“I cannot tell you the value of having an informatics person from the very beginning.”
That statement came from Bev Beckman, the manager of the Health Connections Initiative Project at KentuckyOne Health, a grant-funded public health initiative to improve health equity. The project uses zip codes, GIS mapping and the LACE Index — a readmission risk assessment scoring tool — in its quest to identify the sickest patients who tend to account for the lion’s share of healthcare costs. Her keynote at the MedCity ENGAGE conference this week was a striking balance between harnessing data analytics in its work with hospitals to identify suitable candidates for its program and the fundamental healthcare needs the initiative’s team of professionals seek to provide.
Beckman mapped the average lifespan of Louisville residents based on their zip codes to highlight the significant inequity between the relatively long lives of residents on the east side of the city compared to the west side. A heat map illustrated pockets on that map among the 10 zip codes across the city where the sickest patients tend to reside. The Health Connections Initiative Project works with hospitals to identify suitable patients for its program as they’re discharged from their facilities.
Once a candidate is selected, Beckman highlighted the roles members of her team serve to address patients’ needs from ensuring their dietary needs are met, helping them gain access to transportation to make their doctor appointments and ensuring they have the medical tools they need to manage their condition.
“A lot of their health behaviors are impacted by food, housing, transportation, jobs, and income.
A registered nurse visits the patient’s home, enrolls them and works with patients to set goals to improve their health. A licensed practical nurse makes more frequent visits to work with patients to advance their care plan. A community health worker visits patients weekly and helps the project establish the patient’s trust. They will help prepare participants for their doctor appointments, sit on these appointments to advocate for patients, ensure they understand the physician’s recommendations. They may also help these participants get food stamps, apply for disability, or teach them how to prepare meals that conform to dietary restrictions.
A peer support specialist is another crucial team member, trained in working with patients who share the same problems they have experienced such as personal struggles with anxiety, depression, or substance abuse.
“Social isolation has a huge impact” on these participants, Beckman noted. Another facet of the project is connecting program participants with churches or other relevant groups to ensure they have connections with their communities
Since 2013, there have been 325 program participants who completed the program. Beckman noted it achieved a 16 percent reduction in hospital readmissions. It has saved an average of $35,000 for inpatient costs per patient, improved care coordination and boosted attendance for doctor appointments.
She also highlighted a couple of success stories from the program. One participant referred to as Mr. Thomposon, was able to get off of dialysis. Mr. Carter, a diabetic, completed a diabetes education program and was able to better manage his chronic condition.
Beckman noted that the project has helped bring together healthcare providers across Louisville, a notable achievement given how competitive the market is, she quipped.
The project model is also being scaled to other cities such as Seattle, Little Rock, Arkansas and for the Central American country, Belize.