Beyond Our Doors – Caring for Our Community

Posted on Jun 5, 2018 in Uncategorized | 0 comments

Beyond Our Doors – Caring for Our Community

Clayton Warren | May 3rd, 2018

Alta Bates Summit Medical Center is working together with community clinics and agencies in the East Bay to reshape how people access healthcare. The goal of the Community Integrated Healthcare Partnership is to share and advance innovative strategies with hospital and community providers to help improve whole person and population health using collaborative approaches and data driven solutions.

In 2012, Alta Bates Summit Medical Center reached out to Federally Qualified Health Centers (FQHCs), homeless, housing and mental health agencies and the Alameda County Health System to develop a partnership to help improve the flow of patients through the emergency department as well as to improve care transitions and ensure patients establish a medical home where they can receive routine care.

Video: Learn how Sutter Health’s Alta Bates Summit Medical Center impacts the East Bay through the Community Integrated Healthcare Partnership.

Data Supports New Approach

Stephanie Brown, M.D., ER Physician at Alta Bates Summit

“One of the main goals for this partnership was to improve the flow of patients through the emergency department as well as to improve care transitions,” says Stephanie Brown, M.D. Emergency Room physician at Alta Bates Summit and Co-leader of the project. “For example, care transitions nurses can see exactly see how many patients were contacted by the nurse for follow-up care at a community health center, how many kept those appointments and how many appointments were missed. These numbers drive the program and enable our partners to target their resources more effectively.”

The Community Integrated Healthcare Partnership is data driven and allows clinicians to drill down exactly where resources are most needed. Since tracking patients in the care transitions program, Alta Bates Summit has seen a 25 percent reduction in their readmission rate.

Partnering with Federally Qualified Health Centers

The Community Integrated Healthcare Partnership consists of federally qualified health centers, homeless, housing and mental health agencies and the Alameda County Health System

To ensure a smooth transition and continuing care once the patient is back in the community, Alta Bates Summit relies on long-established relationships with LifeLong Medical Care, La Clinica de la Raza, West Oakland Health Center, and Asian Health Services. These deeply rooted community organizations offer centrally located, affordable, comprehensive and effective primary and preventive care. They also provide language translation services and help identify and remove other barriers to care, such as mental health, substance use treatment, or lack of transportation or permanent housing.

“We collaboratively work with discharge planners and the social workers at Alta Bates Summit to identify and advocate for our patient’s needs,” says Barbara Goldstein, Psychosocial Services Director, LifeLong Medical Care. “This partnership allows our doctors and nurses to know that their patient has been in the hospital, what their follow-up needs are and what they should be paying attention to when the person does come in for their follow-up appointment.”

Many of the following Community Integrated Healthcare Partnership Program are funded through Alta Bates Summit Community Benefit and Sutter Health Philanthropy:

  • Clinic care transition nurses
  • A new clinic for high-risk patients
  • Health equity project
  • Chronic disease resources
  • Closer collaboration with mental health substance use and housing agencies

Tracy Schrider, LCSW, Alta Bates Summit Community Health Social Service Program Manager

“Alta Bates Summit Emergency Department nurse care managers and social workers closely collaborate with FQHC (or community clinics) care transitions nurses,” says Tracy Schrider, LCSW, Alta Bates Summit Community Health Social Service Program Manager and Co-Leader of the project. “This warm hand-off allows patients to gain access to community providers who can offer a wide range of services including preventive care, disease management and social services.”

Improving Care for Frequent ED Patients

Since 2016, PreManage ED© has allowed emergency departments within the Sutter Health network and Alameda Health System to identify thousands of shared patients who visited an ED five or more times in the previous year. Before PreManage ED was implemented, neither health system could identify these frequent visitors as shared patients.

Ronn Berrol, M.D., medical director of the Alta Bates Summit Emergency Department (Photo: Eric Kayne)

“The PreManage ED system instantly alerts our staff when a patient has a case history of using the ED on at least three occasions in less than 30 days,” says Ronn Berrol, M.D., medical director of the Alta Bates Summit Emergency Department in Oakland. “This tool allows us to quickly view the patient’s recent treatment history and pinpoint the reasons why they are visiting the ED so often.”

Watch the Video to Learn More

Learn how Sutter Health’s Alta Bates Summit Medical Center impacts the East Bay through the Community Integrated Healthcare Partnership.

 

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