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Engaging the Chronic Care Patient

Joe Cantlupe, for HealthLeaders Media, November 13, 2013
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Success key No. 3: Life coach program

The emergency department is a place in the hospital where many chronically ill patients wind up because they don't have physicians of their own. As a way to connect—and stay connected—with these patients, Bon Secours Health System initiated a life coach program in which nurses and other personnel are assigned to help patients find medical care outside of the ED.

The life coaches can include nurses, technologists, or pharmacists. Two coaches are at each hospital location, where they reported an average of as many as 200 daily ED visits by uninsured patients without a primary care doctor. The average life coach sees about 10–15 patients a day.

From the outset of the program, Bon Secours staff would see all the patients who came into the ED and determine whether they needed a primary care physician, says Pam Phillips, senior vice president of mission for Bon Secours. Many of the patients did not have insurance. In some cases, they had ailments that didn't require hospitalization.

By connecting these patients with primary care physicians, Bon Secours improved their access to appropriate medical care, she says. In the first year of the program, from September 2008 to 2009, life coaches assisted 1,000 patients who had been using the ED for primary care needs, and only 12 returned. At least 60% of those who were helped haven't returned to the ED for chronic care but are instead receiving care in other settings.

Some of the patients "have acute conditions and eventually have to be admitted because it's so serious, or they come to the ED because they have an earache and it's not emergent but there is nowhere else for them to go," Phillips explains.

When they are directed to primary care physicians, the patients are integrated into the Bon Secours primary care employed network, or connected to a free clinic partner.

Clinicians ask patients about medical issues and, more important, about their social situation, if there's an issue at home, says Phillips. For example, if their electricity was turned off, they could receive a referral to the community agency to pay electric bills. "We try to address the social needs as well as the medical needs," she says. The life coaches also help patients fill out paperwork "because a lot of the people are entitled to benefits and they don't even realize it," she says.

The Bon Secours medical community connected 3,548 patients in 2012 to social services such as food, dental care, financial assistance for rent or utilities, or medication assistance.

"When a patient leaves they actually may have an appointment with a doctor at one of the clinics. A life coach calls them at home, reminds them of an appointment. If they don't have transportation, the coaches help them get it," Phillips says. In that way, it shows that patients can feel comfortable in knowing they have access to care they didn't know they had.

After meeting with the life coaches, 2,498 patients who didn't previously have doctors were scheduled for appointments with primary care physicians in 2012. Bon Secours also does follow-up calls to check on the outcome of the doctors' visits.

"The goal of life coaches is to establish community partnerships to better serve the economically poor with respect and dignity, and to improve access to primary care," Phillips says. "Helping people who don't have a doctor get established with their own physician is the first step in securing their health and consequently the health of the community."

Success key No. 4: Cooperation with competitors

In some cases, hospitals are teaming up to focus on chronic care programs impacting vulnerable populations. The cooperative arrangements include organizations that have been competitive with each other.

By having these organizational team approaches, however, hospital officials say they can improve access to care, target chronic conditions, and open the door for primary care physician referrals. In addition, they can reduce ED use and readmissions.

The 592-staffed-bed New Hanover Regional Medical Center works with Community Care of North Carolina, a community-based physician-led program designed to improve access to primary care medical homes for needy populations, especially for chronic conditions, says Scott Whisnant, director of government relations for NHRMC in Wilmington, N.C.

The collaborative effort "is attractive to the hospital, and we are seeing a better and newer way to treat this type of chronic disease," Whisnant says of chronic conditions. The community program has opened the door for more cooperation in which hospital physicians work with specialists within CCNC to find "best practices to treat patients [and] have care management by going to the home and making sure meds are taken correctly."

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