Bridges to Learning

August 2015

Since 2012, the Bridges to Care program has helped ensure care coordination for Aurora’s most vulnerable populations. As the program faced the end of its grant funding this past June, program leaders assessed how to continue reducing high-cost emergency department utilization and connecting patients with the care they need. Here are some of the lessons, best practices, and opportunities that come as a result of Bridges to Care.  (Pictured L to R: Drs. Wiler, Misky, Capp)

1. Improving population health requires community collaboration. 

The program’s success is in large part due to medical and behavioral health providers as well as community and faith-based organizations working together to help at-risk patients navigate the health care system. 

“It’s been a wonderful opportunity for the School of Medicine to partner with the community in a collaborative way to think about population health,” said Jennifer Wiler​, MD, MBA, vice chair for the Department of Emergency Medicine.  

Roberta Capp​, MD, MHS, assistant professor of Emergency Medicine and Director of ED Care Transitions, said Bridges to Care is a great example of what can happen when communities pull together to improve population health. ​

“The community engagement that has essentially allowed us to effectively communicate and improve the lives of so many people is the by far the most rewarding aspect of the program,” she said.

 “Bridges to Care has given us an opportunity to expand our partnership with other groups in community,” said Dr. Wiler. “We’ve already started discussions with the mayor’s office in Aurora, the local judiciary system, Aurora Mental Health, EMS, and crisis centers.”

2. The Bridges to Care model works. 

According to an audit report prepared for MCPN, Bridges to Care reduced unnecessary health care utilization and increased patient access to primary care providers and insurance.

All participants demonstrated a statistically significant decrease in the average number of emergency department (ED) visits and hospital admissions after completing the Bridges to Care program. The most dramatic differences were seen in the mid- to high-utilizers (four or five+ ED visits in the six months prior to intervention). Their average emergency department visits were reduced to about three visits after graduating.

In addition, the report concluded that as of Dec. 31, 2014:

• 94 percent of participants had a primary care provider 60 days after enrollment.

• About one out of four patients who began the program as uninsured gained insurance upon graduation.

• The number of self-reported “healthy days” patients reported increased at the 60-day follow-up. 

The Bridges to Care model has also made a significant financial impact. Dr. Wiler recently presented data through March 2015 on 223 Bridges to Care patients. The chart on the left represents the actual number of patient ED visits and hospital admissions. The chart on the right represents the total professional and hospital charges six months prior to intervention and six months after.

3. The data will determine what’s essential. 

“The ability to use large scale data to objectively measure what works and what does not has been informative at translating the research and content expertise into policy related items,” said Dr. Capp. 

The essential components of the Bridges to Care program include care coordination across health care systems and community organizations, team integration, and health-coaching. 

Care coordination allows for proactive assessments, interventions, coaching, and support to assist in managing the individual patient’s healthcare needs. Embedding case managers and community health workers from MCPN into the emergency department at UCH allowed for efficient and timely intervention, particularly as it relates to Medicaid patients. And health-coaching, especially surrounding behavioral health issues, was shown to be crucial in contributing to the program’s success. 

“This program is being recognized as a national best practice in part because it offers patients an integrated mental health and physical health assessment,” said Dr. Wiler. “It’s a collaborative approach to healthcare delivery for the whole patient.”

Mental health is a component that’s often missing from care coordination. See how behavioral health​ helped Rebecca Yanes deal with the grief she experienced after amputation.

4. We need to stop blaming the patients. 

“It’s well-known that most high utilizers are sick. But it’s a myth that these people are of low acuity and that they are careless with their health care choices,” said Dr. Wiler. “What we’ve found is there are many barriers and drivers—everything from progressive illness to transportation to child care issues impacting a patient’s ability to seek appropriate care.” 

“It’s not their fault,” said UCH hospitalist Greg Misky​, MD. “The majority of these patients wouldn’t choose the emergency department if other points of access existed or they could navigate them more easily.”

Dr. Capp uses the example of a high emergency department utilizer who lives two blocks from UCH’s emergency department. “It may be that the first available appointment at a clinic that accepts Medicaid is in Arvada, almost three buses away from where this person lives,” said Dr. Capp. “What we have learned is that the label of a ‘difficult patient’ often means they have complex situations, and no one has been able to take the time to sit down and address their circumstances with them.” 

Dr. Capp explains that it’s understandable, given the constraints of our current system. “It’s time and resource intensive, and the health care system does not financially recognize this type of care coordination service.”

5. These lessons are only just the beginning. 

The team believes Bridges to Care is an example of doing patient-centered care the right way. That’s why the team is mining the Bridges to Care data to usher UCH into a new phase of improved care coordination. 

“The data we’re seeing has shown that the 90-day model wasn’t right for every patient,” said Dr. Wiler. “We’re looking at creating a more customized program. Some patients may need a 30-day program; others could need 120 days.”

They are also embarking on further research to identify other interventions that may help improve the health and care of the patients who were refractory to the program. 

The Bridges to Care program has also influenced other projects throughout the state. “Some of the connections I’ve made because of the program have led to other project collaborations in rural Colorado,” said Dr. Capp. “I have been able to inform and help with the dissemination and evaluation of other programs at the regional care collaborative organization level.”

Dr. Misky is interested in applying more of these lessons in inpatient care settings. “The same issues that exist in the emergency department exist—and are sometimes magnified—on inpatient,” he said. “We need to do a better job of listening to the patients’ stories, particularly as it relates to their reasons for coming back. The hospital doesn’t have to be, and can’t be, a silo of care.”

He also believes the Bridges to Care findings also have implications for medical student training. “As an educator, it’s made me think about how I communicate to students about patient stories. They’re balancing a lot, but need to understand that by listening, they’ll inevitably hear some of the barriers their patients have to receiving care,” he said. 

Impact to Providers

Bridges to Care has improved the lives of patients in Aurora who are receiving better care, and it’s also reducing costs for the system. But it’s also impacting providers. 

“At the end of the day, we go through years of education and hard work to make a difference not only in an individual’s life, but at a large scale, and this project has given us the opportunity,” said Dr. Capp. “Programs like Bridges to Care are giving us a glimpse into the future of medicine.”

Dr. Misky agrees. “It’s exciting. We’re learning that improving population health is about getting like-minded folks together and challenging the ineffective status quo as it relates to vulnerable and at-risk patients and their transitional care needs,” he said. “As providers, we need to embrace the role of effecting change when a system isn’t working. Bridges to Care is giving us solid data in support of making such changes.”​