A New Team of Care Managers and Trusted Advisors for High-Risk Patients

The following article appeared in the December 27, 2016 edition of the NYC Health + Hospitals Insider, and highlights our initial care transitions work at our largest partner.

Anthony*, a young man struggling with mental illness and a family history of mental health problems, found himself hospitalized again and again with no one to lean on.

Mercedes*, a woman in danger of going blind, skipped medical appointments and wouldn’t pick up the phone to get care although her potential blindness could be prevented.

These stories represent real-life cases of patients at a number of hospitals in the NYC Health + Hospitals system whose complex medical, emotional, and socio-economic conditions put them at risk of repeated hospitalizations that can be avoided.

But thanks to a new Transition Management Team – part of the Delivery System Reform Incentive Payment (DSRIP) program – many high-risk patients under our care will receive the extra care coordination and attention they need to help improve their health and stay out of the hospital.

“We’re introduced as part of the team at the bedside so that the patient understands from day one that we are on their side,” explains Nyasha Cupid, RN, BSN, Care Manager at NYC Health + Hospitals/Kings County.

Cupid developed a deeper and more meaningful rapport with Anthony and soon became a trusted advisor. She quickly learned the real reason Anthony was not taking his medications: he was experiencing negative side effects and had trouble paying for prescriptions.

Cupid joined Anthony at doctors’ appointments and navigated the system to find a way to help him pay for his medication. With his mental health condition in check, Anthony is now stable, staying out of the hospital, taking his meds, keeping his doctors’ appointments, and looking for a job.

“The Transition Management Teams are filling a unique role and really taking the baton in terms of caring for these patients,” says Dr. Douglas Bails, Chief of Medicine, NYC Health + Hospitals/Bellevue, “We’re seeing patients who had previously been admitted multiple times now staying home and out of the hospital.”

The new teams, now in place at NYC Health + Hospitals/Kings County and NYC Health + Hospitals/Bellevue, create comprehensive plans for patients who are at a high risk of readmission. Consisting of a nurse, a social worker, and a community liaison, each team educates the patient about their health care needs and care plans, explains medications and helps secure them, ensures that the patient attends their follow-up appointments, and addresses social barriers or needs that arise.

So far, the program has served nearly 600 individuals at the two patient care sites. Similar teams will soon be in place at additional NYC Health + Hospitals facilities.

Transition Management Team members at NYC Health + Hospitals/Bellevue
Transition Management Team members at NYC Health + Hospitals/Bellevue

For Mercedes, the team created an intervention plan that included a home visit.

“When we went to her home and explained that our job is to keep her healthy and nothing else — she started to trust us,” says Nancy Aponte, RN, BSN, Care Manager, NYC Health + Hospitals/Bellevue.

It turned out that Mercedes had a low level of health literacy and didn’t fully understand what to do to prevent blindness. She also received an expensive medical bill and was afraid to seek treatment, worried that someone would try to collect the money that she simply did not have.

Aponte worked with the finance department and helped Mercedes to re-enroll in health insurance to cover all her basic needs. Mercedes is on the right track now and tending to her medical care.

“She even called to thank us and sounded excited. I’m sure that was a new lease on life,” says Aponte. “Each of these cases serve as a constant reminder that what one person may see as a few simple steps to take charge of their health can feel like an insurmountable barrier to someone else.”

*not real name

Achieving Transformation Through Training and Education

As we progress with our transformation efforts, it is essential for our partners to have a shared understanding of the Performing Provider System’s (PPS) goals and how to reach them. To that end, OneCity Health has undertaken numerous activities to date – and will soon launch many others – to help train and educate our partners.

From instructing Transition Management Teams to coaching our partners to utilize the Patient Activation Measure® (PAM®) survey, each OneCity Health initiative has been rooted in engaging our PPS partners with educational materials and technical assistance, which helps our partners:

These are just a few examples; education supports improved patient and population health across our integrated delivery system and could extend to areas such as care management and information technology (IT), among other topics. OneCity Health is investing $50 million in workforce training for our network over the Delivery System Reform Incentive Payment (DSRIP) program to support these efforts.

As we make educational content available or schedule opportunities for instruction, we will reach out to our partners and ensure they are well-positioned to improve patient health. Simultaneously, we will coordinate with our PPS partners’ many training-related assets to encourage best practices and leverage our greatest strengths.

Introducing Transition Management Teams

For patients who require extra support when leaving the hospital, OneCity Health recently conducted an initial training for our first group of interdisciplinary Transition Management Teams. These teams work closely with hospital staff to create a comprehensive plan for our patients who are at a high risk of returning to the hospital within weeks of leaving. Pilots for our Care Transitions project, which we previously detailed, occur within the inpatient setting of four OneCity Health partner hospitals.

The Transition Management Team visits a patient identified by the inpatient care team while he or she is still in the hospital and determines if the patient could benefit from additional support over the critical 30 days following discharge. Support may include calling patients within 48 hours of leaving the hospital, assisting them with obtaining medications or ensuring follow-up occurs with a physician. The Transition Management Team also identifies and refers patients for any longer-term care management needs.

For our Transition Management Teams to be successful, it is essential for hospital staff to identify and refer patients who require extra support to stay healthy after leaving the hospital. Additionally, we need to strengthen the provider network that supports our patients’ transitions from the hospital to the community. As our pilot efforts mature, we will begin to incorporate our community partners into this work.

We will discuss the referral criteria in more detail soon. If you have questions in the meantime, please email DSRIPSupport@nychhc.org with the subject line “Care Transitions”.