Contributor: For Complex Cases, Continuity in Acute Care Is Necessary

Anyone who has worked in a hospital can relate to treating a subset of patients over and over again. Their cases are usually confounding, dense, and extend to matters beyond health care. You may emphasize how they need to follow up with a provider, an outpatient clinic, a specialist, or a case manager, but you’re unsure whether they can or will. And when they’re gone, you’re resigned to contributing another log to their electronic health record (EHR) and hoping the next provider to see them can make a breakthrough.

Unmet health-related social needs (HRSNs) are often the greatest factor for patients requiring frequent care in acute settings like hospitals and emergency departments (EDs). Consider patients who experience unstable housing or homelessness—a critical factor in complex care outcomes; when their housing isn’t secure, they are at higher risk of events that may warrant emergency care and hospital admission.

Jubril Oyeyemi, MD, FHELA | Image Credit: © Camden Coalition; Community Health Institute, Virtua Health; Cherry Hill Free Clinic

At a time when approximately one-third of Americans lack a primary care provider, the hospitalist has assumed that role for patients with complex care needs. But in today’s health care systems, patients with HRSNs who are initiating care through acute EDs or hospital settings are encountering unfamiliar faces each time. There is no shared history of care, no context for what this individual truly needs help with beyond what is shared in their EHR data, and therefore, there is little continuity to their complex care needs. The patients who often need the most from us are constantly starting over.

The result is harmful on multiple fronts. Patients with HRSNs feel discouraged from seeking follow-up care, where they have to readdress sensitive, stigmatizing social issues with another new provider. The opportunity for improvement or resolution of HRSNs is diminished when the continuum of care is this compromised. And today’s acute caregivers continue to experience burnout for many reasons, not the least of which is the missing sense of connection with individual patients and the fulfillment of bettering one’s life.

There are ways to foster continuity of care for patients with complex needs without overhauling entire systems or increasing caregivers' workload.

At Virtua Mount Holly Hospital in South New Jersey, we identified 22 high-risk patients with complex care needs based on their frequency of ED visits or hospital admissions. Each patient was assigned to a doctor who had familiarity with the individual’s case and expressed interest in treating them further. When the patients inevitably returned to the ED, the staff knew to deliberately assign them to one of their 2 designated doctors at admission, instead of the standard randomized assignment. The assigned care providers were also tasked with creating a shared care plan for the patient that addressed both health and related social needs.

We called this “the Golden Ticket program,” named after the yellow highlight in our EHR system flagging that patient; it made a significant difference in the outcomes of our cohort.

Consider “Ms. Williams,” a woman in her late 60s with a history of smoking that led to her developing chronic obstructive pulmonary disease (COPD). She required oxygen and was admitted to the hospital due to COPD exacerbations, on average, once every week. Ms. Williams was continually prescribed steroids to treat her exacerbations; by the time her dose tapered, her condition would flare up again, and she was back in the hospital. Over the course of 6 months, she was seen by at least 20 physicians.

The Golden Ticket program began connecting Ms. Williams to her 2 most familiar physicians. The trust between her and her care team grew, and her physicians discovered unmet social needs. Ms. Williams’ housing condition was poorer than we realized; her exacerbations were being triggered by mold in her home. We connected her with community-based organizations that could help address her housing needs. Her once-weekly hospital admissions became once-monthly admissions, and her health-related quality of life vastly improved even as her chronic condition progressed.

This is one anecdote, but the strategy is applicable to every hospital system. A team of 10 hospitalists will average about 20 patients each daily; in most US health systems, all 20 of those patients are randomly assigned. Some advanced programs assign hospitalists to designated floors on each rotation. Although this creates continuity for care team members as they all work together to facilitate throughput, a recurrent complex patient who is randomly assigned to a different floor does not experience that continuity of care.

Intentionally designating frequent patients to a familiar provider makes little difference to that system, yet can generate long-term benefits for patients and providers. All it takes is the support of administrators and commitment from care teams.

The Golden Ticket work provided amazing continuity of care within health systems, and the Camden Coalition’s Pledge to Connect program builds on that by establishing partnerships between health systems and behavioral health providers to ensure patients have continuity of care from the ED to community-based care.

Our early results from Pledge to Connect show remarkable engagement by providers across various health systems, as well as an increased likelihood of patients following through on their referrals to outpatient care compared with standard telephonic follow-up. Next, we are building connections across health systems to enhance the continuity of care throughout the entire South New Jersey region, known as Regional Triage.

Beyond the data and systemic successes, there is something inherently rewarding about providing continuity of care, whether it be done in a single hospital or across a state. This model offers an opportunity for burnt-out providers to experience more humanity in their practice. The “COPD exacerbation in room 3” becomes Ms. Williams from South Carolina, who loves indoor gardening and names her plants.

Comprehensive continuity of care may not be feasible in our emergency and hospital settings; however, for our recurring patients with HRSNs, this is the first step on the journey to wellness.