Community-wide Clinical Care Coordination
Often, patients who frequent hospital emergency rooms are seeking care that is non-emergent. Sometimes individuals need a primary care provider and/or some assistance in resolving social concerns such as homelessness, substance abuse, or behavioral health issues.
The Community-wide Clinical Care Coordination Team (C4T) is composed of physicians, case managers, nurses, and social workers from the THT partners, as well as representatives of community behavioral health and social service agencies. THT takes a holistic approach in looking at recurring users of emergency rooms and, with providers on the same page, patients benefit. Team members focus on patients who are frequently readmitted for congestive heart failure, mental health disorders, and diabetes. They know that empathy, time, and compassion sometimes are needed as much as X-rays and prescriptions are. By making frequent outreach visits to these vulnerable residents, the team can assess and then help with residents’ social issues in addition to keeping tabs on chronic illnesses. They are better able to see what is needed to keep these patients well. Helping a person navigate through the system, visiting their home, and making sure appointments are made is how we are connecting people to the care they need.
Robert Remstein, D.O., M.B.A., leads the C4T. It brings together the case managers and the clinical staff from the hospitals, Henry J. Austin, and community partners, such as Mercer Alliance to End Homelessness, Oaks Integrated Care, Catholic Charities, and the Rescue Mission of Trenton, to coordinate and connect individuals to care in the community. These efforts have been successful in reducing non-emergent visits to the emergency departments of St. Francis and Capital Health. Dr. Remstein said, “It’s the first time in my professional career when what have been competitive entities align around the needs of individuals. This unprecedented level of cooperation benefits everyone.”