Through a Center for Medicare & Medicaid Innovation (CMMI) grant, teams of registered nurses (RNs), community liaison workers, physician advisors and pharmacists began providing similar support in six NYC Health + Hospitals facilities in September 2014. This program resulted in a steady decrease in ED revisits within 30 days of discharge over the course of the intervention period, and highlighted the need to include a social work component to better address patients’ social determinants of health. In May, CMMI staff gathered for an afternoon of training, team-building activities and a discussion on the success to date, lessons learned and next steps.
We plan to apply the findings under this grant regarding patient impact and quality outcomes to OneCity Health’s ED Care Management initiatives, through which we will focus on the highest-needs, highest-utilizing patients instead of all patients with ambulatory care sensitive conditions. Staff will continue to connect patients to primary care, while standardized workflows will help them to better identify providers with capacity, as well as other appropriate outpatient services. Their work will also include developing patient care plans, follow-up phone calls and, when appropriate, home visits, as well as medication reconciliation coordinated through the pharmacist and linking patients to community care management.
In addition to connecting patients to primary care, ED staff can also refer patients to care management services such as NYC Health + Hospitals/At Home, which includes primary care-care management, and our Health Home At-Risk program. Patients will also be linked to OneCity Health partners who provide community support, such as helping patients adhere to their treatment plan and other follow-up services.
Thank you to our CMMI teams for their enthusiasm and participation at our recent event. We look forward to building off their success and expanding our support for patients in the comings months.