MAKING A DIFFERENCE
Maine Quality Counts
Community Care Teams
Every patient has a story. But not every patient has a health care provider to listen to her story and understand its significance to her unique treatment choices and needs.
Providers and policymakers know that a relatively small group of patients with complex or chronic conditions too often end up in the emergency department (ED) or in-patient hospital care. Many of these patients are admitted for multiple expensive hospitalizations that might have been prevented had health or life issues been addressed more proactively.
MeHAF grantee Maine Quality Counts created eight "Community Care Teams" (CCTs) to better address costly hospital and ED overuse. The CCTs, which are generally comprised of a nurse, a social worker and nurse-program manager, work with primary care practices that are part of the Maine Patient-Centered Medical Home Pilot. Patients at high risk for ED use and hospitalization are identified for CCT support through hospital usage data.
The CCT based at Androscoggin Home Care and Hospice uses a 'home health' approach to helping these vulnerable patients. Team members first establish a relationship with patients and work to reconnect them with a primary care provider. But the most important approach is a simple one. They take the time to listen.
Often the reason for a patient's over use of hospital or ED care is not a need for better medical or drug management, but is more basic. One elderly patient with several chronic conditions had a spike in emergency room visits after she started traveling to visit her ailing husband in a facility located far from their home. The patient's medical record didn't contain this critical information, which she incidentally mentioned to the CCT nurse when the nurse asked, "What would you most like to change about your life now?" Rather than talk about her own condition, the patient replied, "I'd like my husband to live closer." Listening to the patient's concerns led to changes in her husband's placement that improved the patient's quality of life and dramatically decreased her ED use.
Using techniques that shift the focus from "treating the diagnosis" to understanding all the elements of patients' lives and circumstancesthat can affect their health, the CCT can devise practical and creative solutions to help people "graduate" from CCT-management back to less intensive management by their primary care provider. In a modern twist on house calls, inexpensive visits with phone support and taking the time to listen all become powerful prevention tools that exponentially reduce hospital-related costs.