Care Coordination

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.”

Care Management Team

The highest utilizers of Trenton’s emergency room and inpatient services are getting support from Trenton Health Team’s Care Management Team (CMT). The four-member CMT includes a nurse case manager, a social worker, and two community outreach workers. The CMT’s program for high utilizers offers complete care known as wrap-around services, which include social and psychological services as well as primary healthcare.

True medical emergencies are rarely the reason why high utilizers visit the emergency room, but that doesn’t mean they are healthy. Most high utilizers have one or more chronic conditions, and require care that an emergency room is not designed to provide. Chronic conditions require consistent monitoring and an ongoing relationship with the patient to manage the illness and reduce the likelihood of complications. When patients visit multiple emergency rooms and receive treatment from different clinicians, they receive fragmented and sometimes repetitive or contradictory treatment that is aimed at temporarily solving the problem rather than managing conditions over the long term.

Chronic conditions also have strong ties to the patient’s lifestyle. Trenton’s highest utilizers of the emergency room often need help managing the areas of their lives that impact their chronic conditions. If a patient does not have enough food to eat, for example, he or she cannot use diet to manage their heart disease or diabetes. If a patient cannot afford medications, the disease goes unmanaged. If they are having trouble with housing, they cannot establish healthy routines. Transportation to the pharmacy and medical appointments is another challenge for many high utilizers. Unmanaged chronic conditions lead to true medical emergencies, a costly alternative compared to prevention and ongoing management.

The THT’s Care Management Team helps its patients access the full range of services they need as part of their healthcare. If necessary, a CMT member will accompany a patient to appointments, take them to the pharmacy to get medications and help connect them with social services to facilitate improvements related to food, clothing, shelter and finances. This approach to care management addresses the whole patient and acknowledges the reach of chronic conditions beyond the exam room.