Beyond Our Doors | Alta Bates Summit Medical Center | 3 min version

Summit Medical Center in Oakland and Berkeley
is part of Sutter Heath, a nonprofit health care
system in northern California. Sutter Health Hospitals care
for more than 3 million people and for more low-income
patients in northern California than anyone else. The medical center is located
in one of the most diverse areas in America in terms of economic
status, education, and race. In 2012, the Medical
Center played a key role in convening the community
integrated health care partnership. STEPHANIE BROWN: The initial
impetus for the partnership was to improve the
flow of patients through the
emergency department, as well as to improve
care transitions. We had much success
with these programs, and we saw a
significant decrease in emergency department
length of stay. We then saw that many of
our complex care patients were getting readmitted far
too often to the hospital. So we expanded our program
to include inpatients. And through our
programs, we were able to see a 25% reduction
in the readmission rate. MANJULA GUNAWARDANE:
Many of these patients are both inpatient
and ED high utilizers. And it really gave
us a perspective on what’s happening in the
community, the resources that are out there, and how
disintegrated care was. INTERVIEWER: The
partnership consists of clinics, our public hospital,
county health system, homeless and housing agencies, mental
health agencies, payers, and our county EMS. TRACY SHRIDER: Our
greatest teachers are our patients, particularly
those with high utilization. DREMAINE: I think they all
should have that communication, irregardless of
what hospital you’re from and regardless of what
insurance company you’re from. I think everybody
should coordinate. BARBARA GOLDSTEIN: We’re really
breaking down those silos. It involves a lot of
relationship building. On a daily basis, we’re talking
to the discharge planner and the social workers
at the hospital. RONN BERROL: By talking
to these community clinics that we barely knew the phone
numbers to before, let alone had the correct address. But now our case managers are
talking to their case managers. Our doctors can send message
electronically to them. INTERVIEWER: Our tools to
manage patient and communicate with our partners include
a data-sharing tool. Social workers and
nurse case managers staff our emergency
department seven days a week. We develop our shared care
plans with our partners for our patients with
high utilization. SUBJECT: And you could also
ask a pharmacist if you have– MANJULA GUNAWARDANE:
You feel like you’re supported once you discharge
these patients because there is a clear handoff to
someone who is really going to pick up that patient. INTERVIEWER: Partnership
programs also include clinic care transition
nurses, urgent care, a new clinic for high risk
patients, our health equity project, chronic disease
resources, and closer collaboration with
mental health, substance use, and
housing agencies. Many of our programs are funded
through community benefit and philanthropy. ELSIE KUSEL: Our role is to
provide situational awareness to our partner hospitals about
the high utilizers of the 911 system. JASON REINKING:
We coordinate care around some of the
homeless patients that have been using
the emergency room for their medical services. The system of notification
is critical for us to be aware if they’ve
used the emergency room. INTERVIEWER: The partnership
has had a significant impact on our patients, our partners,
and our Medical Center. STEPHANIE BROWN: I feel
better as a doctor knowing we have all of these
important relationships. RONN BERROL: We are now
all talking to one another. And how we develop those lines
of communication was the key. And I think it’s the key to
anyone else who is trying to replicate some of this. [MUSIC PLAYING]

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