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Program ensures continuity of care for complex patients

Jan. 4, 2018, 9:54 AM

The Vanderbilt Familiar Faces program coordinates care to meet the needs of patients with complex medical conditions who repeatedly come to the ER, have a high number of clinic visits, and/or are often admitted to the hospital. (photo by John Russell)

Lou Ann Owens had lost count of how many times her husband Paul had been hospitalized by mid-2017, so when a team from the Vanderbilt Familiar Faces (VFF) program visited his room in August with an idea that might reduce his hospital stays and better manage his health, the couple immediately agreed to participate.

“We’ve probably been in to see the Familiar Faces team three times since then for situations we felt needed to be dealt with immediately, situations where otherwise we would have gone to the emergency room,” said Lou Ann. “The three times we’ve seen them, we’ve avoided hospital stays entirely, which is absolutely amazing.”

Patients served by the new VFF program include those with one or more chronic illnesses who experience acute medical events that frequently bring them to clinics and the emergency room, and that often lead to hospitalizations.

“Vanderbilt Familiar Faces creates a patient-centered medical home for individuals who frequently need our Emergency Department and inpatient services,” said Shubhada Jagasia, MD, vice chair for Clinical Affairs in the Department of Medicine. “While this is a small proportion of the overall patient population we care for, this group accesses healthcare in the acute setting at a much higher frequency.”

This mirrors national healthcare trends. Five percent of Medicaid patients account for almost half the program’s spending, according to a 2015 Government Accountability Office report. And five percent of patients account for 50 percent of total healthcare costs nationally, according to a 2012 report by the Department of Health & Human Service’s Agency for Healthcare Research and Quality.

“This program puts a structure in place to better ensure these patients stay healthier and at home longer between regular medical appointments, or if they have no access to primary care, that our clinicians meet that need,” said Mitch Edgeworth, MBA, CEO of Vanderbilt University Adult Hospital and Clinics. “There are many health concerns that can be managed successfully without a hospital re-admission, and we’re stepping up to make sure individuals who frequently return to our emergency room and clinics receive the care they need so their chronic conditions don’t escalate into a crisis.”

VFF goals include:

  • Improving the consistency of patient care
  • Improving patient access to primary care, social services and behavioral health resources
  • Improving patients’ ability to manage chronic disease(s)
  • Improving patient satisfaction and trust in the healthcare system
  • Reducing or eliminating the frequency or the worsening of patients’ chronic disease(s)

“This is an important step in making care less fragmented for complex patients. It is a remarkable team effort,” said Nancy Brown, MD, chair of the Department of Medicine.

Jagasia worked with Eduard Vasilevskis, MD, chief of the Section of Hospital Medicine, and other clinicians to develop a 2016 pilot program with 30 adult patients equally divided into groups of patients with sickle cell disease, congestive heart failure and a variety of internal medicine diagnoses.

“During the pilot, the numbers of emergency room visits, inpatient admissions, outpatient visits, and the length of stay for admissions were monitored,” said Chris Turner, MD, MMHC, medical director of the VFF program. “After six months, there was a 25 percent decrease in the number of emergency room visits, a 30 percent drop in inpatient admissions, and a 60 percent increase in outpatient visits.”

Based on this success, the full program was launched in mid-August 2017 with an initial group of 65 patients. Each patient’s electronic medical record (EMR) now includes a notation that they are part of the VFF program and links to their individualized care plan. Their care plan provides a management strategy for the patient’s medical conditions in the inpatient and outpatient setting, and across transitions of care. The patients are managed consistently and around the clock by VFF. The VFF program’s patient list is expected to grow through referrals from providers throughout VUMC and inclusion of other high-use patient populations.

The VFF team includes four physicians, four advanced practice providers, a licensed clinical social worker, an RN case manager and a program coordinator. A pharmacist will also soon join the team, Turner said.

Paul Owens’ list of health issues is lengthy. He has a hard-to-manage form of type 1 diabetes, and he recently fractured a femur. Then, he had a stroke that affected his speech and motor skills. As if that weren’t enough, he developed a fluid buildup in his kidneys called hydronephrosis. In the past, seeing his primary care physician quickly for acute illnesses was challenging. His next option was a walk-in clinic; there, providers usually referred him to the VUMC Emergency Department.

Now, if Paul needs to be evaluated, he comes directly to the VFF outpatient clinic, which is adjacent to eight VFF-designated beds in Medical Center North.

“My husband is chronically ill, but he’s not had a decline in his health since we began participating in this program,” Lou Ann Owens said. “Having a medical team we can get a hold of 24/7 and that he is able to see quickly has given us both great peace of mind. It’s been a Godsend.”

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