Overall, the medical center's Transition Support Program (TSP) boosted post-discharge appointment compliance among heart failure patients to 97%, lowered the 30-day readmission ratio to 0.76, and generated $13.4 million in contribution margin. With this success, Advocate has expanded the program to multiple hospitals in the system. Read about Advocate's unique take on patient navigation and how it addressed each of these goals at once.
What role do the volunteers play?
Advocate's TSP is comprised of volunteer navigators who help qualifying patients coordinate follow-up appointments, such as specialty and primary care visits and diagnostic tests. The volunteers round with the care teams for assigned patients, allowing the volunteers to collaborate closely with the service lines, care management, and community health teams and understand each patient's needs. The volunteers are also responsible for motivating the patient to complete his or her follow-up and helping the patient better understand his or her care.
Who are the volunteers?
Primarily, the volunteers are students pursuing an undergraduate or graduate degree who are required to complete a certain amount of volunteer hours in a hospital setting as part of their course work. Volunteers complete comprehensive training that includes simulation and career development. And due to its location and status as a large teaching hospital, Advocate Illinois Masonic Medical Center sees a wide variety of volunteers reflecting many diverse cultural and linguistic backgrounds.
Which patients does the program target?
Patients who enter the program have multiple non-medical risk factors in their patient profile. They tend to be patients who are at high-risk for readmission, patients without assigned primary care physicians, and patients without strong social networks that can ensure they attend follow-up appointments. The program also targets patients admitted for chronic diseases, such as heart failure and cancer. They have barriers to care, such as a lack of health literacy, insurance, or transportation, and may have limited English proficiency, food insecurity, and housing instability.
How can I implement this?
Advocate Illinois Masonic Medical Center makes this program work by partnering closely with local colleges and universities and pairing these highly skilled volunteers with an intuitive referral management software that eases the complexity of the referral process. Doing so reduces the training burden on the volunteer workforce and frees up time for them to see more patients. With this combination, the medical center deploys its patient navigators as drivers of quality metric improvement and as a mechanism to drive growth—a powerful combination of goals that any health system would do well to target.