are all interrelated if you are going to effectively manage chronic illnesses outside of the hospital."

Foster says it's critical to leverage the existing resources that will vary from community to community.

"Maybe the same volunteers doing Meals On Wheels we could provide some basic training on how to be a home health coach and at least provide basic assessments of patient needs," he says. "Then you may have a second level where you have some folks with clinical training. We are doing a pilot in one rural community here around community para-medicine. We take paramedics when they're not on calls to clinical evaluations or withdraw blood for evaluations. They can go to the homes of the highest risk patients."

"We have some communities where retirees are being trained to be community health workers. We have some communities working with a university or a college and they are getting students to do this. It's a matter of looking at the resources in the community, what already exists, and how to connect them in a more efficient way. Until now they've been kind of in their own silos."

These home health visits will allow providers to evaluate and address living space issues for patients that would go unnoticed inside the hospital walls."

"There will be patients with high readmissions rates that just have a very poor environment as far as they don't have a good social infrastructure with family members or access to transportation. Those are the ones where having the Meals On Wheels and having someone come into their home to check on them is important."

How will we know if these coordinating efforts are working?

"Probably the biggest measure at least in the early stages is going to be readmission rates and preventable emergency room visits," Foster says. "That is the way you identify these patients before they have two, three, four, five readmissions, is that initial admission or the ones who are coming in frequently to the ER."

When asked what healthcare delivery in South Carolina might look like in 10 years from now, Foster envisions regional integrated community health systems and health improvement networks that include hospitals, patient-centered medical homes, and primary care practices that are connected with other human services.

"They won't have to be owned by one entity. You would have some coordinating structure a core group but you pull together all the key resources and have a community-based health improvement network that is looking at the needs of various populations," he says. "Right now this is focused on the resources that will help people manage their own health."