Health disparities disproportionally drive ED visits and readmissions and can lead to high financial penalties for organizations.
Vulnerable populations, such as seniors or uninsured individuals, are particularly likely to find themselves back in the hospital: They may lack the resources to access care until their need is critical—at which point readmissions are more likely and care is more costly.
That's why Massachusetts General Hospital leaders hired a Community Resource Specialist (CRS), who has addressed the non-clinical needs of vulnerable patients by using several strategies, such as helping patients find housing or connecting them to legal assistance.
Mass General's CRS connects patients to care
Mass General's experience shows how important it is to pay close attention to the unique needs of your patients and offer support when they need it.
Here are three big takeaways for improving vulnerable populations' access to care:
1. Leverage volunteers to serve as a companion. To cite one example, Mass General's CRS noticed that a senior patient was showing up for specialist appointments, but leaving without being seen. The CRS determined that while waiting, the patient grew anxious about being in a hospital. The CRS then scheduled a volunteer to meet and wait with the patient for appointments, which proved successful: The patient made it to the remaining appointments.
Benchmark your patient access performance
2. Maintain a database of high-need services. To save time, the CRS and Mass General maintained and utilized a database of community resources available to patients. For example, the CRS kept track of medical device suppliers, transportation services, and food programs, such as Meals on Wheels. Most importantly, the CRS followed up with patient requests to ensure that they received the requested services.
3. Prioritize your efforts. You can't solve every problem—but you can figure out who needs your help the most. Mass General's CRS used an IT system that displayed individual schedules for each member of the care team. The CRS prioritized tasks by time sensitivity and flagged high-priority requests for same-day completion.
By employing a CRS, Mass General facilitated patient care early on in the continuum, which led to numerous benefits.
Cost savings and reduced ED visits. After hiring a CRS, Mass General reduced ED visits by 13%. Combined with a decline in unnecessary hospitalizations, Mass General experienced 7% annual net savings on enrolled patients and generated $2.65 in savings for every dollar spent. For institutions interested in reducing readmission penalties, a CRS could prove invaluable.
Improved operational efficiency. Mass General's CRS improved staff efficiency by increasing patient adherence to care plans and reducing absenteeism. This avoided treatment delays and prevented inefficient use of hospital resources. Similarly, a CRS can help institutions enable top-of-license clinical practice for care teams.
Better care for the patient. Mass General's CRS improved the health literacy of patients, ensuring that patients were aware of and able to attend important follow-up dates, and that they received necessary medical equipment and social services. A CRS can thus help organizations optimize patient management while improving quality outcomes.
Learn how to advance health equity
Check out our webconference recording that highlights the importance of prioritizing health care disparities and outlines the primary methods, key stakeholders, and critical tools for identifying your community's most pressing needs.