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Patients First with Seton Total Health Person-Centered Care

By on February 29, 2012 in Central Texas, Featured with 0 Comments

Total Health Partners launched in December. Its team is comprised of nine people – a physician, registered nurse, nurse practitioner, social worker and five health promoters. Photo: Seton Healthcare Family

by Health News Texas Staff

An auto accident last year left him homeless and unable to find work. He struggles with controlling his blood pressure, which often leaves him short of breath and with congestive heart failure. His medical care comes mostly from Austin emergency rooms. He’s assigned to a community health clinic, but it’s across town from where he stays, and his only transportation is a bicycle. To make things worse, his backpack with his blood pressure medication was recently stolen. The staff at Seton Total Health Partners helped him file a police report, obtain a new prescription and get it filled. Without their help, he likely would have soon found himself sick and back in the hospital.

That is just one example of the types of patients assisted by Seton Total Health Partners, a new program that targets patients with complex medical problems who have difficulty navigating the complexities of the health care system to obtain the medical care they need. As a result, they are frequent visitors to emergency departments or often admitted to hospitals to regain control of their health. The program is geared toward helping patients who are the highest utilizers of medical services (emergency room visits or in-patient hospital stays), who have unstable medical conditions or who lack the resources to pay for care and can benefit from the program’s assistance.

Dr. David Ramirez, medical director of Total Health Partners, said the reality is that a small percentage of medically complex patients account for a disproportionate share of the care given by health care providers. Photo: Seton Healthcare Family

Dr. David Ramirez, medical director of Total Health Partners, said the reality is that a small percentage of medically complex patients account for a disproportionate share of the care given by health care providers. The health care system isn’t working for these patients. Programs such as Total Health Partners can help improve the system for everyone by making it easier for people to navigate and obtain the care they need.

Helping Patients Find Long-Term Health Care Solutions

Total Health Partners is a team comprised of nine people – a physician, registered nurse, nurse practitioner, social worker and five health promoters. Patients come to the program primarily through referrals by hospital social workers, case managers, outpatient clinics in the community, ED staff, emergency medical services personnel and even self-referrals. Most patients will already have been in the Seton system and identified as frequent users of medical services for whatever reason.

For some, their stay in the program may be relatively short. For others, it may be for a longer period until the Total Health Partners staff can help them regain control over and better manage their health. The program is designed to help patients find long-term solutions for their medical care, such as a community clinic or primary care physician, instead of going to the hospital or emergency room.

Laura Rosales, a registered nurse and the program’s manager, said some patients may not be able to take care of themselves because they don’t have access to a physician or to transportation to obtain medication refills. That may be all the help they need. Other patients may use the program as their transitional medical team until they either can apply for disability benefits or find a permanent medical home, such as a primary care physician or another coordinator of their medical care.

“This program goes to the core of the Seton mission,” Laura said. “We have to do things differently. For those of us who have been in health care for a long time, we know that sending people to the hospital is not always the answer. One way to help people stay out of the hospital is to give them what they need in the community.”

Overcoming Barriers to Obtaining Medical Care

The program’s health promoters assist patients with accessing the resources they need to manage their medical care. Health promoters often go with patients to doctors’ appointments to serve as patient advocates, helping ask the right questions and cutting through the medical terms so that patients understand what the physician recommends. They also help patients overcome some of the barriers to obtaining medical care, such as identifying and collecting medical records, scheduling doctor’s appointments or obtaining prescriptions.

“I try to call patients every morning to see how they are doing,” health promoter Rico Lyons said. “By me doing that, it’s a preventative measure. It helps us head things off before anything happens. A lot of our patients are reluctant to call us because they don’t feel comfortable asking others for help. We want them to trust us and be able to ask for that help.”

Jennifer Fryer, a licensed clinical social worker with the program, says many of the program’s patients are busy dealing with basic survival issues during the day. Survival takes precedence over medical needs. For example, if the weather is supposed to turn cold one night and they don’t get in line early for the shelter, they will freeze. Those survival issues can cause them to miss doctors’ appointments or to not take appropriate care of their medical needs. Total Health Partners helps bridge that gap.

“They have a lot to do during the day just to get meals and to find a place to sleep,” she said. “We can help with the other barriers that come up with their health care.”

A Seton nurse practitioner and a health promotor meet with a patient in a program initially targeting patients at high risk for adverse health outcomes and particularly those with sickle-cell disease, skin ulcers or heart failure to learn more about these conditions. Photo: Seton Healthcare Family

Many of their patients lack regular Internet or phone access. In today’s world, that can make it difficult for them to obtain the medical care they need, obtain medical records or apply for assistance.

Dr. Ramirez said today’s health care system is difficult to navigate, especially for people lacking resources. Instead of being limited to the traditional doctor-patient model of providing care, Total Health Partners brings together patient, physician, nurse, nurse practitioner, social worker and health promoter to take a comprehensive look at all aspects of a patient’s life to identify the challenges that each person faces in obtaining the medical care they need. In doing so, the program hopes to provide patients with the tools needed to take care of themselves using community resources.

“We want to go beyond what has traditionally been done and do things that are in the patient’s best interests by looking at all aspects of their lives,” he said.

Accessing the Program

Even though the program is still new, it is already receiving four to five patient referrals a day. Once a referral is received, the staff reviews the patient’s hospital discharge summary and medical history. If possible, they may also talk with the referring team to learn more about the patient.

The program is initially targeting patients at high risk for adverse health outcomes and particularly those with sickle-cell disease, skin ulcers or heart failure to learn more about these conditions. Once the team has reviewed a patient’s medical history, someone from the program will meet with the patient to evaluate their medical and social needs and to see how they might benefit from the program.

However, Jennifer says, the patient has to be open to receiving help and to making changes to better care for their health. That’s quite a commitment because it means trusting someone else with personal matters. Too often, people find themselves in trouble, but either don’t feel comfortable asking for assistance or don’t know where to turn to find it.

Jennifer Fryer, a licensed clinical social worker with the program, says many of the program’s patients are busy dealing with basic survival issues during the day. Photo: Seton Healthcare Family

“A lot of people are in the position they are in because they have had some sort of catastrophic event in their lives – an illness, disease or car accident,” she said. “That can happen to anyone. We need to do a better job taking care of patients where they are in their lives, where they are in the system and where they are with having insurance or with not having insurance.”

Delivering the Right Care at the Right Time Makes a Difference

In the coming months, the Total Health Partners team will conduct outreach to other Seton hospitals, community clinics, medical care providers, emergency management services staff and local social services organizations. The outreach is to let others know about the program as well as to identify community resources available to program patients.

Ultimately, Total Health Partners helps patients who are ready and willing to take control of their medical care by linking them with community resources that they can use over the long-term to manage their medical issues. The program’s goal is to accommodate up to 1,000 patients a year, Dr. Ramirez says.

“Delivering the right care at the right time at the right place benefits everyone because it reduces unnecessary and avoidable utilization of services, allowing those resources to be used other places,” he said. “One of the nice things about improving the quality of care we deliver is that it is to everyone’s benefit. There is no conflict between quality of care and cost if the care is optimal.”


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