New pilot program connects nurses with high-need patients

A nationwide effort to prevent medical emergencies before they reach the hospital has come to Montana in the form of a pilot program that disperses nurses into patients’ homes, doctor appointments and daily habits.

The fragmented health care system of today wasn’t built to support individuals with complex physical, behavioral and social needs, said Lesly Starling, a resource nurse for Kalispell Regional Healthcare. It’s easy for a patient to feel lost while juggling health concerns.

“They know something’s wrong, but they don’t have transportation to the hospital, or don’t have a primary care provider, or a way to pay for it,” Starling said. “So they wait, until it’s an emergency.”

Starling joined Kalispell Regional this fall as one of three nurses in the state tied to the Special Innovations Project. The new program provides intensive outpatient care management to high-need and high-cost patients.

When someone arrives in the emergency room more than twice in six months, “We call that a super-utilizer,” Starling said.

Readmission cycles ripple beyond families struggling to manage their health.

Nearly one in five Medicare patients discharged from a hospital — or 2.6 million seniors — are readmitted within 30 days, according to the Centers for Medicare and Medicaid. The price tied to those hospitalizations exceeds $26 billion each year.

The Special Innovations Project connects Starling to patients under the hospital’s roof. Then for 30 to 90 days she is a part of her patient’s transition from the hospital to recovery.

She goes to her patients’ doctor’s appointments as a “medical mediator.” If a patient has a support group telephone conference about managing a chronic illness, Starling joins the conversation.

She also enters patients’ homes to spot further barriers. That could mean looking through a person’s medicine cabinet, evaluating if they need help signing up for health insurance, home-delivered meals or simply helping them find a shower chair.

“It goes back to understanding the issue is more than just medical gaps,” Starling said. “Most of these patients have unmet basic needs. You have to be able to see the whole picture of this person’s life to see those gaps.”

LARA SHADWICK, the pilot program’s director with Mountain-Pacific Quality Health, said this is the first time a model like the Special Innovations Project has been attempted in Montana.

Funding for the program came from a nearly $2 million award Mountain-Pacific secured from the Centers for Medicare and Medicaid.

The award was paired with a $250,000 grant from the Robert Wood Johnson Foundation. Montana was one of six states in the country to receive the grant.

“The field of complex care is still emerging,” Shadwick said. “People know what they want to accomplish, but everyone is still trying to figure out how — especially in rural health, where there’s greater distances to travel to patients and smaller teams.”

The pilot program’s funding will spread across three coalitions — one in Kalispell, Helena and Billings. As each cohort develops their models, Shadwick said collaboration will grow between the coalitions as they share unidentified patient case reviews.

The program also offers care coordination software that allows entities to share patient information. With the software, the patient’s primary care physician can access their hospital records or see that they’re enrolled in Meals on Wheels to prevent duplicating efforts. The software also allows the coalition to track whether the patient avoids medical crises after cycling out of the outpatient care program.

Shadwick said funding for the project is staggered through May 2018.

“If this is successful, we hope that this work is absorbed within the community as that money runs out,” Shadwick said.

NORTHWEST MONTANA Care Transitions Coalition is monitoring the project in the Flathead. Since 2012, Flathead hospitals, clinics, assisted-living centers, health care businesses and professionals have worked to smooth communication between their services.

Jennifer Crowley, owner of life-care planning consulting company Eagleview West, said it initially felt strange to sit at the table with her competition.

“It completely changes the dynamics. You communicate and feed off each others’ strengths and help each others’ weaknesses, and we’re all competitors,” she said. “But in our business, you’re not dealing with an unhappy customer when something goes wrong — you’re dealing with a health crisis.”

Jane Emmert, director of ASSIST, a nonprofit that connects socially and physically isolated community members with services, helps lead the coalition.

“For about four years, we’ve worked to remove the barriers between health entities and social services,” Emmert said. “It started with understanding what each organization does to connect people to the right resource. As our communication’s grown, so has our understanding of where stumbling blocks for patients exist.”

She said the pilot program will be the first time the cohort will have a way to collect data that documents whether their effort is working.

It also allows the coalition to extend its reach, she said. Some participants in the program will receive tablet computers to manage their medical documents and stay remotely connected to their resource nurse.

So far, Starling has paired with six patients in Kalispell. She said she hopes to partner with 65 patients by this summer.

Shadwick said while the program currently has a shelf life of two years, she expects to see the model grow across the state and nation.

“If you build the communication channels for most complex patients, you’re building the avenues for the less complex cases, and that can impact health-care throughout Montana,” Shadwick said.