Care Coordination at Copley Hospital

By: Leah Hollenberger

Social Determinants of Health

The Social Determinants of Health (Image via American Public Health Association)

 

Many words have been written about care coordination and addressing the social determinants of health as a way to reduce healthcare costs. But what does that really look like?

Healthy People 2020 defines social determinants of health as “the conditions in which people are born, live, work, and age that affect their health.” They include factors such as education, the safety of our homes and neighborhoods, financial security, the cleanliness of our water and air, access to good nutritional food, etc.

Care coordination is a collaboration between providers, social services and the patient themselves. It often sounds simpler than it actually is. Let’s be clear: one meeting doesn’t lead to change. Thoughtful, consistent care coordination involving the patient and all members of their care team is needed over the long term to help someone become healthier. That care team can include local health care providers, substance abuse counselors, mental health counselors, RN case managers, social workers and a variety of other case managers from across local agencies.

So how does it work? Let me share a few examples. (Note: We have changed names to protect privacy.)

The Right Care in the Right Place at the Right Time
Copley recently treated Joe in our ED and, due to the severity of his illness and the resources required to manage his care, transferred him a tertiary hospital. His health improved but he still needed weeks of inpatient skilled nursing and complex care coordination to ensure once he was home, he had a secure social support network to assist him. Joe wanted to be cared for at Copley as it was closer to home and easier for his family to participate in his care. The tertiary hospital was reaching capacity, and, coupled with the need for local care coordination and Joe’s preference, contacted Copley. There was no question that Copley could provide the medical care, but we weren’t sure if we would be able to meet his other needs to ensure a smooth transition. After three weeks of collaborative teamwork with nurses, providers, pharmacists, care managers, social workers, Chaplaincy, nurse leaders, and the patient himself, a plan was developed to address both Joe’s social and clinical issues so he could be admitted to Copley and provided with the appropriate continuation of care. Joe was able to receive the inpatient skilled nursing care and complex care coordination he needed in a more affordable setting, closer to home.

Reducing Avoidable Emergency Department (ED) Visits
John is a middle-aged man who has come to Copley Hospital’s Emergency Department nearly 40 times in the past two years.  In addition to his alcoholism, John struggles with mental health issues and has a long cardiac health history. He is considered a “super-utilizer” of medical services. Copley has a full-time social worker in our ED as part of an Emergency Department Care Coordination pilot with Community Health Services of Lamoille Valley. The social worker assesses the patient’s needs 1:1 either at the bedside or through a follow-up call. Copley’s social worker was able to connect with John 1:1 in the ED earlier this year.

Copley’s social worker subsequently met with John each time he presented to the emergency department and followed up each visit with a phone call to review discharge plans and follow-up appointments. With John’s permission, she kept each of his various providers informed after each visit. After several visits, John met with Copley’s ED social worker and his primary care RN care coordinator to talk about his goals and what he thought he needed to be successful. Two weeks later, he decided he was ready for treatment and came to the Emergency Department for help. Copley’s ED team, inpatient medical social worker, and ED social worker all worked throughout the day to help get him admitted into an appropriate facility for inpatient alcohol treatment.

The ED social worker continued to check in with the inpatient facility and advocate for John. He was able to remain in the program for a longer period of time and she coordinated transportation with Rural Community Transportation (RCT) in advance for his follow-care plan appointments. Forty-eight hours after discharge, John met with his primary care RN care coordinator to review his discharge plan and ensure he had what he needed to be successful. Copley’s ED social worker continued to contact John and his providers regularly, confirming he had attended appointments with his substance abuse counselor, psychiatrist, primary care provider, specialist appointments, and RN care coordinator. This plan was followed for four weeks, at which point, John’s ongoing case management was transferred to his primary care RN case coordinator.

The outcome? John has maintained his commitment to make healthier choices. The shared care plan continues, with the goal of eliminating future costs of avoidable visits to the ED, by keeping John and patients like him, feeling engaged, motivated, and supported to make healthy choices.

Reducing Costs
Copley Hospital recently participated in an initiative to reduce the percentage of ED visits of 29 identified “super-utilizers” by implementing a shared care plan. The 29 “super-utilizers” accounted for 4% of the total ED visits in the initial 90-day time period; they accounted for only 1% in the second 90-day time period. A potential $144,300 was saved by this decrease in ED visits. This collaborative initiative involved Blueprint for Health Medical Homes (Community Health Services of Lamoille Valley, Northern Counties Health Care, Family Practice Associates in Cambridge and other primary care practices), Vermont Chronic Care Initiative with the Vermont Department of Health, and other local health agencies along with Copley Hospital.

These are just three examples of care coordination at Copley. We plan to continue the ED Care Coordination pilot, with Copley helping to fund the social worker position in the ED. However, we know this will not be enough to meet the need.  We continue to strive to provide excellent patient care for needed services and invest in programs to help reduce the rising cost of health care. Copley will continue to advocate for and contribute to shared care plans to connect patients with needed health services and social determinants support, collaborating with existing organizations and resources, to help patients make healthy choices.


Leah Hollenberger is the Vice President of Marketing, Development, and Community Relations for Copley Hospital. A former award-winning TV and Radio producer, she is the mother of two and lives in Morrisville. Her free time is spent volunteering, cooking, playing outdoors, and producing textile arts. Leah writes about community events, preventive care, and assorted ideas to help one make healthy choices.

About the author

Live Well Lamoille
Live Well Lamoille

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