Independent Health has a long history of working with physicians and hospitals to improve our members’ experience and health outcomes, while also lowering trends that deliver more affordable care. Since October 2021, we have partnered with the Erie County Medical Center (ECMC) to develop a pair of innovative care programs for chronically ill members who have been discharged from an inpatient hospital stay, as well as members who have been discharged from emergency treatment for a psychiatric or substance use disorder.

Through this collaboration, ECMC has hired a transitions of care team that is funded by Independent Health to support our members through their hospitalization and transition back into the community. Here’s an overview of how these transformational programs work.

Care Transitions

Individuals suffering from multiple chronic conditions often find themselves needing inpatient hospital care to treat exacerbations. Short-term hospital stays address the most immediate treatment needs for most patients. However, some individuals are at a higher risk for readmission back to the hospital because of the complex nature of their medical conditions. They require higher touch follow-up and coordination following their hospital discharge to maintain the health gains they made in the hospital, especially during the gap post hospital discharge but before their scheduled appointment with their community provider.

Although their short-term stays address the most immediate treatment needs, the patients’ long-term needs often go unaddressed. The longer the gap between the patient’s discharge and follow up care with an appropriate provider increases the chance for readmission, poor outcomes, and unneeded expenses.

To help address this issue, ECMC has implemented a Care Transition Program that focuses exclusively on Independent Health members who have been identified as needing this high-touch care. An integrated team of ECMC clinicians and support professionals proactively works with the most acute/high-risk members on a care plan for discharge and 30-day follow up. For example:

  • An ECMC pharmacist meets with patients being discharged to perform medication counseling in the hospital to improve education and understanding about the importance of medication adherence.
  • ECMC also employs patient navigators and social workers who will help link the patient to community resources or to a primary care physician for follow-up care.

As a result of the Care Transitions Program, our members have received better post-discharge care and are thus less likely to be readmitted to the hospital. Since deploying this program, Independent Health has noted a 4.3% drop in the readmission rate to ECMC for our members.

Virtual Bridger

Individuals with mental illness or a substance use disorder need significant support and care to help them in their recovery, especially after they are discharged from emergency treatment. The pandemic has exacerbated individuals’ illnesses and has underscored the need for the uninterrupted transition from short-term to long-term treatment.

In order to improve the connection of patients treated through ECMC’s Comprehensive Psychiatric Emergency Program (CPEP) to community-based behavioral health services, Independent Health and ECMC have created the Virtual Bridger Program. The goal of this program is to connect a patient to an established outpatient behavioral health program to provide needed on-going treatment and reduce crisis episodes which require emergency behavioral health care. 

The ECMC staff contacts the Independent Health member within two days of discharge to assess the member’s condition, ensure they obtain the right medications, determine barriers connecting to outpatient services, and ensure the patient follows through on their follow-up visit with their provider. The clinician will also assess during the conversation if the patient is stable or needs more immediate intervention. In some cases, this could mean an immediate telehealth visit rather than an emergency department intervention. For example:

  • An ECMC social worker recently worked with a patient with an opiate use disorder worried about relapsing because of an error with the patient’s Suboxone prescription quantity. The social worker was able to correct the prescription error and assisted the patient in completing a follow-up visit with the appropriate provider.

The Virtual Bridger Program has successfully engaged with nearly 58% of the patients, which means there is a better chance of success for members in getting the support and care they need to optimize their recovery.

Thanks to the Care Transitions and Virtual Bridger programs, ECMC has become the “proving ground” for this transformational approach. Other local hospital providers are awaiting results of this approach to determine how best to implement it into their processes.