Partnership program empowers patients to access appropriate care

An outpatient case management intervention known as Care Partners is a collaboration between Duke University Hospital, Durham Regional Hospital, Duke HomeCare & Hospice, Durham Community Health Network, and various community-based health care agencies.

The goal of the Care Partners program is to enhance the focus and care of patients with chronic diseases.

The program uses a patient-centered model to help empower patients to optimize their health, gain further understanding of their chronic disease, and to have timely access to appropriate services and providers, enhancing their ability to manage their care outside of the acute or emergency department setting.  

In this model, patients are joined with a “care partner” who is supported by an oversight team of individuals representing the participating groups.

Care partners are clinically trained professionals with backgrounds that include nursing (diabetes, geriatric, nutrition), social work, and community health education. The oversight team members' broad range of additional training strengthens their ability to make resources available to these patients. 

Engaging and Empowering Patients

Patients enrolled in Care Partners are empowered to better understand their health problems, make more effective use of the health care system and improve self-care in order to manage health problems outside of the emergency department and inpatient setting.

An initial analysis of utilization and readmission data at Durham Regional Hospital and Duke University Hospital revealed that, in some instances, patients were seeking their care at both hospitals, and at times on the same day. Frequency of emergency department visits for some patients exceeded 50 visits in 12 months.

Through engaging with the patients, the team learned that patients often experienced difficulty in keeping follow-up appointments and getting their prescriptions filled. 

Care Partners seeks to address these issues by voluntarily enrolling residents of Durham County with chronic medical conditions and high risk for medical crisis or recurrent hospitalization. The patients are also either enrolled in NC Medicaid or Carolina Access.

Enrolled patients participate in a three-phase, nine-month intensive program, which includes phone follow-up and home visits. Each phase consists of inclusion criteria as well as expected interventions during each phase.

Key components include assessing current health literacy, building trust and honest communication with patients, and providing consistent education and follow-up.

“We found in most cases, our patients had given up. We had to gain their trust and convince them things could be better,” says Pam Aldridge, director of Revenue Enhancement and Clinical Documentation Improvement at Durham Regional Hospital, who adds that there are many contributing factors, including homelessness, mental health issues, and substance abuse. “We couldn’t treat chronic conditions without first treating behavior.”

The program has additional goals which include:

• Seamless and appropriate care for patients along the care continuum
• Coordination and optimization of care across all care settings
• Patient education and empowerment
• Integration of health care “systems” to enhance communication among care providers
• Creation of a sustainable operational and financial structure which allows for program growth and success
• Support for hospital operational and financial efficiency
• Reduction of inappropriate use of acute and emergency resources
• Reduction of inappropriate readmissions to the acute setting

Impressive Results

Twelve patients were enrolled in the Care Partners program between July 2009 and April 2011. The impressive results include:

• 30-day readmission rates reduced by 45 percent
• Inpatient admissions reduced by 37 percent
• ED admissions reduced by 49 percent
• Clinic encounters increased by 80 percent

“Patients who enrolled and graduated from the Care Partners program report significant improvement in the overall quality of their lives and ability to manage their health,” reports Mary O’Brien, director for Patient Resource Management at Duke University Hospital.

"The Care Partners model, which incorporates home visits as an integral part of the program, along with regular support from the oversight committee, has been key in supporting patients, and Care Partners in achieving a successful outcome."