In the summer of 2012, a program called Bridges to Care came on the scene in Aurora. It targeted one of health care’s most enduring problems: the large number of people who repeatedly use the emergency department (ED) or are admitted to the hospital for problems that could be handled in the outpatient setting.
Bridges to Care (B2C) was funded by a three-year, $4.2 million grant from the Centers for Medicare and Medicaid Innovation to the Metro Community Provider Network (MCPN), an organization dedicated to providing health care to the underserved. The goal was to connect frequent ED and hospital users to health care coaches and coordinators who would use a 60-day program to identify individuals’ barriers to care, set them up with services to help overcome those obstacles, and coach them to develop the skills and resources to manage their own health.
By any number of measures, B2C was a success. But the grant ended last June, leaving supporters to work on sustaining the program while increasing the number of patients and including more organizations that can at least indirectly affect people’s health, from fire and police departments to schools to substance abuse disorder treatment facilities.
“We’re trying to use learnings from the first phase of B2C to improve efficiencies and optimize outcomes – and with decreased resources,” said Jennifer Wiler, MD, MBA, vice chair and associate professor with University of Colorado School of Medicine’s Department of Emergency Medicine.
With support from University of Colorado Hospital, which helps to identify potential B2C candidates, the program served some 600 patients during the three-year grant. Hospital and MCPN leaders are still analyzing the data, but the early returns are impressive. Among some 225 B2C program graduates, the number of ED visits to UCH decreased 49 percent, while the number of hospitalizations fell 55 percent, said Heather Logan, MCPN’s director of accountable care. That resulted in savings of nearly $8 million in charges, Logan said.
Preliminary data also indicate that B2C graduates used fewer resources than other patients who frequently use the ED and hospital, said Roberta Capp, MD, assistant professor of Emergency Medicine at CU. Capp’s analysis of six months of pre- and post-intervention data for 188 B2C graduates showed that the number of ED visits and hospital admissions decreased at far greater rates than for patients in a large control group.
Bridging the gap
Bridges to Care proponents at MCPN and UCH are now looking for ways to ensure B2C continues. For now, Logan said, support comes from the Anschutz Foundation and the Community First Foundation, with the Rose Foundation a possibility. In addition, UCH continues to share with MCPN support for a “community health liaison” in the ED who connects potential B2C candidates with an MCPN care coordinator. Aurora Mental Health, which was a key player in the original B2C grant, provides in-kind services to patients, Logan said.
The long-term goal is to win financial backing from the state’s Department of Health Care Policy and Financing (HCPF) and its Regional Care Collaborative Organizations (RCCOs), which are designed to provide coordinated care to Medicaid patients.
The idea is for providers who care for B2C patients to receive per-member-per-month payments with financial incentives for managing patient utilization and outcomes. It’s part of a “national conversation” about developing payment models that reward coordinated patient care rather than fragmented, episodic care that drives up health care costs without improving patient outcomes, Wiler said.
Fine-tuning the process
While discussions with HCPF progress, work continues to improve B2C. The original program focused on Aurora residents, but it now includes patients from east Denver who frequently use UCH and need a primary care provider (PCP), Logan said. Following the model established at UCH, Lutheran Medical Center in Wheat Ridge now has an MCPN community health liaison embedded in the ED to identify potential B2C candidates, Logan said.
Another goal is to expand contacts with inpatients at UCH who need primary care, said Greg Misky, MD, a UCH hospitalist and CU associate professor of Internal Medicine. Misky said one in three patients on the hospital’s Medicine Service is underserved.
The first phase of B2C provided enrollees with 60 days of support, with a minimum of eight home visits from medical and behavioral health providers who assessed patients and helped coordinate their care. Now the program is “tiered,” Logan said, to provide support in 30-day increments, up to 120 days. A multidisciplinary team, including a health coach, social worker, medical provider, and behavioral health provider, meet to assess each patient and develop a graduation “checklist” of their needs, such as help with medications.
If patients need more coaching at the end of the prescribed period, they get it, Logan said. “We have the flexibility to keep them in the program so they can be successful.”
Logan said intensive coaching is also necessary to improve access to specialty services. Many providers have limited slots for Medicaid patients and may be reluctant to treat them because of poor experiences, including missed appointments, lack of preparation, and failure to follow plans of care, she said. To address that, B2C care coordinators help to prepare patients to meet with specialists and will attend appointments to support them, Logan said.
The first round of B2C also showed that for many patients, health care is only one piece of a complex life puzzle. Misky recounted an experience with a 53-year-old heart failure patient – not enrolled in B2C – who had stopped taking his medications. His condition was complicated by depression and substance abuse, Misky said, but the biggest barrier was he didn’t believe, or trust, what his providers told him.
“In a fragmented system, we need health care providers who are invested in sorting through patients’ issues and figuring out where health care fits in their lives,” Misky said. “We don’t need to grow more physicians to do that, but rather advanced practice providers, community health workers and transition coaches, and so on. Building trust with patients is what is important.”
It is also vital to build relationships with other services that affect people’s health, Capp said – housing, transportation, legal services, and so on. To that end, she’s coordinated three community-wide meetings with representatives from MCPN, Aurora Mental Health, detox centers, fire departments, senior housing, and others frequently involved in the lives of the underserved.
Painting the whole picture
The challenge is to create a system that addresses patients’ needs as part of a continuum rather than a series of isolated events. That’s particularly true when it comes to mental health care, Logan said. Indeed, the data show that nearly 80 percent of B2C patients have a diagnosed behavioral health issue, Logan said.
The experience of a recent B2C graduate illustrates how medical and behavioral issues intertwine, Logan noted. Asked why she had visited the ED so frequently, the patient said she had lost her husband in a car accident. In the midst of her grief, she failed to manage her diabetes and made frequent trips to the ED, where she was stabilized. However, the medical treatment didn’t address the depression underlying her apparent noncompliance with her diabetes treatment.
After enrolling in B2C, the patient received regular therapy sessions and stabilized her mood safely with antidepressants, Logan said. She found motivation in caring for her children and learned ways to manage her diabetes. Now, rather than using the ED, she consults her PCP when she has issues.
This example and others (see accompanying story) illustrate the need for providers to do “a deeper dive” to find “triggers” for a patient’s medical problems, instead of settling for the “Band-Aid” of an ED visit or hospitalization, Logan said.
The B2C program has helped to encourage that view, Misky said. Today’s collaboration between UCH and MCPN providers would have been “unheard of” three-plus years ago, and coordinated care and follow-up for those most in need have improved, he said. But without additional changes, the hospital’s capacity to meet growing demand will be strained, he added.
“By every definition, we still have a long way to go,” Misky said. “We have to improve care for inpatients and provide mental health services or the bed situation at UCH won’t get any better.”
The B2C program has been a success, and it has demonstrated just how pivotal relationship-building can be for patient care, Capp said.
“Now we have to expand services, and that requires an additional financial investment,” she said.