A crucial part of population health is keeping patients healthy outside the hospital. But certain patients, due to their surroundings or their illnesses, often bounce back to the emergency department or to an inpatient stay after discharge. To get a handle on their most challenging populations, three hospitals built programs that provide medical and social support to their communities.


Even the best hospital care, combined with thorough discharge instructions and a follow-up appointment, can still be undone by community-level factors like living alone, unemployment or limited access to care. When a patient returns in an ambulance two weeks later for reasons beyond the hospital’s control, it is penalized for not preventing that readmission. In fact, a Health Services Research study published in February concluded that community-level factors, rather than hospital performance, explained nearly 60 percent of variation in readmission rates.


As health systems assume accountability for people’s health status, however, addressing these factors must be added to existing responsibilities. This means that hospital boards and their leadership teams arrange for patients to be surrounded with the support they need to overcome serious physical, social and behavioral barriers to health once they’re outside the hospital’s protective bubble. It requires new partnerships with post-acute care providers, personal relationships with people in dire situations and a community presence for clinicians formerly confined to medical facilities.

A handful of organizations already identified basic strategies to stave off crowds of returning patients. One good example is at Cumberland-based Western Maryland Health System where readmissions have plummeted 46 percent in two years, largely because of an emphasis on community-level initiatives that, among other achievements, cut readmissions from skilled nursing facilities by 38 percent.

In Louisville, an initiative by KentuckyOne Health to fundamentally improve the lives of a small number of people repeatedly returning to its hospitals helped to drive a 25 percent drop in readmissions for that vulnerable population within a year, and a 50 percent reduction in overall admissions per patient. When people from that group were hospitalized, their stays were 66 percent shorter.

In Wichita, Kan., just 106 patients of Via Christi Health coping with end-stage lung disease had accounted for 812 hospital trips in a year, but an intensive program reduced by 80 percent the emergency department visits and inpatient admissions those patients logged in the ensuing year. A second program, to help struggling inpatients comply with follow-up care once discharged, enrolled 298 patients in the first year. Total ED and inpatient encounters dropped nearly 90 percent, from 742 in the 30 days prior to joining the program to 96 during the first 30 days of assistance by staffers in a special transitions clinic.

Traditional acute care services get better and better, but hospitals still have a serious gap to fill, says Jennifer Jackson, M.D., medical director of the Via Christi Transitions Clinic. “We do things well about 80 percent of the time, and so what’s left are these chronically ill, low-health-literacy populations that require a lot of resources and require thinking outside the box,” says Jackson. “We can patch them up here [in the hospital], but if we don’t affect their long-term environment, then it’s really not going to do much good because they’re just going to end up back in the ER in the next couple of weeks.”

Jennifer Rodgers, R.N., Via Christi’s assistant chief nursing officer, adds that it’s vital to “have a senior leadership team and a board that really see into the future and understand that we’ve got to look at new models of care and different ways of delivering care more than we ever have before.”

Pinpointing the Risk

Transitional care can be as simple as phone calls or text messages from nurses, or as intense as home visits accompanied by efforts to supply a patient with the financial support, social assistance, transportation access and nourishment necessary to stay on track and avoid relapses. These tactics work. Patients with complex chronic conditions who received such care in North Carolina, for example, were 20 percent less likely to be readmitted during the subsequent year than those receiving traditional care, according to a study in Health Affairs published in 2013 that analyzed a statewide Medicaid transitional program begun in 2008.

But a more focused study by the same authors in the March 2015 issue of Annals of Family Medicine found that most of those patients actually didn’t benefit from early follow-up — though a subset at highest risk of relapse benefited greatly. For boards looking to make the biggest impact on readmissions, concentrating efforts and resources on the sickest, most expensive individuals will yield the biggest bang for the buck.

KentuckyOne’s Health Connections Initiative was designed to provide a range of support for the most frequent users of hospital services in Louisville, says Alice Bridges, vice president for healthy communities. “With limited resources, it does make sense to focus on those vulnerable populations where you can make a significant difference.”

Mapping out the top 5 percent of hospital and ED users by location, the program leaders identified hot spots on the west and south sides of Louisville. “It was no surprise to us that communities that popped up in our analysis corresponded with areas that have low educational attainment, high mortality rate, high crime rate, food deserts — all of these social determinants that really do have such a strong relation to health outcomes,” Bridges says.

Western Maryland strove to create partnerships that make pre- and post-acute care the central focus of health care efforts, rather than the hospital and ED. It has forged or strengthened ties communitywide with physicians, urgent care centers, diagnostic centers, the county health department, and especially skilled nursing facilities, says Barry Ronan, president and CEO.

The moves were in response to an agreement five years ago with the Maryland Health Services Cost Review Commission, regulator of health care compensation from all payers in the state, to accept 100 percent fixed revenue for patient care. That created incentives to provide care economically and in the most appropriate location, Ronan says. Areawide cooperation was essential to get all sites of care “assisting us in addressing readmissions, admissions as well as overall utilization.”

Early on, the health system saw the need to improve the transfer between its hospital and local nursing homes. As admissions decrease, more acute care patients who formerly would be in hospital beds are in SNFs, says Nancy Adams, R.N., chief nursing officer. “They had a lot of work to do to ramp up their nursing staff to be able to manage that level of acuity.”

Via Christi’s program for end-stage lung disease took an aggressive approach to a serious problem of serial hospitalization. “These patients get sick and they get sick fast, and they need an alternative to calling 9-1-1 and being picked up by an ambulance and going to the emergency room,” says Jackson, medical director of the Transitions Clinic. The alternative is bringing the care to the patients, in the form of clinicians and social workers who are empowered to address the environmental factors that contribute to the patient’s health problems.

Hands-on Care

Transitional programs require highly focused and creative mobilization of care teams to keep up with volatile patient conditions and break down barriers to getting both clinical and community assistance with these patients’ many needs.

At KentuckyOne, for example, a registered nurse assesses a targeted patient, reconciles medications, sets goals and turns the patient over to a social worker to anticipate and address threats to health, says Beverly Beckman, project manager for its Health Connections Initiative. Problems might include not enough food in the house, no car to get to the doctor for follow-up, inability to use public transit because of health reasons or not enough money for medications.

The initiative helps patients to apply for food stamps, disability payments, drug-company subsidies and other services that patients either don’t know about or can’t figure out, says Karen Burnett, a team manager. If a patient can’t get to the doctor, medical practices with home visit capacity come to the patient. A dietitian meets patients at a grocery store to go over what to shop for on a prescribed diet. “It’s very difficult to eat healthfully if you don’t know what that means, and you don’t know how to buy the correct ingredients,” Burnett says.

Much of the patient assistance is delegated to a community health worker, who is not a medical professional, but rather a lay representative from the patient’s neighborhood with the trust and knowledge of available resources to get people what they need. “Having a helper is really crucial, particularly for these people,” Bridges says.

KentuckyOne can pursue clinical issues, but can’t curb readmissions and lower costs by itself, Bridges emphasizes. “No one entity can do it alone; the secret to measurable change is to work in collaboration with others,” she says. “But the hospital can be a powerful inflection point to connect with people when they’re in a vulnerable moment … and to get people the resources they need to continue to function successfully in the community and to prevent them from needing acute services in the long term.” The results speak for themselves: From the onset of the program in September to the end of February 2015, readmissions within 30 days among program enrollees dropped from 34 to 23 percent.

Readmission prevention at Via Christi begins before discharge, identifying people who don’t have primary care physicians, can’t get in to see their own doctors within several days of leaving the hospital, or have applied for care at a free clinic but may wait six weeks or more for the first appointment, says Rodgers. The Transitions Clinic makes sure these patients get their medications and see a physician within five days of discharge, then follow up by phone for 30 days or more to get them past the 30-day readmission window and do “whatever it takes to get them transitioned safely,” she says.

Outside the Hospital

Following patients to their post-discharge environment can reveal the need for further action. Whether it’s a post-acute facility or a residence, the situation might be ripe for a readmission.

In examining the roots of readmission decisions at area skilled nursing facilities, Western Maryland found that staff were not equipped with skills to identify, evaluate and communicate changes in resident status. Often a readmission would not have been necessary if a resident’s medical situation were managed earlier and more adeptly, says CEO Ronan.

It turned out that a readmission was a default action of sorts, whether or not the problem was serious enough. “As a rule, when they would call the medical director with some change in a resident’s condition, the response would typically be, ‘Send them to the emergency department.’ So, we have worked very hard to establish mechanisms so that does not have to be the first choice,” he says.

Various experts educated SNF staff on responses to situations involving particular diagnoses, with options to initiate before deciding to move a resident to the hospital. The health system also created an RN Transitionist Program to coordinate the patient’s discharge to a SNF. As part of the discharge plan, the transitionist works with patients and family members, reconciles medications and makes sure an understandable, viable care plan accompanies a patient to the SNF. The transitionist follows the patient there to bring staff up-to-date. The improvement has been dramatic, Ronan says.

That led to further focus on continued monitoring, through what’s been dubbed a “SNFist” role. Pronounced “sniffist” — combining the acronym for skilled nursing facilities and the hospitalist role in acute care settings — it involves a physician or nurse practitioner stationed every day at selected facilities. To test the model, Western Maryland has instituted SNFists at three facilities.

The health system contracts with an independent medical group which, in turn, contracts with the SNFs.

The Via Christi program for patients with lung disease, called Community Cares, deploys clinicians and social workers in a bustle of attention dedicated to preventing acute episodes. These patients usually are too ill to go to the doctor so they stay home and get sicker until they have to call 9-1-1. “Rather than expect this chronically ill, very debilitated patient population to make their way to us, we need to go to them,” says Robin Chadwick, senior director of operations. The caregivers come to know the patients well and use that familiarity to intervene in ways that can help get them out of a crisis.

Nurse practitioners under a physician’s supervision can write orders and treatment plans, says Chadwick. They set up a rescue plan including medications and breathing aids to use, and instruct when those may be needed. It puts control in the hands of the patient and family when symptoms arise.

Extreme Situations

The Community Cares program frequently finds living conditions that cause patients to keep coming back to the hospital time and again. Nearly all patients are on oxygen, and “it’s a chore for them to get somewhere,” dragging a tank wherever they go, Rodgers says. It may be challenging just to get up from the recliner, where they had probably been sleeping, to go to the bathroom or to the kitchen for coffee.

“To think about that population jumping into the car and going to the doctor’s office, that’s a really big deal,” she says. The ED, via ambulance, becomes their primary access to care, and that explains why ED utilization is so high.

One instance captures the urgency. A woman was referred to the Community Cares program, and “when the nurse practitioner went to see her, this patient was in such a state and so vulnerable that she was literally deciding, ‘Do I run my concentrator, so I can get oxygen or do I run the generator so that I can have heat?’ She couldn’t have both. And she didn’t have running water, and she really didn’t have any food in that camper.” Within 24 hours, a team went out to do an emergency placement in a facility with running water and food and a means to deliver oxygen. Those stories illustrate “how you keep people out of the hospital. Those are how you change lives,” Rodgers says.

Both the Community Cares and Transitions Clinic are replete with examples of why Via Christi patients don’t comply with treatment plans or make appointments. “We have people whose addresses are ‘under the street bridge’; we have patients who are living in hotels, who are living in drug houses,” Jackson says. The health system might not be able to change a person’s environment, but it can remove some barriers to care, she says.

Increasingly, the shift into the community will bolster a health system’s financial health as well. Whenever possible, KentuckyOne connects efforts to business objectives such as readmission rate, says Bridges. “That’s the right thing to do, and that’s where we can pull levers in terms of organizational resources to get some things done.” The Louisville network, she says, has made a significant investment in healthy communities, beginning with her position as the executive in charge of outward-facing initiatives. 

John Morrissey is a contributing writer to Trustee.