To reduce ED visits and hospitalizations, University of California, San Francisco (UCSF) adapted the evidence-based Geriatric Resources for the Assessment and Care of Elders (GRACE) model. Called "Care Support," UCSF's program uses a social worker and nurse practitioner dyad to co-manage patients' spectrum of physical and mental health needs through post-discharge home visits.
UCSF's return on their investment was significant—their program reduced median ED visits for 152 high-risk patients by 5.5 and 33% more patients reported positive health, according to their pre-/post-intervention evaluation. Here are three simple steps central to the dyad's success.
1. The Care Support program targets patients with high utilization, after receiving PCP approval
Eligibility is based on patients' utilization history (i.e., minimum of three ED visits or two hospitalizations in the previous six months). Prior to outreach, the Care Support team requests PCP approval. If the PCP agrees that the patient is appropriate for the program, the dyad contacts the patient via phone.
In addition to the phone call, the team sends a letter and "facecard" featuring a photo of the Care Support team. To increase the likelihood patients open it, the envelope is hand-stamped (rather than using bulk mailing stamps) and the enclosed letter is signed by a member of the Care Support team. The nurse practitioner and social worker (NP-SW) dyad calls new patients up to three times before moving on.
2. An in-home assessment kicks off evidence-based care protocols
The NP-SW dyad performs a comprehensive, in-home evaluation of patients' medical and psychosocial needs. Observing patients in their own environment provides the team with insight into the social context of their day-to-day needs.
Their comprehensive assessments includes fall risk, housing status, depressive symptoms, and dependency in activities of daily living. The dyad also collaborates with patients to determine their personal goals to inform care planning.
3. Dyad holds weekly case conferences with interdisciplinary team to develop personalized care plan and discuss ongoing management through graduation
Embedded in the primary care setting, the dyad leads weekly, two-hour case conferences to develop a care plan based on specialist input (e.g., geriatrician, pharmacist, and palliative care specialist) and standardized protocols.
The most commonly used protocols include self-management, social service coordination, and advance care planning. Whenever a patient is discussed during a case conference, a summary note is routed to the PCP on the EHR.
How you can best provide active care transition management
Like with UCSF's model, successful population health management means not forgetting to assess patients' psychosocial barriers in tandem with clinical indicators of condition control. From there, you have the information you need to provide active transition management to the right specialized care team to drive longitudinal coordination post-discharge.
See our Population Health Job Description Library
Download a variety of population health-related job descriptions in the medical home, integrated pharmacy, care management, and leadership arenas.