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Adirondack Health Institute is an independent, non-profit organization supporting hospitals, physician practices, behavioral health providers, community-based organizations, patients and others in our region to transform health care and improve population health.

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NEWS & EVENTS

What is Happening at Adirondack Health Institute

AHI EVENTS

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AHI NEWS

Alice Hyde Partners with Community Connections to Address Unmet Social Needs

Tracy Lauzon is a community navigator employed by Community Connections of Franklin County. You won’t often find her at the Community Connections office, though. She is based full-time at The University of Vermont Health Network – Alice Hyde Medical Center in Malone, New York. Both organizations welcome Tracy onto their team as a bridge between medical and social services.

When Tracy began working as a navigator in the Alice Hyde emergency department (ED) in October 2017, 179 people were identified as “multi-visit patients (MVPs)” who presented at the emergency department four or more times over twelve months. One year later, fewer than 25 individuals meet the criteria of a multi-visit patient. Additionally, the original cohort of 179 has reduced their cumulative ED visits by 42 percent.

Patients meet Tracy or her colleague, Tiffany Hohol, after they have received medical services in the ED. Together, they discuss underlying non-medical factors that may have led to the patient coming to the emergency department or may contribute to future visits.

Do they have a primary care doctor?

Is their food supply adequate?

Do they have health insurance?

Do they have a safe place to sleep?

After uncovering concerns, Tracy and Tiffany pull in their colleagues at Community Connections to address these social determinants of health that contribute to the individual’s frequent use of the ED.

Just being present and asking if they need help can be a huge comfort to patients, Tracy says. “Everyone knows me and my family. The first thing I usually hear is, ‘How are your parents doing?’ I’m a familiar face.” After catching up, Tracy then asks direct questions to gauge the overall state of health for the patient. She inquires about potential concerns including their ability to pay their heating bill, insurance status, general needs for help around the house and their overall well-being, among others.

Patients who have insurance, but are not connected to primary care represent the greatest number of referrals, according to Tracy. One man, in particular, stands out to her. He used to present to the emergency department frequently complaining of back pain. When she asked the man why he hadn’t seen a primary care provider about the concern, he admitted it had not occurred to him this was a primary care issue. With the help of Community Connections, he is now connected to a practice and Tracy has not seen him in the emergency department in several months.

Months of planning between Alice Hyde and Community Connections reinforced the medical center’s dedication to identifying social determinants of health. What they found, however, was the task often landed on the shoulders of the nursing staff: men and women who had been trained to expertly handle critical medical situations, not to maintain expertise in the community’s social service network. But, that is exactly what the team at Community
Connections have been trained to do.

By inviting Community Connections into their emergency department, Alice Hyde has empowered their team to work at the top of their licenses as medical professionals.

Debbie Beach, RN nurse manager in the emergency department at Alice Hyde, has seen a weight lifted from her staff since the partnership began last year. Before Tracy and Tiffany were onsite, Debbie explains, “It could get complicated and time-consuming very quickly. We reach out to discharge planners and case coordinators to get as many services as possible in place, but it’s a lot of phone calls back and forth. Even just to find someone a ride home is difficult.”

Now, Tracy and Tiffany and just a few doors down to address the patient’s non-medical needs.

“Partnerships like the one we have with Community Connections can help us make a meaningful difference in the lives of the people who come to us for care,” explained Alice Hyde President Michelle LeBeau. “Having Tracy and Tiffany on site allows the skilled medical team to do what they do best – address the medical needs of our patients – and offers easy access to professionals who can help support them with other needs. It’s a wonderful dynamic for our patients and our community.”

The smoother connection to social services has not been limited to the 3:00 – 11:00 shift when a navigator is on-site, either. Since partnering with Community Connections, Debbie explains, the emergency department team is now more aware of the services available to their patients. Staff used to commonly feel overwhelmed thinking “What can I do for this person?” or “Where can they go?” The situation was stressful, Debbie admits, as there were other patients waiting who also needed their attention. But, since partnering with Community Connections, they know who to call for help.

Community Connections is also guiding patients after they leave the hospital. A navigator will follow up with a patient one day, three days and one week after initial contact to ensure patients are successfully connected to primary care.

Lee Rivers, executive director of Community Connections, sees consistent follow-up as a key component of the program. “When we call to check on the person within 24 hours, it gives them a chance to tell us about any difficulties they’re experiencing. And, it gives our staff a chance to ask, ‘Have you made an appointment with primary care yet?’” After all, Lee explains, “We all can use reminders.”

And, Community Connections isn’t doing this alone. They partner with other community-based organizations in the area and help streamline communication between the CBOs and the medical community. With the help of Community Connections, medical providers are receiving more efficient and comprehensive feedback on the progression of care to address the unmet social needs that may have been identified at Alice Hyde.

The partnership has already realized a $375,000 reduction in emergency health care costs over a 12-month period with an investment of barely 5 percent. It’s $375,000 that can be shifted to community-based care, prevention and wellness. The partners continue to collect data that reinforces the positive trend to be able to clearly demonstrate the efficacy of the program to managed care organizations and other payers in the future.

Can we help relieve your team of the stress, time and cost of addressing social determinants in your office or hospital?

ADK Wellness Connections, sponsored by AHI, helps connect the medical community to organizations like Community Connections that can relieve the burden providers and their staff feels when presented with challenging social needs.

To find community-based organizations in your area that can help address your challenges to delivering the quality of care you pride yourself on, contact [email protected].

Bridging the Relatability Gap Between Doctor and Patient

People gravitate toward the familiar. It’s human nature.

Clans, cliques, social circles…no matter what we call them, self-identified groups give their members a sense of comfort. It’s a comfort that their cohort relates to their struggles and successes without judgment.

But, familiarity can also draw emphasis on who is not like us…who would never understand us…who we don’t fully trust.

For example, think of an individual struggling with mental illness and addictions who has isolated family, friends and potential employers and finds himself unable to afford heating fuel for his home in Plattsburgh. With very rare exceptions, he will see nothing relatable in the physician treating his most recent COPD complication.

Physicians and the medical community experience these seemingly insurmountable experiential gaps on a daily basis. The lack of relatability that could only come from common lived experience, leaves the medical community vulnerable to many challenges in providing the best care possible, including:

● Half-truth responses to critical questions about the patient’s history;
● Missed appointments;
● A limited view of what factors in the homelife contribute to the patient’s presenting condition and overall wellness;
● Lack of confidence that the patient understands crucial care instruction;
● Unreliable compliance with the prescribed medication regimen;
● And dozens more.

This gap, however, is not insurmountable. Community-based organizations who enjoy deeply-rooted trust from the populations they serve, earned over decades or more of shared experiences, regularly act as bridges between physicians and patients.

Professional support with lived experience

The team at National Alliance on Mental Illness (NAMI) Champlain Valley is one of those bridges. NAMI identifies as a peer-support organization, one where all staff members self-identify as having a personal behavioral health history.

“Isolation is a big issue when talking about mental illness,” explains Carrie Lavasseur, outreach coordinator at NAMI. She immediately thinks of Jim – a client who used to regularly visit the emergency department with complaints of chest pain. He had no connection to primary care because he had missed so many appointments with his former provider. He had never before met with a behavioral health counselor.

After Carrie received a call from the social worker at The University of Vermont Health Network – Champlain Valley Physicians Hospital (CVPH) that Jim had been to the emergency department again, and had still no presenting medical cause, Carrie went to meet with him. Jim told Carrie about his anxiety and how he frequently feared he was experiencing a heart attack. “I could tell him, ‘I’ve had a heart attack, and I’ve had an anxiety attack, too. This is how they feel different,’” Carrie says.

Although Jim has a supportive wife who regularly pushed him to socialize and get out of the house more, Carrie explains, Jim resisted the encouragement on the grounds that his wife didn’t understand what he was going through. Carrie understands.

Jim now has regular visits with a new primary care provider – someone Carrie found closer to his home. He is also seeing a behavioral health counselor.

Prior to his appointments, Carrie helped Jim identify what he was feeling, and how to talk about it with the doctor. She helped him understand questions he may be asked, and why they were important. As an individual, Carrie saw the situation from Jim’s point of view. As an experienced professional who has partnered with the medical community for years, she also could see the situation from the provider’s point of view. She bridged the gap.

Beyond finding solutions to his medical needs, Carrie introduced Jim to the Impeerium Peer Network, where he could be surrounded by individuals in similar circumstances. He took an art class, attended social gatherings and now maintains friendships with several of the men and women at Impeerium.

Jim has found his tribe. He has people to talk to when he’s struggling. People who have been there. People who won’t judge.

Providers can’t provide everything

Brenda Stiles, Director of Quality and Care management at Adirondacks ACO and for CVPH’s care management team, describes a peer support program as, “Been there, done that.” This is the unique value NAMI brings to her patients. With certain populations, Brenda describes, “NAMI are the only ones who can engage and keep people engaged. They can self-identify and work with people in a way that we usually just can’t.”

According to Amanda Bulris-Allen, executive director of NAMI Champlain Valley, working with people can mean anything from accompanying a client to a medical appointment; assisting with medication management; locating an individual with no permanent address to help conduct hospital discharge instructions; and much more. It has even been as extreme as bringing heating fuel to a client and filling his tank for the winter – a client who had recently presented at the emergency department with symptoms of hypothermia.

“We’re not going to say ‘Sorry, that’s not my job,’” Amanda says. “We’re solutions-focused.”

Peer-support is a major component of both CVPH’s and the ACO’s strategy to reduce potentially-preventable admissions to the hospital – a strategy that is showing positive results. Continuing efforts that began in the 2016 DSRIP MAX series (Medicaid Accelerated Exchange) with AHI; partners in the region, including Adirondacks ACO, CVPH, and NAMI, have identified the patients who visit the emergency department most frequently and made deliberate outreach to address their medical as well as unmet social needs.

Most recently, the partners have been able to reduce the average number of emergency department visits among the highest-utilizing patients (29 individuals) from almost 8 across a 3-month period, to 4.5.

“The true essence of the work focused on the engagement of patients where they are at and gaining insight and a true understanding of the barriers and problems they are facing on a daily basis,” Brenda says. “NAMI has a long history of providing peer support services with positive outcomes in our community. Our organization does not possess the expertise that NAMI has.”

According to Brenda, the only way to improve the quality of care delivered to patients, to relieve the medical community of the common barriers in providing comprehensive care to the people who need it most, and to engage patients in their own health is through partnerships between the medical and social services communities. “The need for our community-based organizations to support the work we do is vital for our patients and community,” she declares.

ADK Wellness Connections, sponsored by AHI helps connect the medical community to organizations that will help them fully care for their patients. Organizations that can ensure medication instructions are understood and followed…organizations that deliver medically-appropriate diets to those in need…organizations that bridge the gap between provider and patient.

To find community-based organizations in your area that can help address your challenges to delivering the quality of care you pride yourself on, contact [email protected].

Mental Health Association in Essex County Launches Promising Crisis Prevention/Emergency Room Diversion Initiative

A new crisis prevention/emergency room diversion initiative recently implemented by the Mental Health Association in Essex County has shown early promise. Shelby Davis, Mobile Crisis Prevention Coordinator, has stepped in to help the organization’s care management team, diligently working with people identified as emergency room high-utilizers to prevent unnecessary visits and improve outcomes.

According to Marisa Gaddor, the organization’s Chief Care Coordinator, the team accesses client records daily. Gaddor explained, “I log into PSYCKES (Psychiatric Services and Clinical Knowledge Enhancement System) to pull up indicators and look at progress reports, narrowing my search to clients who have been flagged. We investigate emergency department visits to see what happened. What triggered the visit? Was it a legitimate visit?” Once Gaddor has a better handle on each situation, she forwards the information to Davis who then sends an introductory letter to the client and calls to set up an initial in-person meeting. “She figures out what happened. Is there anything missing? Is this a situation that keeps repeating itself?” said Gaddor. Once the picture becomes clearer, Davis then shares information with all involved providers, the client, and family members, if appropriate, so everyone is on the same page.

“We look at things like the (client’s) medication management plan, current diagnosis, safety screenings, and more, so we can come up with a more holistic care approach. At the end of the day, we’re trying to coordinate the work of our care managers and ER staff, sharing information and presenting data that we hope is useful,” said Gaddor.

“Shelby is also a 9-1-1 dispatcher and an EMT, so she’s linked everywhere,” stated Gaddor. “What she’s accomplished so far with these clients is very impressive. She’s really hustling. We are very excited to see how her hard work will impact future outcomes.”

For more information on this initiative, contact Gaddor at [email protected], or Davis at [email protected].

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