http://www2.ljworld.com/news/2010/feb/19/lawrence-memorial-hospital-models-new-community-ca/

It’s a new part-time position, and the goal is to help vulnerable patients get the care they need after being discharged from the hospital.

“People, a lot of times, think they are just going to bounce back and they are going to do fine and they don’t need anybody in their home, but then sometimes when they get home they realize, ‘Oh gosh, this is a lot harder than I thought it was going to be,’” said Linda Gall, director of Care Coordination at LMH.

The new community care navigator is Kristen Byington, and she will be calling patients to make sure their needs are being met at home. The patients will be referred by the in-patient social workers and registered nurse case managers.

Byington, a graduate of Kansas University’s School of Social Welfare, will make sure patients understood their discharge instructions, received their medications and were able to make follow-up appointments, among other things. She also will connect them with services such as free meal programs, transportation and clinics that serve low-income residents.

“There’s so many community resources, but there’s not really one main clearinghouse for people to call and find out what’s available,” Gall said.

The goal is to keep people healthy and to prevent unnecessary hospital admissions.

Byington will call patients within 72 hours of being discharged, and then will check back about every two weeks until she feels the patient’s needs are being met.

A successful model

Gall said LMH modeled the position after the Vulnerable Patient Network program at Baylor Health Care System in Dallas. The program provides home-based care and social support services to uninsured and underserved patients with complex medical conditions.

The program has kept patients out of hospitals, and in return, saved hospitals and taxpayers in uncompensated care. It’s a win-win concept that started with an internal medicine doctor making house calls.

About 10 years ago, a 16-year-old boy broke his neck diving into a swimming pool. He survived, but was paralyzed from the neck down. After spending two months at Baylor University Medical Center, he was ready to be discharged, but social workers couldn’t find primary care for the boy. So, they turned to Dr. James Walton, who worked at Central Dallas Ministries, a charity clinic.

Walton provided care in the boy’s home for free.

“He survived, surprisingly to me and everyone else. He did well, and they sent me a couple more patients a few months later,” Walton said.

He spent about an hour with each patient once a month. Before long, Walton had 16 patients on top of a full-time job.

After five years, he successfully convinced Baylor to expand the program.

Today, the Vulnerable Patient Network program has about 80 patients at any given time, and it provides medical services, coordinated care and social support for free. The program is based at the Baylor Family Medicine at Worth Street, a charity clinic, where patients’ electronic medical records are kept. Doctors, nurses and other health professionals donate their time. There is a full-time nurse practitioner, a full-time community health worker and a physician who provides oversight.

Benefits abound

Walton, vice president and chief health equity officer for Baylor Health Care System in Dallas, said the program pays off.

“It doesn’t take a lot of technology to prevent admissions,” Walton said. “Just making sure a quadriplegic gets the right mattress to lie on, saves you hundreds of thousands of dollars of wound care.”

Another example, is making sure patients who suffer heart disease get their medications.

An analysis of heart failure patients in the program compared hospital utilization and uncompensated costs six months pre- and post-enrollment. Emergency department visits decreased 26 percent, admissions decreased 63 percent and uncompensated costs decreased 53 percent or $200,000.

Sometimes, Walton said, patients just need some social support or TLC.

“We’ve built ramps,” he said. “We got a lady a dog because she needed a companion.”

He recalled a unique visit with an elderly woman.

“There were piles and piles and piles of clothes and stuff,” he said.

There was a narrow path from her chair to the bed and to the stove. She said she was saving it for a garage sale. Walton knew she was too sick to have a sale and she didn’t have family to help her. So, he asked how much she would like to make, and she replied, ‘$70.’ So, he offered to buy it and she gladly accepted. He recruited help and they cleaned out the house.

“There’s all kinds of ways of doing this. It’s being extremely creative and going beyond just medicine,” he said.

That’s what Lawrence Memorial Hospital plans to do.

In March, Byington will start by offering help and resources over the phone to about 20 patients per week. It’s the hospital’s first step in extending social work services beyond a discharge, and it’s a step that very few hospitals have taken.