Care Transformation Center Blog

How Mercy Health overhauled its approach to care transitions—and cut ED visits by 30%

by Rebecca Tyrrell, MS and Darby Sullivan

Up to 90% of a patient's health status can be attributed to non-clinical factors such as employment status, social integration, and access to safe housing and healthy food. However, typical care transitions programs often fail to identify these types of challenges, which can be particularly problematic for complex, fragile patients.

Mercy Health System, a three-hospital, 566-bed community teaching health system in Southeastern Pennsylvania, tackles this challenge in an innovative way: Their population health leaders developed a multidisciplinary care transition support program consisting of a licensed social worker and a community health worker (CHW) to provide supplemental social services to patients with complex needs.

Social services team provides wraparound care transition support to supplement clinical care

Mercy provides traditional clinical care transition support to high-risk patients. Nurses located in Mercy's corporate office provide telephonic care management services to address these patients' clinical needs and refer them for ongoing care management support in the primary care setting if needed.

The social services dyad, made up of the social worker and the CHW, complements the clinical care. In order to provide holistic support, high-risk patients with complex clinical and social needs are referred to a social worker for supplemental psychosocial assistance. The social worker, who splits time between primary care practices and the hospital in order to coordinate cross-continuum transitions, provides wraparound support including strengths-based counseling, community resource referrals, and legal services.

The social worker then triages the most complex patients to the community health worker, who provides additional in-person and telephonic support. This includes at-home visits, safety assessments, medication reconciliation, food insecurity assessments, and home cleaning services.

Once the dyad has taken on a patient's case, they collaborate with the clinical care management team to ensure that patient's psychosocial challenges don't affect the outcome of the care plan.

Community health worker critical to providing sustainable, effective community support

The CHWs contribute the dyad program's effectiveness by providing non-intimidating, culturally appropriate, and cost-efficient care to vulnerable patients.

At Mercy, the CHW role is very structured: CHWs go through a six-to-seven-week extensive training program before taking on a caseload of 25-30 patients per week. Patients work with community health workers for one to six weeks, depending on the patient's needs, before transitioning to solely primary care.

Mercy's patient-centered care transition social support is popular among high-risk patients because they obtain much-needed and otherwise inaccessible care. In addition, the program reduces fragmentation across settings by facilitating warm handoffs in order to provide sustainable, ongoing care. These social support offerings have resulted in a 31.25% reduction in ED visits.



8 steps for deploying clinical pharmacists in ambulatory care

Clinical pharmacists are uniquely skilled at identifying and correcting medication issues. That's why many health systems are deploying pharmacists in ambulatory care settings.

Check out our infographic to learn eight steps for how to deploy clinical pharmacists in outpatient clinics.

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