What if health care professionals working with medically complex patients could easily coordinate holistic care plans to meet all of their patients' social service needs in their community? Would it decrease the patients’ chance of being re-admitted to the hospital? Could it eventually lower healthcare costs for the entire system?
A new project launched by the Camden Coalition of Healthcare Providers may provide answers. For over ten years, the Coalition has worked to improve the access, quality and capacity of health care in the city of Camden, New Jersey.
The Coalition’s multidisciplinary care teams support frequently-hospitalized patients with complex care needs. They work with the individuals in a short-term intervention to stabilize their health. Many of the patients served by the care teams are taking multiple medications, have two or more chronic medical conditions, and are susceptible to social vulnerabilities such as homelessness, addiction, and unemployment.
"A lot of our case managers are skilled and know a lot of information, but not all of that information lives within everyone. That’s impossible. So certain people have more domain expertise but this allows that information can be shared. So the knowledge doesn’t have to live within one person."
Laura Buckley, Social Work Manager for the Coalition, outlines the challenges of keeping medically complex patients in Camden healthy and out of the hospital. “Certain patients can have unstable housing, and when people are unstably housed, it can be difficult to coordinate their health care. For others it may be the exacerbation of mental health and addiction. The struggle to connect to those resources can increase the likelihood of [the patient] being readmitted. Because discharge planning in the hospital often can happen so quickly it can be a challenge to make sure that everyone is on the same page."
The Coalition’s care teams help patients navigate an overwhelming and fractured system, empowering them to not only address their medical issues, but social barriers as well.
The journey begins at the hospital where care teams meet patients at bedside. Patients and Coalition staff discuss the patient’s health goals based on areas of need that the Coalition calls "domains of care." Examples of these domains are "housing and environment,” “education and employment," or "food and nutrition." Coalition staff learn the patient’s personal story and collaborates with them to connect with the best programs to support their stated goals.
For the last decade, this has largely been facilitated by experienced case managers, using note cards to guide their patients through the process of attaining their goals. Without a centralized, up-to-date resource library, care teams had to rely on their own specialized knowledge to connect patients to services.
Over the last several months, the Camden Coalition and Aunt Bertha have collaborated to develop an online tool that links them directly to the social services they need to support their patients. The tool guides a user through the same domains of care and interventions, but now, when the case manager selects an intervention, they can enter the patient's zip code, and the programs that support their specific intervention immediately populate.
The new online tool allows care teams to create an integrated care plan that supports the patient's social needs in addition to their medical care. "We’re still asking what goals they want to work on,” says Buckley. “Once they identify a few things, we can use Aunt Bertha to link them [to programs] or start that plan... It doesn’t change the questions that we’re asking but it helps us to find an answer sooner."
The tool allows for shared knowledge across an interdisciplinary team. "A lot of our case managers are skilled and know a lot of information, but not all of that information lives within everyone. That’s impossible,” says Buckley. “Certain people have more domain expertise but this allows information to be shared. So the knowledge doesn’t have to live within one person."
To support and empower their patients, the Coalition provides their patients with a resource binder and their own link to Aunt Bertha where they can search for additional resources. Buckley says that she is hoping that by empowering patients to find their own resources, they'll be able to support themselves. "A lot of times patients do have smart phones. [Aunt Bertha] is an added benefit – a resource pocket guide that they can have on them at all times. It ensures sustainability of the intervention and helps empower our patients to find the resources and access the resources they need when we’re not there, which is the ultimate goal."