As an organization, Parkview Medical Center in Pueblo, Colorado prides itself on its mission of delivering the highest possible quality care to its patients – and a core component of that mission is a community-oriented approach to tackling social determinants of health.
The impact that social determinants can have on the quality of a patient's care journey can't be overstated. These social factors – whether transportation issues, language barriers, educational disadvantages, food insecurity or low income – have a profound effect, not just on health, but on a person's ability to navigate the care system. Parkview knew that in order for the hospital to achieve certain quality benchmarks it had to reduce 911 calls and emergency department utilization especially. So in 2015 it turned to the community.
The key partnership that developed was one with the Pueblo Fire Department. Together, the two entities are at the forefront of an SDOH program called DOTS, which stands for "Directing Others to Services." Its focus is on transitions, and it helps guide people to the right resources, with a focus on frequent 911 callers and ED utilizers. The cornerstone of this approach is addressing patients' needs at home whenever possible as opposed to in costly emergency settings.
When the program was in its infancy, the hospital and fire department got together with a hospitalist group and community health center to set goals around care coordination and the transfer of relevant information to all providers, with the ultimate aim of reducing admissions. According to Kelea Nardini, Parkview's assistant vice president of quality and post-acute care, the organizations talked about getting information into one central database that everyone could access. The hospital and fire department were often tending to the same people, but couldn't interact with each other in real time.
"We would know, when we would meet, when these different organizations touched the same person, but we didn't know it in real time," said Nardini.
Having that real-time communication capability was essential, and so Parkview purchased software from Pieces Connect to get the job done. Predictive analytics and natural language processing pull relevant information from the electronic health record and share it with all parties. If a patient is visited inside their home, those tending to that patient then have most of the information they need to get them pointed in the right direction.
"We work with all the partners in the community to build a robust referral network, so they have all the resources they need for the patients they're serving in their area," said Lehanne Doyle, vice president of client success at Pieces.
A WELCOME ENTITY
Typically, it's the fire department that tends to patients inside their homes. What makes the department such a valuable partner is that they're already a known and welcome entity in the community.
"One thing that's a unique ability for the fire department is that people allow us into their homes," said Pueblo Fire Chief Barb Huber, who supervises the DOTS program. "They recognize us, we're a trusted part of the community, so when we say, 'We're here to help,' they let you in. That's a big part of getting people connected to the resources. That was probably the biggest piece we had to offer."
Importantly, the fire department lends a hand in both emergency and nonemergency situations. According to Kelly Firestone, the community risk reduction coordinator who deals directly with DOTS clients, there used to be a criteria of 10 or more 911 calls before a person was considered for the program, but that has since been nixed because of the program's ability to act as a preventative health service. DOTS connects people to relevant resources that address anything from food and transportation to mental health and general confusion with navigating the healthcare system.
"We don't just hand them a brochure with a bunch of numbers," said Firestone. "We make a call for them, and then they make some calls. We do whatever that person needs to get these resources into the home."
'BEING A HUMAN'
One anecdote in particular exemplifies the potential that DOTS has for patients.
A senior woman living in the Pueblo area lost her husband a number of years ago, and this husband left her a healthy chunk of money upon his death. Since he had a savings account, he didn't qualify for Medicaid, and for a long time, the woman would use the money she inherited to pay off his medical bills. The money was used solely for bills, leaving her with just social security as her income. Since the husband didn't qualify for Medicaid, she assumed she didn't either.
This was problematic, as she was in serious need of hearing aids.
"She was trying to get hearing aids, and she said she had Medicare only," said Firestone. "She's getting social security, and she's in a nice home, but basically she didn't have anything. She thought she didn't qualify for Medicaid because she was told she didn't qualify years ago. We revisited that, and lo and behold, she qualifies – very much so. Now she doesn't have to pay for medication and all this other stuff, and she can relax a little. She would still be paying for the stuff she doesn't have to pay for because she wouldn't get to be on Medicaid."
While this particular patient needed help signing up for Medicaid, others may need help getting an appointment with a primary care physician. Yet others may not be able to endure long wait times when put on hold by triage teams. Each visit is unique, and with DOTS, each visit is tracked, and a personal touch is given to each person who qualifies for the program.
One of the best parts, said Nardini, is that DOTS is essentially self-regulated.
"There are no regulations for this program," she said. "They get to do what they need to do for these patients, and no one tells them, 'Shame on you, you can't do that because it doesn't fit this rule or regulation.' And the program has decreased unnecessary ED utilization."
And how. To date, the program has reduced ED utilization by more than 40%. DOTS clients have reduced their 911 calls by 50% on average, but many have zero calls because they now have community resources they can contact at any time. And every ED visit that DOTS has prevented translates to at least $4,000 in savings for the hospital.
Nardini said Parkview is lucky in the sense that it's an independent hospital that only answers to its board of directors, which is partially composed of community members. But that doesn't mean larger health systems can't get in the game; they just need community buy-in and a means of communicating and sharing information.
Huber said that, for organizations looking to wade into the SDOH pool, it never hurts to dip one's toes in and test the water.
"Start small," she said. "If you call 911 10 times in a one-year period, that's where we started. Just find one person – it's really easy. It's not a big convoluted thing. If you find one person that could use some resources, just help that one person, and then move onto the next and move onto the next. It's just being a human to another human."