[MUSIC PLAYING]
NARRATOR: Alta Bates Summit Medical Center
in Oakland and Berkeley is located
in one of the most diverse areas in America
in terms of economic status, education, and race.
In 2012, the Medical Center played a key role
in convening the community integrated health care
partnership.
The partnership consists of clinics, our public hospital,
county health system, homeless and housing agencies,
mental health agencies, payers, and our county EMS.
STEPHANIE BROWN: The initial impetus for the partnership
was to improve the flow of patients
through the emergency department as well as
to improve care transitions.
We had much success with these programs,
and we saw a significant decrease
in emergency department length of stay.
We then saw that many of our complex care patients
were getting readmitted far too often to the hospital,
so we expanded our program to include inpatients.
And through our programs, we were
able to see a 25% reduction in the readmission rate.
RONN BERROL: So these partnerships
with these community clinics and our other local emergency
departments have been critical in understanding why someone's
coming to our emergency room, why they're not
going to our clinics.
Traditionally, we didn't share information,
and we found out that sharing information actually
is a very powerful thing.
We can provide better health care.
And by talking to these community clinics
that we barely knew the phone numbers to before,
let alone had the correct address--
but now our case managers are talking to their case managers.
Our doctors can send a message electronically to them.
MANJULA GUNAWARDANE: Many of these patients
are both inpatient and ED high utilizers.
And it really gave us perspective
on what's happening in the community, the resources that
are out there, and how disintegrated care was
beyond our walls.
And it's been critical in trying to understand where
these patients are coming from, what
their needs are beyond what we know when they're here
in the hospital.
TRACY SCHRIDER: Our greatest teachers
are our patients, particularly those with high utilization.
DREMAINE: I think they all should have that communication
regardless of what hospital you were from, regardless of what
insurance company you're from.
Everybody should coordinate.
BARBARA GOLDSTEIN: LifeLong's care transitions program
is a very close collaboration with Alta Bates and Summit
where we identify our patients who
have been using either the hospital emergency
department or our inpatient at the a hospital
and we help to create the bridge for that patient
back into community services.
On a daily basis, we're talking to the discharge planners
and the social workers at the hospital
to identify who the patients, what their needs are.
And we can put notes in our medical record
to let our doctors and nurses know
that this person has been in the hospital, what their follow up
needs are, and what they should be paying attention
to when the person does come in for their appointment.
NARRATOR: We develop our shared care plans
with our partners for our patients with high utilization.
STEPHANIE BROWN: The partnership is data driven,
so when we look at the numbers, we're
really able to drill down exactly where our resources are
most needed.
For example, with our care transition nurse program,
we're able to see exactly how many patients were contacted
by the nurse for follow up care at a community health center,
how many kept those appointments,
and how many appointments were missed.
Those numbers drive our programs,
because we're able to target our resources more effectively.
NARRATOR: Partnership programs also
include clinic care transition nurses, urgent care,
a new clinic for high risk patients, our health equity
project, chronic disease resources, and closer
collaboration with mental health,
substance use, and housing agencies.
Many of our programs are funded through community benefit
and philanthropy.
ELSIE KUSEL: Our role is to provide situational awareness
to our partner hospitals about the high utilizers of the 911
system.
The partnership has made changes in taking
better care of these patients because there's now
a coordinated effort and sort of a single mission in mind.
JASON REINKING: We coordinate care
around some of the homeless patients that
have been using the emergency room
for their medical services.
The system of notification is critical for us
to be aware that they've used the emergency
room for one reason or another.
And then we can be focused to actually from a referral
perspective follow them up and sort out
whatever issue is going on at that time that caused
the emergency room visit.
NARRATOR: The partnership has had significant impact
on our patients, our partners, and our medical center.
MANJULA GUNAWARDANE: You feel like you're
supported once you discharge these patients because there
is a clear handoff to someone who's really
going to pick up that patient.
STEPHANIE BROWN: I feel better as a doctor knowing we
have all of these important relationships.
RONN BERROL: We're now all talking to one another,
and how we develop those lines of communication was the key
and I think is the key to anyone else who's trying
to replicate some of this.