COA, Crossroad partnership focuses on care coordination for most frail patients

Tuesday, April 30, 2013

COA care manager Nancy Dombek and Crossroad Clinical Coordinator Kyle Vath outside the health center`s Liberty Street location

Earlier this year, long-time Council on Aging (COA) care manager, Nancy Dombek, set up an office at Crossroad Health Center on Liberty Street in downtown Cincinnati. Nancy is there to fill an important gap in health care delivery for the clinic`s older patients: care coordination.

"For these patients, there is a gap from the doctor`s office to their home," Nancy said. "I fill that gap, making sure patients understand and can carry out their treatment orders, including their medications, and I also connect them to community resources and in-home care services."

Nancy`s work is part of a care coordination pilot project developed by Council on Aging and Crossroad to test a new model of care management, one in which health care and long-term care services are coordinated out of the physician`s office. Nancy is currently working with 22 older patients at the center, who are all COA home-care clients. In addition to coaching, Nancy visits patients in their homes, coaches them on managing chronic diseases and attends their primary care appointments.

Crossroad Health Center, a non-profit primary care health center, was a natural fit for the pilot because it offers services based on the Patient Centered Medical Home (PCMH) model. According to the National Committee for Quality Assurance, a PCMH is a model of care that strengthens the physician-patient relationship by replacing episodic care with coordinated care. Each patient has an ongoing relationship with a personal physician who leads a team at a single location that takes collective responsibility for patient care, providing for the patient`s health care needs and arranging for care with other providers.

According to Crossroad`s Clinical Coordinator, Kyle Vath, RN, there are three key benefits of the PCMH model and care coordination programs like the one underway at Crossroad: improved population health, a better patient care experience, and a decrease in the cost of health care.

An early success story for the pilot involved a patient who was notorious for missing her appointments. Nancy was so determined to get the patient to the center that she scheduled the appointment herself, wrote the appointment on the patient`s calendar, and made repeated calls to the patient to remind her of the appointment. When the appointment date arrived, so did the patient.

The patient was surprised at Nancy`s level of involvement. She told Nancy, "no one has ever been there for me." Nancy arranged additional services for the patient, including Meals on Wheels and transportation to a follow-up appointment with a specialist.

The pilot has several measureable outcomes, including lower ER visits, nursing home admissions and hospitalizations among patients; a reduction in medication discrepancies; and an increase in the patient contacts with their primary care physicians. Additionally, the University of Cincinnati is seeking a grant from the National Institute on Aging to conduct research and evaluate the pilot project.

"This program works and is needed for this population," Nancy said. "They need that warm hand-off from the doctor to a care coordinator, and I have the doctor`s ear when I voice the needs and concerns of the patient. It is a great circle of care that works."

Kyle says having Nancy on site has already made an impact. "There is a better understanding of which patients we should refer to COA programs and services," Kyle said. "When both organizations` main objective is about the care of the patient, they make great partners."