A pilot program launched this spring by The Independence Center aims to disrupt the hospital-to-nursing-home pipeline while also reducing hospital readmission rates.

“We’ve set out to prove we can transition people with disabilities out of the hospital to home after an acute episode rather than a nursing home,” said Patricia Yeager, CEO of The Independence Center.

The nonprofit created the Hospital to Home pilot program, which started in April, in partnership with UCHealth Memorial Hospital.

“There’s a lot of research around ‘Why doesn’t health care work?’” Yeager said. “And, usually it’s social determinants of health, like housing, having a job, having transportation, food, security, and all of those kinds of things, so that’s our specialty — the social determinants of health.”

As part of the program, Memorial Hospital staff identifies potential candidates and then reaches out to Mandi Strantz, the nonprofit’s care transition coordinator.

Strantz will work with patients with disabilities and their families to coordinate services to help them return home.

- Advertisement -

“Families have told me that it can be really overwhelming to deal with a loved one getting out of the hospital,” she said. “There’s a lot of information coming at them, and they don’t know where to get the resources they need. The goal is that I’m going to be the expert and connect them to those outlets.”

Services include meals in the home, transportation, setting up home health care, occupational therapy, physical therapy, respiratory therapy, setting up homemaking services like housekeeping and grocery pickup, receiving and setting up durable medical equipment and helping with medication delivery and funding. The nonprofit’s incoming board chairman, Joseph Foecking, is director of rehabilitation at Memorial Hospital. He said the program originally set out to assist one patient a month.

“But, they’ve actually picked up some steam, and they’re able to do more than that,” he said.

Thus far, Strantz has enrolled 12 patients into the program.

“I probably have had over 60 patients that have been brought to my attention and that we’ve talked about helping,” she said.  “And even if they don’t officially become part of the pilot, I’m still able to help connect a lot of them to community resources through the social worker at the hospital.”

Foecking said the program provides assistance needed beyond medical care that, if not received, often leads back to the emergency department.

“When I look at folks who are coming into the hospital, we are wonderfully designed to meet their medical needs, but that doesn’t necessarily meet their needs in the community,” he said. “You have folks that have emotional needs; you have folks that have functional needs, and this program can be the bridge to accomplish all of that for patients.”

The program also is designed to prevent readmission, Foecking said, adding there are certain insurance companies that will refuse to cover a patient if readmitted within a certain period for the same condition.

“So if you came in with pneumonia and the hospital treated you for it and you’re medically stable and leave but then come back right away for that same complaint, some of the insurers will say we’re not covering the cost of the second admission,” he said. “They say it’s because you’ve already been treated for the condition.”

“We’re that bridge between the hospital and getting on with your life.”

— Patricia Yeager

Yeager said one of the program’s participants is an 18-year-old, recovering from a gunshot wound.

“We helped his family member become his caregiver and get paid, because she had to quit her job to take care of him,” she said. “We also helped buy him an air conditioner because he was getting dehydrated and that could have ended with him going back to the hospital.

“The hospital can’t go and do that, and now, he’s back in school and about to graduate, so we’re that bridge between the hospital and getting on with your life.”

Yeager said they’ve discovered it’s essential that program participants have either a family member or friend willing to step in and assist for it to work.

“They really have to have that support to get back home, and then, if there’s mental health or addiction, particularly addiction issues, then we become kind of stuck as well,” she said. “That’s an area that we need to close the gap in our services is the addiction treatment and mental health help.”

The pilot initially was supposed to last six months, but after receiving more grant money, the nonprofit was able to extend it to May 2019, Yeager said.

“Before then, we hope to have a contract with Memorial [Hospital] for it,” she said. “That partnership is what we’re hoping will carry this through.”

Foecking was unable to comment on whether the hospital intends to award a contract to the nonprofit once the pilot ends.

“My role has really kind of been facilitating this and helping it get started,” he said. “To me, the next steps are going to be The Independence Center working with [Memorial’s] care management program.”

However, the fact the program has been able to keep about a dozen patients from going to nursing homes already makes it a success, Foecking’s said.

“But in terms of judging that success in another fashion, whether that’s financial or economical, that’s going to have to be a conversation between The Independence Center and our care management program,” he said. “To me, it’s a very innovative and unique program. It’s a new way of looking at things, which I think is exciting.”

Both Yeager and Foecking said the nonprofit/health care provider model is one that needs to happen more in the future.

“There’s really a push for the health care world to start contracting with nonprofits instead of building their own services in the community,” Yeager said. “It’s using us who already have the expertise and the trust of the population. It’s also quicker than having the hospital set up everything on their own.”

Foecking added, “The most exciting thing about all of this is the partnership piece, and the idea that UCHealth Memorial is partnering with folks and organizations in the community.”