Earlier this year, Baylor Health Care System Foundation received a $6.9 million grant from the Deerbrook Charitable Trust. This significant grant will help Baylor Scott & White Health test a new model of care that aims to keep one of our most vulnerable groups of patients —older adults —out of hospitals by focusing on prevention and wellness. If proven successful, the model could be adopted by other health care systems across the country to improve patient outcomes while reducing health care costs, readmission rates and mortality rates.
The nation’s need for change in the health care model for older adults stems in large part from poor care coordination – especially as patients transition from one setting to another, such as from the hospital to their homes. Many of these patients have multiple chronic conditions and take numerous medications. Poorly coordinated care for these patients leads to poor outcomes, more hospitalizations and higher costs.
“As the first baby boomers begin turning 65 this year, there is an increased need to enhance care for the rapidly growing elderly population,” said Joel Allison, president and chief executive officer of Baylor Scott & White Health. “This grant will allow us to improve the health of this group of patients in their own communities and further our commitment to being a national leader in health care by focusing on high quality care, clinical excellence, innovation and population health strategies, while always staying focused on the patient.”
Filling the Gap
“Historically, to improve the coordination of care and access to care, we’ve always used advanced practice nurses,” said Mae Centeno, vice president for Chronic Care Continuum at Baylor. “While there were some savings, this is an unsustainable model because of the increasing numbers of older adults with health issues, increased health care costs and decreased Medicare reimbursements.”
This new model would help expand the capacity of primary-care practices for high-risk older adults in Baylor Scott & White-affiliated primary care practices in North Texas by adding clinical pharmacists, licensed social workers and community health workers, the newest players in health care.
Community health workers (CHWs) are laypeople in the community, often transitioning to second careers, who complete 160 hours of state-mandated training, plus additional training as needed; in this case, working with older adult patients.
“The strength of community health workers is that they’re non-clinical, and they have a strong connection to the communities they are serving,” Mae said. “They serve as a liaison between a health care practice and the patient.”
The CHWs will also receive training in educating patients and helping them navigate the health care system. “Because they are seen as a patient’s peer, they can speak and translate in a manner the patients will understand and not feel threatened. We can also impact a broader population,” adds Centeno.
Personal Care Based on Level of Risk
This newest project builds on momentum from an earlier project also funded by a grant from the Deerbrook Charitable Trust. Deerbrook has a strong interest in advancing care for the elderly. In 2011, the Trust initially approached the Baylor Health Care System Foundation with the seed of an idea and called upon them to strategically plan, develop and execute programs that advance the field of geriatric care.
The goal of the program was to reduce readmissions. To that end, the Transitional Care Team used a risk-stratification software tool that helped predict whether a patient would be readmitted. Patients were classified as low-, medium- or high-risk based on their likelihood of readmission.
“With this information, we were able to provide patients appropriate resources based on their risk,” Mae said. Low-risk patients were given an 800 number to call if they had questions about their care. The results of those questions were visible to the Transitional Care Team. When necessary, these patients would receive additional interventions. Medium-risk patients received the 800 number, plus phone calls from a nurse on the third, seventh and 21st days after discharge. High-risk patients received the medium-risk interventions, plus an in-home visit by a nurse practitioner 30 days after their discharge.
“We served more than 1,500 patients and reduced readmission rates by almost half,” Mae said. “If patients were readmitted, their expenses were lower, and we reduced mortality rates. Because of the pilot’s success, we are expanding this model to other hospitals within our system.”
Mae said this latest grant is inspiring because it builds on previous experience and allows Baylor Scott & White – North Texas to pilot a program that could improve patients’ lives outside the walls of the hospital setting.
“If we’re successful, we will provide better care for our patients and improve patient outcomes at a lower cost. And if we can do this, we’re impacting not just patients within our system but potentially patients and health care systems around the country.”
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* based on unaudited 2014 fiscal year statements
About Baylor Scott & White Health
As the largest not-for-profit health system in the state of Texas, Baylor Scott & White is empowering customers to live well by reimagining traditional healthcare — creating more convenient, personalized and informed experiences. It serves more than three million customers through 53 hospitals, including flagship academic medical centers in Dallas, Fort Worth and Temple; the Baylor Scott & White Research Institute; 1,300+ access points; 59,000+ team members; and its leading digital platform — MyBSWHealth. The system's award-winning employer solutions include Baylor Scott & White Health Plan, Baylor Scott & White Quality Alliance and Levanto — a company offering digitally enabled health products. Founded as a Christian ministry of healing more than a century ago, Baylor Scott & White's mission is to promote the health and well-being of all individuals, families and communities. For more information, visit: BSWHealth.com