Innovative program bridges patients’ gaps in health care

August 26, 2013

WellSpan’s Bridges to Health is a cutting-edge program for “high utilizers,” people with more ED visits and hospitalizations than others with similar problems.

“These patients are consuming more health care resources than appear to be in their—or the community’s—best interest,” said Chris Echterling, M.D., the Bridges to Health medical director.
 
His team seeks out high utilizers, tries to learn the circumstances that have led to this situation and works with the patient to figure out a better care plan moving forward.

Determining the patient’s goals and how those goals can be addressed as opposed to seeing the patient as simply “non-compliant” is a foundational principle of the Bridges to Health approach.

“Our patients have legitimate medical problems, but it usually becomes pretty clear that other issues are complicating their ability to deal with those medical problems,” said Echterling, who is also the WellSpan Medical Group’s associate medical director for quality and innovation, and medical director of the Healthy York Network.

“Often there is a history of loss or trauma in their lives, which has made it difficult for them to build trusting relationships,” he explained.  “Sometimes their priority is not their diabetes, but other issues like the grandchild for whom they have sole responsibility.” 

High utilizers typically share a common thread: they’ve fallen into a health care gap.

“In almost every situation it seems that despite our best efforts, we as a health system have not communicated very clearly with the patient, or with one another,” Echterling said.

Bridges to Health spans those gaps.  Its physicians, nurses, and social workers do whatever necessary to restore effective care. 

They visit patients’ homes.  They solve transportation and insurance problems.  They sit in on specialist appointments, ensuring good communication. 

It’s slow, arduous work, but it can help interrupt the cycle of high utilization.

The team enrolled their first patient in September 2012.  Currently they have 40.  Most patients, since joining the program, have significantly reduced their ED visits and hospital stays.

In May 2013, Bridges to Health reached a pivotal milestone—its first patient transitioned back to his previous patient-centered medical home.  A patient named David, who spent nearly eight months in the program, successfully transitioned back to his primary care provider. 

The team helped him solve some personal problems that were creating barriers to his utilizing health care services effectively.  Now his chest pains and fainting spells are managed more effectively. 

“That represents our goal in this program,” Echterling said.  “We have two or three other people in the same position, and if all goes as planned, we should soon be able to transfer them back to their primary care physician within the next month or so.”