Accountable Community of Health
Background & Goal
The fee-for-service model of health care in the United States has created silos which cause medical errors, wastes resources, and duplicates efforts. With the transformation away from family physicians to specialists and hospitalists, patients often have 3 to 4 providers involved in their care. To address these issues, Billie Lynn Allard, MS, RN, led a nursing team at Southwestern Vermont Health Care in the development of a Transitional Care Nursing (TCN) program which utilized acute care clinical nurse specialists to facilitate care across the continuum for high-risk, high-cost patients. Following the implementation of the initial TCN, it became evident that a broader approach was necessary to truly impact the health of the community. What evolved is the creation of an Accountable Community of Health which employs multiple community sectors, reduces duplication in services, and shifts acute care resources across the community as part of an integrated care delivery system free to patients.
The Accountable Community of Health model is a multifaceted care delivery system integrated into a broad spectrum of community programs designed to address the root causes impacting health and obtain optimal patient outcomes. A summary of these programs is set forth below:
- Transitional Care Nursing, in partnership with primary care providers identifies high risk patients with chronic disease, providing navigation, education on symptom identification and medication adherence while identifying gaps in care coordination.
- The Community Care Team consists of community partners who craft interdisciplinary shared care plans and facilitate collaborative care coordination for patients with substance use and mental health issues.
- Interventions to Reduce Acute Care Transfers (INTERACT™) empowers nursing assistants to utilize evidence based protocols to promptly identify changes in condition decreasing transfers to hospital
- Diabetes Care and Prevention is provided by Certified Diabetes Nurse Educators embedded in primary care offices, hospitals and skilled nursing facilities.
- Integrated Social Work gives a warm hand off of patients discharged from the hospital to Transitional Care Social Workers who assist patients to follow through with post discharge instructions and connect with resources.
- The Home Safety Initiative engages at-risk high school youth to improve the safety of homes for the elderly and disabled by installing handrails, shower supports, and railings with direction from occupational therapist.
- Medication Management and Education enlists pharmacists from the hospital to perform comprehensive medication management/education to patients in hospital and primary care office.
- Emergency Department Imbedded Physical Therapists places a physical therapist in the ED to allow for timely assessment and expedited treatment planning.
- Maternal Transitions of Care is a pilot program aimed to bring about positive outcomes – in health and maternal custody - for babies of expectant mothers with a substance use disorder.
- Bennington Communitive Collaborative consists of sixteen community members meeting monthly with the mission of “building a high performance system that supports measurable improvement in the health of the community.”
Evidence of Success
Accountable Community of Health noted a 56.1% reduction in hospital admissions and observation status visits among high risk patients participating in the TCN program over 180 days, with a sustained decrease of 46.8% over a one year period. The Community Care Team demonstrated a 34.7% reduction in ED visit among patients with addiction and mental illness who frequented the ED when comparing 6 months before intervention and 6 months after (n=150 patients). A 12.4% reduction in A1C was achieved by patients working with a Certified Diabetes Educator within primary care practices. After the implementation of a pulmonary rehabilitation program, the 30 day readmission rate decreased from 17.26% to 2.56%.