This is an excellent report on a “Bridges to Care” (B2C) program that used a multidisciplinary care team, including Community Health Workers (CHWs) to reduce preventable ED visits and hospital admissions in a Medicaid population.

The extensive use of CHWs in the study can be compared to the use of trusted Community Paramedics with comparable training, as we have highlighted in the past. Imagine the added benefit of using an EMS-based MIH program, that could not only do the proactive home visits with providers similar to CHWs, but do an evaluation and possible primary care re-direction in the event of a 9-1-1 call.

Interestingly, the study explains there were an average of 8 home visits over a 60-day enrollment – which is very similar to the average number of visits in MedStar’s and other MIH programs of 14 patient contacts (including 9-1-1 patient contacts) over 90-days.

Finally, many of the findings in the study are eerily similar to what most established MIH programs have experienced regarding things like number of visits and length of enrollment to achieve the desired outcomes, the timing of the 1st enrollment visit, the linkage between the time of ED visit and the referral, and the most prevalent co-morbidities.

http://content.healthaffairs.org/content/36/10/1705

A few highlights from the study:
“We evaluated how participation in Bridges to Care (B2C)—an ED-initiated, multidisciplinary, community-based program—affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group.”

“In this article we compare participants in the B2C program with patients who received standard care (the control group) with respect to three outcomes: ED use, hospital admission, and primary care use.”

“B2C, a multidisciplinary program based on the Camden Coalition model, was developed collectively by the community and health care provider stakeholders and the Innovation Center project sites. It provides intensive medical, behavioral health, and social care coordination services, with up to eight home visits within sixty days of an ED visit or hospital discharge from a team comprising a primary care provider, care coordinator, health coach, behavioral health evaluator, and community health worker (all of whom are employed by the local federally qualified health center).”

“The B2C intervention begins with enrollment, a brief assessment, and scheduling of home visits while the patient is still in the ED or hospital. The first home visit occurs 24–72 hours after the enrollment date and is conducted by the community health worker and the care coordinator to complete the enrollment forms, provide the patient with B2C contact information, and talk about the patient’s goals.”

“The most common comorbidities were hypertension, mental health disorder, asthma, and diabetes. We note that 27.6 percent of enrollees did not complete the sixty-day program.”

“We believe that the program’s success stems from bringing together different health care systems (hospitals, federally qualified health centers, and others), breaking down silos between disciplines, and focusing on continuity of care in the outpatient setting.”

“This study has several implications for policy and health care practice. Some experts argue that an intervention program should reduce ED utilization by 40–50 percent, but we believe that the reductions we found in ED use and hospital admissions (of 28 percent and 16 percent, respectively) are more realistic—and replicable, given that our study had a control group. In addition, building and implementing an intensive, community-based, transition-of-care program such as B2C requires an up-front financial investment, with a delayed return on investment. Also, no billable codes exist for providing ED care transitions, where programs such as this could be funded in the future. We learned that for B2C to reduce the use of acute care, outreach to and enrollment of high utilizers had to happen in real time in the ED.”