Transforming Health Care Together

Alice Hyde Partners with Community Connections to Address Unmet Social Needs

Tracy Lauzon is a community navigator employed by Community Connections of Franklin County. You won’t often find her at the Community Connections office, though. She is based full-time at The University of Vermont Health Network – Alice Hyde Medical Center in Malone, New York. Both organizations welcome Tracy onto their team as a bridge between medical and social services.

When Tracy began working as a navigator in the Alice Hyde emergency department (ED) in October 2017, 179 people were identified as “multi-visit patients (MVPs)” who presented at the emergency department four or more times over twelve months. One year later, fewer than 25 individuals meet the criteria of a multi-visit patient. Additionally, the original cohort of 179 has reduced their cumulative ED visits by 42 percent.

Patients meet Tracy or her colleague, Tiffany Hohol, after they have received medical services in the ED. Together, they discuss underlying non-medical factors that may have led to the patient coming to the emergency department or may contribute to future visits.

Do they have a primary care doctor?

Is their food supply adequate?

Do they have health insurance?

Do they have a safe place to sleep?

After uncovering concerns, Tracy and Tiffany pull in their colleagues at Community Connections to address these social determinants of health that contribute to the individual’s frequent use of the ED.

Just being present and asking if they need help can be a huge comfort to patients, Tracy says. “Everyone knows me and my family. The first thing I usually hear is, ‘How are your parents doing?’ I’m a familiar face.” After catching up, Tracy then asks direct questions to gauge the overall state of health for the patient. She inquires about potential concerns including their ability to pay their heating bill, insurance status, general needs for help around the house and their overall well-being, among others.

Patients who have insurance, but are not connected to primary care represent the greatest number of referrals, according to Tracy. One man, in particular, stands out to her. He used to present to the emergency department frequently complaining of back pain. When she asked the man why he hadn’t seen a primary care provider about the concern, he admitted it had not occurred to him this was a primary care issue. With the help of Community Connections, he is now connected to a practice and Tracy has not seen him in the emergency department in several months.

Months of planning between Alice Hyde and Community Connections reinforced the medical center’s dedication to identifying social determinants of health. What they found, however, was the task often landed on the shoulders of the nursing staff: men and women who had been trained to expertly handle critical medical situations, not to maintain expertise in the community’s social service network. But, that is exactly what the team at Community
Connections have been trained to do.

By inviting Community Connections into their emergency department, Alice Hyde has empowered their team to work at the top of their licenses as medical professionals.

Debbie Beach, RN nurse manager in the emergency department at Alice Hyde, has seen a weight lifted from her staff since the partnership began last year. Before Tracy and Tiffany were onsite, Debbie explains, “It could get complicated and time-consuming very quickly. We reach out to discharge planners and case coordinators to get as many services as possible in place, but it’s a lot of phone calls back and forth. Even just to find someone a ride home is difficult.”

Now, Tracy and Tiffany and just a few doors down to address the patient’s non-medical needs.

“Partnerships like the one we have with Community Connections can help us make a meaningful difference in the lives of the people who come to us for care,” explained Alice Hyde President Michelle LeBeau. “Having Tracy and Tiffany on site allows the skilled medical team to do what they do best – address the medical needs of our patients – and offers easy access to professionals who can help support them with other needs. It’s a wonderful dynamic for our patients and our community.”

The smoother connection to social services has not been limited to the 3:00 – 11:00 shift when a navigator is on-site, either. Since partnering with Community Connections, Debbie explains, the emergency department team is now more aware of the services available to their patients. Staff used to commonly feel overwhelmed thinking “What can I do for this person?” or “Where can they go?” The situation was stressful, Debbie admits, as there were other patients waiting who also needed their attention. But, since partnering with Community Connections, they know who to call for help.

Community Connections is also guiding patients after they leave the hospital. A navigator will follow up with a patient one day, three days and one week after initial contact to ensure patients are successfully connected to primary care.

Lee Rivers, executive director of Community Connections, sees consistent follow-up as a key component of the program. “When we call to check on the person within 24 hours, it gives them a chance to tell us about any difficulties they’re experiencing. And, it gives our staff a chance to ask, ‘Have you made an appointment with primary care yet?’” After all, Lee explains, “We all can use reminders.”

And, Community Connections isn’t doing this alone. They partner with other community-based organizations in the area and help streamline communication between the CBOs and the medical community. With the help of Community Connections, medical providers are receiving more efficient and comprehensive feedback on the progression of care to address the unmet social needs that may have been identified at Alice Hyde.

The partnership has already realized a $375,000 reduction in emergency health care costs over a 12-month period with an investment of barely 5 percent. It’s $375,000 that can be shifted to community-based care, prevention and wellness. The partners continue to collect data that reinforces the positive trend to be able to clearly demonstrate the efficacy of the program to managed care organizations and other payers in the future.

Can we help relieve your team of the stress, time and cost of addressing social determinants in your office or hospital?

ADK Wellness Connections, sponsored by AHI, helps connect the medical community to organizations like Community Connections that can relieve the burden providers and their staff feels when presented with challenging social needs.

To find community-based organizations in your area that can help address your challenges to delivering the quality of care you pride yourself on, contact [email protected].

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