When we think about the challenges of healthcare, we tend to focus on most immediate signs of treatment: what’s going on in the operating room, how medications are working, whether or not infections are being spread. We also tend to think in terms of a relatively simple relationship between patient and caregiver.
The complex reality of how population health functions, though, is quite different. There are not only broad economic and social inequities that limit the possibilities of receiving care, but patients experience a diverse array of providers—from primary care physicians to outpatient specialists to home care workers—all of which work differently and interdependently. A patient’s access to each caregiver is different, and with each transitional move there’s a chance of miscommunication or lack of shared knowledge that could lead to poor outcomes. Some evidence suggests that up to 80% of the most dangerous medical errors occur because of poor communication as a patient moves from one setting and mode of care to another.
David Isenhower, MD, Self Regional Healthcare’s Chief Medical Informatics Officer, has been one of the key supporting figures in the system’s Transitional Care Clinic, a short-term medical home for high-risk patients who need careful assistance in managing their care.
“This whole realm of medicine we’re calling population health is [just] doing the things we should have done all along,” Isenhower explained. “But practically none of it is actually ‘doctor work’ [in the traditional sense]. Once you solve those social issues, they can be successful in a straightforward practice.”
The idea for the clinic was hatched with the realization that bridge clinic for high-risk discharged patients would be one of the best ways to prevent readmissions, since many are a product of poor care post-discharge. Dubbed the Transitional Care Clinic, it was originally housed at one of the free clinics in Greenwood, Clinica Gratis.
“The director [of Clinica Gratis] was interested in doing a trial run, a proof of concept,” said Isenhower. “She had a grant, we had a doctor, and we put them together.”
From the very beginning, the clinic found there was a high demand for their work from both patients and doctors.
“A lot of these folks haven’t had much medical care, so they have things like uncontrolled diabetes or uncontrolled hypertension,” explained Cyndi New, RN, the clinic’s manager. “They have a lot of healthcare illiteracy. So we try to get them in the best shape we possibly can before placing them with a permanent medical home.”
“The doctors in the hospital love it, because they now have a place they can send somebody who didn’t have a place to go for follow-up care,” Isenhower points out. “It was going well enough that the hospitals actually noticed.”
Last October, the Transitional Care Clinic opened as part of the hospital proper.
“The majority of our referrals are from the hospital inpatient side and the Emergency Department,” said New. “A lot of behavioral health partners in town [also] send us patients who need a medical care home. A lot of primary care physicians don’t necessarily want to manage behavioral health medicine, but if we work together, we can see patients for their chronic conditions and medical needs, then the behavioral health specialists can see them for their mental health needs.”
Though the clinic began with the specific purpose of addressing shortcomings of a siloed approach to care, their work is distinctly different from that of a free clinic or primary care physician.
“Doctors who participate in this transitional care clinic are not held to the same productivity requirements that those in a normal employee practice are,” explained Isenhower. “We recognize that these are complex patients who have many things that have never been sorted out. It can be a disaster if you try to drop them into a normal clinic that has normal RVU (relative value units, a measure of physician time efficiency) productivity driving it.”
For Isenhower, it’s about even more than just taking the extra time. He refers to the approach as a “skill of transition” that doctors have to acquire to be successful at clinics like these.
“That skill is not [necessarily] present in every family medicine or primary care clinic,” he pointed out. “You have to have the right people beyond the doctors there, too. And you need doctors who are willing to take the time and be pretty demanding about the details they need to sort out.”
When talking with Isenhower and New, it’s clear that the Transitional Care Clinic thinks of themselves as troubleshooters and problem solvers as much as temporary primary care providers. The group looks to prepare patients to deal with the vast world of healthcare and give them the tools to be successful in that system. So in addition to providing temporary primary care, they also collaborate with AccessHealth and Welvista to make the finances work for many of their patients; assign community health workers to assess cultural barriers patients might face; and utilize nurses and a social worker to assist with high-risk Medicare patients. They address transportation barriers such as whether a patient can make an appointment on time and how to build flexible systems that get patients to providers.
“We've learned so much from managing our population health programs, so if a patient is late for an appointment we call them to see why and get them rescheduled. It's not an automatic no-show,” said New. “We let them come an hour later, or later that afternoon and provide transportation if they need it. We ask for co-pays, but we also don't turn them away. We really get to work with the patient as they learn how to navigate the healthcare system.”
Isenhower echoed her point, noting the positive feedback they get from primary care physicians these patients transition to.
“What we hear back now, instead of them being tough patients, is that they are very easy patients,” he said. “These are folks who historically would have been the ones that didn't show up on time, that did not comply with treatments, but they've been socialized by this experience and understand what it means to be successful in a practice.”
He also believes part of the clinic’s success stems from its commitment to “the simplification of complex care,” noting that sometimes it’s the unrealistic expectations of a patient that lead to care transition failures.
“It's the boldness of saying ‘we are intentionally not going to overwhelm you right now because it's too much for you to handle,’” explained Isenhower, citing a young man with diabetes who benefitted from the simplicity of a fixed dose schedule rather than constant management of his blood sugar levels. “We're making control steps here. That's not a light thing, not a trivial thing, to do.”
The clinic also prides itself on working closely with community health workers who have a strong sense of the patient’s position and cultural background. As much as they can, they try to have one of those workers accompany patients on their first visit to a primary care or specialist physician.
“We're very interactive,” says New. “I depend on the staff—they are the ones dealing with the patients every day, going to the homes and going to the practices. We've got a great working atmosphere within the clinic.”
The two are justifiably proud of the work that their clinic does. While current funding comes in part from a Duke Endowment grant, the clinic has the full support of the hospital’s administration which should allow them to continue their work well into the future.
“If we didn’t have the backing, the buy-in and support from the administration this wouldn’t be possible,” said New. “I know other organizations that really struggle to get people to understand the importance of population health, and we just don't have that here. People really look us to come up with the next thing, the next innovation.”
** The Transitional Care Clinic has contributed to SRH’s current all payor readmission rate of 10.59% compared to FY15’s rate of 13.96%. The organization has also exceeded our goal to decrease in low acute, non-emergent, ER visits.***