Provider organizations are tackling social issues in order to help patients better manage their health and to avoid incurring government penalties.
This article appears in the April 2015 issue of HealthLeaders magazine.
As hospital and health system leaders look for ways to improve their population health management capabilities, it is becoming clear to some that they need to develop community outreach programs to assist patients in overcoming the social barriers that exist in many areas.
Hunger and nutrition challenges, low literacy rates, and a lack of safe housing are among the biggest obstacles faced by many patients who are high utilizers of healthcare services. Through community-based initiatives, provider organizations can help patients get beyond these hurdles to be able to prevent and manage chronic diseases and other costly health problems.
Focus on public health
Successful population health management requires an innovative way of thinking about care delivery, says Randy Oostra, president and CEO at ProMedica, a Toledo, Ohio–based health system with 2,268 licensed beds and fiscal year 2014 budgeted revenue of $2.6 billion.
"It is well established that we can't afford healthcare as it is designed in this country. We still need a foundational change, and we need to focus on public health because so many social determinants have such a vital role in a person's overall health," Oostra says.
"Who better to focus on these issues than healthcare providers? In many cases, health systems are mission-based, nonprofit, tax-exempt organizations, and they have the resources to tackle these issues. It just hasn't been an area of focus," he says. "We should all be concerned about public health issues, such as hunger, nutrition, obesity, housing, and behavioral health. Our mission at ProMedica is to improve our patients' health and well-being. There is no asterisk on that saying it has to happen within our walls."
Confronting hunger as a health issue
About eight years ago, ProMedica decided to launch a campaign to deal with one big issue on an organization level throughout the counties it serves, which include urban, suburban, and rural communities.
"We started like most health systems would do, with obesity, and that very quickly led us to nutrition and hunger. Many people want to paint these as welfare issues, but they really are public health issues," Oostra says.
"Food really does drive health in a way that we probably haven't stopped and looked at closely enough as a society," adds Barbara Petee, ProMedica's chief advocacy and government relations officer. "It really gets back to: If you can't afford to put the basic things in place, you aren't going to be worried about the next steps in taking care of your health."
Since zeroing in on hunger and nutrition, ProMedica has rolled out a series of initiatives intended to bring healthful food and nutrition education to school children, create political awareness that hunger is a health issue and not solely an economic problem, and reclaim food from local businesses for redistribution to food banks to serve to those in need.
"If food … never leaves the sterile environment of the kitchen, it can be quickly repackaged, frozen, and transported via refrigerated trucks," Petee says. In 2014, ProMedica reclaimed more than 110,000 pounds of food with the help of its community partners, which include a casino and a AAA ballpark.
The health system also spent about $40,000 in 2014 to hire two part-time food packers, Petee says. "The investment up front is so small compared to the impact."
Oostra says ProMedica is working now toward the goal of screening patients for food insecurity at all of its clinical sites so that it can intervene where necessary. "You can screen patients for hunger, and when you find out they are food insecure, you can provide resources that identify and meet their food needs," he says. "Once you have asked the question, you have to do something about it."
Through advocacy and community-based efforts, ProMedica has gained the support of local philanthropist Russell Ebeid, whose $1.5 million donation is being used to fund in large part the ProMedica Ebeid Institute for Population Health. With the goal of bringing a healthy food market to a Toledo neighborhood that suffers from a dearth of fresh, affordable food, the institute is scheduled to open in 2016 and will also feature a kitchen with classroom space, behavioral health services, financial literacy programs, and a job-training program.
"There is a lot of research that shows if you have fresh fruits and vegetables in proximity, you are likely to have better overall health," Oostra says. "One of our donors is providing the funds, the city of Toledo gave us an empty building, a number of institutions have stepped up around providing services, and we are going to see if we can case manage a geography and work directly with residents in their community on a day-to-day basis to have a positive impact on their lives."
Keeping patients out of the hospital
At Wilmington, North Carolina–based New Hanover Regional Medical Center, a 628-bed teaching hospital with fiscal year 2015 budgeted revenue of $902.5 million, the leadership team has been motivated by the Centers for Medicare & Medicaid Services' reimbursement penalties for excessive 30-day readmissions to find a way to help patients stay out of the hospital.
CMS' Hospital Readmission Reductions Program began in October 2012 by penalizing hospitals up to 1% of their Medicare reimbursements for high readmission rates for patients with heart attack, heart failure, and pneumonia. The stakes are increasing as the maximum financial penalty grows to 3% in fiscal year 2015 and chronic obstructive pulmonary disorder and total hip and knee replacements are added to the list of health conditions included in the calculation.
As part of its readmission reduction project, New Hanover piloted a community paramedicine program in 2013 by having a few paramedics work with a small number of heart failure patients who were frequently hospitalized and had an inordinate number of emergency department visits.
"In 2013, 29% of New Hanover's requests for 9-1-1 services were not emergencies," education coordinator David Glendenning, NREMT-P, says of the organization's decision to start the program. "These were medical situations that could have gone to sites other than the ED for care, or, hopefully, could have been handled in the home."
The pilot results were significant: ED utilization dropped by 93% and readmissions dropped by 54%.
"Before the pilot started, one patient was admitted to the hospital five times in five weeks. After beginning to work with the paramedics, the patient was only admitted once in six months," Glendenning says. "Another patient had 13 ED visits in the six months prior to the intervention and only one ED visit in the six months following."
Coordinating care across the continuum
While the data set was small, it was enough for New Hanover to receive a $281,000 grant from the Duke Endowment along with other grant money, and those resources are being used to expand the program, which in 2015 comprises five full-time paramedics and a community pharmacist.
Working closely with patients' primary care physicians, discharge nurses, home healthcare workers, and case managers, the paramedics try to ensure the best care possible is provided across the continuum.
"The patients go through that full continuum of care so it's very important for caregivers to coordinate their services and make the continuum as effective as possible," says David Parks, the hospital's vice president cardiac and clinical support. "The paramedic, home health, and pharmD positions are all married under the readmissions reduction project, which falls into my scope of responsibilities, so we have everyone working together with no walls. They all talk to each other on a regular basis about which patient needs what services."
Training for the paramedics includes 100 hours of Web-based coursework and 200 hours of education in areas such as nutrition, mental health, social services, cardiovascular medicine, and rehabilitation. The paramedics also shadow a home health employee and a hospital nurse to become familiar with patients' needs.
Two areas where patients often benefit from extra counseling and where paramedics can have a major impact are medication reconciliation and nutrition, Glendenning says.
"For example, if the paramedics look in the cabinets of a heart failure patient's home and see nothing but salty food, they can help explain on a level the patient can understand why they shouldn't be buying these things. Or the patient may have 15 medication bottles gathered up on the counter because no one wants to throw old medications away. The paramedic will clear that up right away by contacting the primary care physician and adjusting or removing medications. It's a win-win for the patient and the doctor. Also, from going in and out of patients' homes, the paramedics can see things like the front steps are dangerous for the person or something in the home isn't safe, and they can work on fixing the problem."
Glendenning adds that New Hanover is very proud of the paramedicine program and the results that have been achieved so far.
"In the last six months of fiscal year 2014, the 30-day readmission rate of congestive heart failure patients in the program was just 9.3%. The national average for this patient population is typically between 20% and 25%," he says. "In the first quarter of the current fiscal year, the readmission rate of all of our patients in the community paramedicine program is 9.1%. The [national] average 30-day readmission rate for patients in the same risk category is 15.2%."
Preparing to become an ACO
In addition to being immediately effective in keeping patients out of the ED and hospital, Parks says the community paramedicine program also ties in with New Hanover's long-term plans to become an accountable care organization and take on the financial risk of managing the health of populations.
"We don't currently have an ACO to where we save money by preventing the readmission. When the hospital reduces readmissions, we are actually shorting ourselves money," he says. "However, we are moving toward the environment of the ACO and looking at how we can manage the care of our patients in the most cost-effective way possible, which usually is not in the hospital setting. Having that patient come into the hospital is not optimal if they can be taken care of at home."