Between 30% and 50% of health outcomes are directly impacted by social determinants of health, according to the World Health Organization. Community needs assessment data showed Erie County Medical Center’s patient population suffers from disproportionately high rates of asthma, chronic obstructive pulmonary disease, cardiovascular disease, diabetes and obesity — all exacerbated by a lack of access to care resulting from SDOH. ECMC responded by implementing its Transition of Care and Complex Care Management Program.
ECMC’s program aims to eliminate health disparities, poor health outcomes and hospital readmissions through preventive and coordinated care management, and aligns with the New York State Prevention Agenda’s chronic disease preventive care and management focus area. Through this initiative, an integrated interdisciplinary team, designed to assess and treat the “whole” person across the care continuum, provides the clinical social support necessary to address health. The team is rooted in coordination, patient-centered access, transition management and community collaboration.
ECMC partnered with a number of community organizations for this initiative, including Independent Health Association, General Physicians PC, ECMC Family Health Center, Internal Medicine Center, VIP Primary Care, Downtown Clinic for Behavioral Health Services, Best Self Behavioral Health, Community Health Center of Buffalo, Inc. and Jericho Road Community Health Center.
Through this program, ECMC identified 47% of admitted patients as high risk and requiring intervention. ECMC successfully linked 36% of high-risk patients without a primary care provider to a transition of care visit post-hospital discharge. Additionally, the team successfully provided counseling and bridging to follow-up mental health appointments to 38% of patients in need of behavioral health services post-discharge.
At the conclusion of the first year of the program, ECMC saw a reduction from 10.3% to 6.1% in the readmission rate for the identified high-risk patient population.
For more information, contact Lucia Rossi, vice president, ambulatory services and population health, at 716.961.6949 or firstname.lastname@example.org.