Program helps asthmatics, diabetics to manage at home

March 1, 2011

Seton leaders to explain approach at Catholic Health Assembly


When they are discharged from the hospital, patients with chronic conditions may get plenty of instructions from their doctors on how to care for themselves once they return home. But do they have the wherewithal to follow the instructions?

A program from the Seton Family of Hospitals helps ensure that the answer to this question is yes, particularly when it comes to patients with chronic conditions and a high risk of hospital readmission.

"We're trying to make sure patients can access the resources they need, so we can improve their care," post-hospitalization, explained Steven Conti, director of disease management for the Seton Family of Hospitals in Austin, Texas. That Central Texas system includes five medical centers, two community hospitals, two rural hospitals, an inpatient mental health hospital and a network of primary care and rehabilitation facilities.

Since 2006, Seton has been collaborating with health care providers across Central Texas to identify people who have asthma or diabetes, who are uninsured or underinsured, and who are prone to frequent acute health crisis that brings them to the emergency room or requires hospitalization. Seton staff members contact identified patients and offer them free help with managing their conditions after they leave the hospital. The staff members focus on four keys to successful disease management: locating funding for the patients' care, connecting them to a primary care home, ensuring they have access to pharmaceuticals and helping them with follow-up.

Conti and two colleagues will describe the program during a session at the 2011 Catholic Health Assembly called "Home-Based Chronic Disease Management: An Innovative Response to Reform." Conti's co-presenters will be Cynthia Barrera, project manager, and Christopher Valmores, clinical manager, both of Seton.

A wide-cast net
Seton's chronic disease management program draws its patient base from a wide network of health care providers, both inside and outside of Seton's network. Major medical centers, clinics, physician practices, federally qualified health centers and even school nurses throughout the Austin area refer appropriate patients to Seton's program. Patients also can self-refer.

Seton also identifies patients using the ICare database, a repository of health information that Seton and other Austin safety net providers keep on uninsured and underinsured patients. They track patient encounters and then share the data through a health information exchange so that they can determine which individuals may be using the local health care system inappropriately. The chronic disease management program staff analyzes this data and flags people who have chronic disease and who are heavy users of inpatient services.

Seton staff get in touch with the people who have been referred in, as well as those they have flagged in the database, and invite them to use the self-management program. For those who join, the Seton program staff become their supporters, educators, advocates and cheerleaders. "Our staff members wrap around each individual and help them," said Conti.

Staff members include social workers, dieticians, nurses, an advanced practice nurse, a medical director and others — 15 people now, and more being added as the program expands to about 23 workers in the coming months.

Seton chose to focus initially on asthmatics and diabetics in part because both conditions are prevalent in Central Texas. More importantly, though, said Conti, health care providers know how to identify and address many of the issues that can lead to readmission for both conditions.

"Both conditions have readmission rates that are the symptom of a larger problem: many people with chronic disease lack access to the resources they need to manage the disease," Conti said.

Dollars and cents
Many people simply can't afford follow-up care. To counter that, program staff check to see whether patients are eligible for Medicaid, the State Children's Health Insurance Program, Medicare or for charity aid from Seton's medical assistance fund or another aid program. They assist patients or their parents as they apply for the aid.

Seton staff also walk low-income patients through the process of applying for free medication from pharmaceutical manufacturers or from the Dispensary of Hope, a Nashville, Tenn.-based pharmacy aid program, that operates as a division of Saint Thomas Health Ventures. Both Saint Thomas Health Services and Seton are members of St. Louis' Ascension Health.

A place to call home
Lack of a medical home is another barrier to chronic disease management. The Seton program staff tap into their network of partner health care facilities, both inside and outside of Seton, to determine which clinicians will take on new low-income patients. Program staff members help the patients to connect with their new medical home. Normally, program staff set up the appointments and place reminder calls to patients.

From the outset, program staff are in regular phone contact with their patients, and they schedule frequent in-home visits and educational sessions at Seton hospitals. The staff break down patients' at-home regimen in small bites in order to identify and address gaps. Do the diabetics understand portion control? Do they know how and when to check their blood sugar? Do the asthmatics know how to use their nebulizer? Can they evaluate their symptoms and know when to alert their doctor to a change?

The frequent contact lasts about a year, long enough to ensure patients feel competent to manage their conditions by themselves. Conti said, "That's what's novel — we're helping patients to manage their own disease. It's self-empowerment. In many other programs that are out there, the clinicians try to manage the condition for the patients. We shift that responsibility to the patient over time, so that they are being intentional about managing their condition."

Better health, better bottom line
The program is returning results.

Asthmatics in the program cut their emergency department visits by 37 percent, and their inpatient stays by 63 percent. Nearly a third of the patients reported they had no asthma symptoms three months after joining the program. Diabetic participants cut their emergency department usage by 33 percent, and their inpatient care by 75 percent.

Both programs also demonstrated a savings, as measured in cost avoidance. Together they save the community between $600,000 and $700,000 per year, over the cost of the program. The annual budget for Seton's chronic disease programs for underserved people is about $1.25 million. The results have convinced Seton to expand the program to patients with heart disease.

Conti noted that Seton's approach is in line with health reform's mandate to promote wellness and provide cost-efficient, seamless care for patients — a goal that requires improved collaboration among providers.

Fresh starts
Conti, Barrera and Valmores said the program changes lives. Program staff helped a jobless father to get job training and to move his family, including an asthmatic daughter, to a nice apartment from an unsafe trailer that had aggravated the child's respiratory condition. The staff helped a woman who had moved from California to Texas to get asthma medication. Prior to getting it, she had feared leaving the house because of breathing problems.

"It's our mission at Seton to serve the poor and the vulnerable, and that is what we're doing in this program," said Barrera.

Learn more about the Seton session, the assembly program and registration. The assembly takes place June 5 to 7 at the Hyatt Regency Atlanta.


Copyright © 2011 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Copyright © 2011 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.