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By PAMELA SCHAEFFER

For addressing the host of issues that lead vulnerable people to become super-users of health care, KentuckyOne Health in Louisville, Ky., has developed a recipe that incorporates what Alice Bridges calls a "secret sauce." 

Bridges, vice president for healthy communities at KentuckyOne Health, is the "executive champion" for Health Connections Initiative, a program started in 2013 and designed to improve health outcomes for participants by helping them to manage their complex medical conditions.

Carrie Brown, left, meets with Bethany May, a community health worker on her KentuckyOne Health Connections Initiative team. The program taught the 82-year-old how to manage her congestive heart failure and what to do to prevent a health crisis when her symptoms escalate. A social worker also participates in the home visit.

KentuckyOne's recipe draws its basic ingredients from two well-known programs aimed at improving patient outcomes and reducing costs of care for low-income, high-need, vulnerable patients: the so-called Camden "hotspotting" model, developed by Dr. Jeffrey Brenner in Camden, N.J., and the Care Transitions model, developed by Dr. Eric Coleman of the University of Colorado. Both are designed to identify and assist hospitalized patients at risk for re-hospitalization to better manage their post-hospital care and chronic illness.

Map making
KentuckyOne is part of Englewood, Colo.-based Catholic Health Initiatives, and Health Connections is funded exclusively by grants from CHI's Mission and Ministry Fund. (See sidebar.)

When Diane Jones, CHI's vice president for healthy communities, and other CHI leaders began looking for areas to implement their vision of a Camden-style program aimed at improving the lot of patients with complicated physical and social needs who are high users of health care, they fixed their sights on West Louisville, where the public health department had already established a Center for Health Equity. The center's focus is acquiring data for addressing the social determinants of health in West Louisville, a cluster of low-income, high-crime neighborhoods with generally poor health outcomes and a high mortality rate, and it had gathered a rich source of information useful to those developing Health Connections.

KentuckyOne drew the first map for its hybrid "hotspotting" program in early 2013, using data on Jefferson County patients discharged from its Jewish Hospital. The system identified 10 ZIP codes in West and South Louisville as "hotspots," or concentrations of "super-users" of health care. Those super-users were defined as patients who had four or more inpatient stays or outpatient visits to KentuckyOne facilities within a year. The new transitional care program, called Health Connections Initiative, only enrolls people from those ZIP codes. In addition, patients must be at risk of hospital readmission within 30 days of discharge. (See sidebar below.)

Health Connections Initiative patient George Willis meets with a nurse in his home in southwest Louisville, Ky. Willis graduated last month from KentuckyOne’s hospital-to-home transition program for patients at risk for avoidable hospital readmissions. Program staff follow up with him to monitor his progress.

Jewish Hospital and Sts. Mary & Elizabeth Hospital in Louisville launched Health Connections in 2013 and CHI St. Vincent Infirmary in Little Rock, Ark., followed with its launch a few months later in March 2014. KentuckyOne's University of Louisville Hospital came on board in the fall of 2014. More recently, St. Joseph Medical Center in Tacoma, Wash., and Highline Medical Center in Burien, Wash., both affiliated with CHI Franciscan Health in Tacoma, have started similar programs.

The goal always has been to develop a program that could be replicated at selected CHI hospitals around the country, Jones said.

Learning curve
At Jewish, a precursor care transitions program for patients with congestive heart failure taught administrators the value of home visits to vulnerable patients after their hospital stay. At first, patients received follow-up phone calls from a registered nurse who offered disease management coaching and checked on their well-being. The calls continued for up to four weeks after discharge. Later, Jewish Hospital partnered with the Louisville health department to dispatch a community health worker on home visits to vulnerable patients. "We found those patients who got the home visits had much better outcomes than those who had only phone contact," Bridges said.

Trying "to reach people on the phone and motivate behavior change was not especially successful," she said. Many low-income patients have fluid home arrangements — sometimes staying with a relative or a friend. "They might not even have a number where we could reach them from one day to the next." Home visits, she said, proved far more conducive to developing trusting relationships and to gathering accurate information, such as the quality of family dynamics, contents of the refrigerator and medications on hand. "The actual situations were often different from what patients had reported," Bridges said.

Today, patients typically stay in Health Connections for up to 90 days. In Louisville, the program has two paid health care teams, consisting of a registered nurse, who makes the initial home visit and coordinates the care plan, a licensed professional nurse, a social worker and two community health workers. Enrollees are seen up to twice a week by a team member, with the community health worker having the most frequent contact, followed by the social worker.

Ending isolation
The community health workers, who generally have no clinical background, are the team members Bridges refers to as the "secret sauce."

"They are critical to making this program work," she said. "They play a critical role as knowledgeable connectors to neighborhood resources and serve as the trusted friends." Sixty-five percent of the program enrollees are socially isolated, Bridges said — widowed, single, divorced or separated with no one to help them navigate the health system. Often the community health workers help a patient prepare questions for his or her doctor and go along on the office visits. "This is very beneficial to patients who are often overwhelmed or who have low health literacy, helping them adhere to the plan of care," Bridges said.

Medical home
Although some program participants may have been seeing a variety of medical specialists for their conditions, team members strive to connect each enrollee to a primary care physician, or ideally, to a medical home, and to be sure they understand the red flags that should prompt a timely call to a provider. The program has educated more than 200 medical providers (physicians, physician assistants and nurse practitioners) and their office staffs on the value of coordinating care delivery with the Health Connections team and found them all to be receptive, Bridges said.

Other experts "on call" as needed by Health Connections patients include a dietitian and a "peer specialist," a community member with personal experience with mental health issues or chemical dependency. Additionally, the 70 percent of Health Connections patients who qualify to receive direct medical care or therapy in the home get simultaneous services from VNA Nazareth Home Care in Louisville, which is partly owned by CHI.

Bridges said the well-coordinated care inspires renewed confidence among people now able to better manage their medical needs and has also led a significant decline in depression among enrollees. (See report.)

To Jones and Bridges and members of the health care teams, the best indicators of success are the improved quality of life experienced by program graduates like Patricia Merriweather and Carrie Brown.

Simple pleasures
In the year before she enrolled in Health Connections, Merriweather, 66, of West Louisville, had complications of her chronic obstructive pulmonary disease that led to eight visits to Jewish Hospital's emergency room, four outpatient visits and five inpatient hospitalizations. Her disease management improved when she was in the program. After she was given an additional diagnosis of lung cancer, Health Connections extended her stay in the program to four months. In that pre-program year, self-consciousness over her oxygen needs and frequent shortness of breath had caused her to withdraw into isolation at home. Now, with support from the health care team and greater confidence in her physical abilities, she ventures out to community bingo games and family get-togethers.

Brown has a similar success story to tell. At age 82, with comorbidities of congestive heart failure and diabetes, she often ended up in the emergency room. Health Connections team members helped her to sort out the roles of her various specialists, something she had not completely understood, and taught her to use the "stoplight" tool to assess exacerbations of her symptoms and place calls to the correct health care provider. The team coached her on keeping track of her medications and medical appointments and registered her with Medicaid-funded transportation. By the time she graduated, Brown had renewed her social connections, resumed attending weekly church services and inviting family and friends for home-cooked meals. She continues to do well, according to her community health worker.

Jones says the "driving force" for the program has been its "great potential to improve the lives of vulnerable patients and to provide for them in the future in a more positive way. And, if we can begin to address needs sooner, hopefully we can keep patients healthier."

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