Beyond Our Doors | Alta Bates Summit Medical Center | 5 min version

Summit Medical Center in Oakland and
Berkeley 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. The partnership consists of
clinics, our public hospital, county health system,
homeless and housing agencies, mental health agencies,
payers, and our county EMS. 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. RONN BERROL: So
these partnerships with these community clinics
and our other local emergency departments have been critical
in understanding why someone’s coming to our emergency
room, why they’re not going to our clinics. Traditionally, we didn’t
share information, and we found out that
sharing information actually is a very powerful thing. We can provide
better health care. And 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 a message
electronically to them. MANJULA GUNAWARDANE:
Many of these patients are both inpatient
and ED high utilizers. And it really gave
us perspective on what’s happening in the
community, the resources that are out there, and how
disintegrated care was beyond our walls. And it’s been critical in
trying to understand where these patients are
coming from, what their needs are beyond what
we know when they’re here in the hospital. TRACY SCHRIDER: Our
greatest teachers are our patients, particularly
those with high utilization. DREMAINE: I think they all
should have that communication regardless of what hospital you
were from, regardless of what insurance company you’re from. Everybody should coordinate. BARBARA GOLDSTEIN: LifeLong’s
care transitions program is a very close collaboration
with Alta Bates and Summit where we identify
our patients who have been using either
the hospital emergency department or our
inpatient at the a hospital and we help to create the
bridge for that patient back into community services. On a daily basis, we’re talking
to the discharge planners and the social workers
at the hospital to identify who the patients,
what their needs are. And we can put notes
in our medical record to let our doctors
and nurses know that this person has been in the
hospital, what their follow up needs are, and what they
should be paying attention to when the person does come
in for their appointment. NARRATOR: We develop
our shared care plans with our partners for our
patients with high utilization. STEPHANIE BROWN: The
partnership is data driven, so when we look at
the numbers, we’re really able to drill down
exactly where our resources are most needed. For example, with our care
transition nurse program, we’re able to see exactly how
many patients were contacted by the nurse for follow up care
at a community health center, how many kept
those appointments, and how many
appointments were missed. Those numbers
drive our programs, because we’re able to target
our resources more effectively. NARRATOR: 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. The partnership has
made changes in taking better care of these
patients because there’s now a coordinated effort and sort
of a single mission in mind. 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 that they’ve
used the emergency room for one reason or another. And then we can be focused
to actually from a referral perspective follow
them up and sort out whatever issue is going on
at that time that caused the emergency room visit. NARRATOR: The partnership
has had significant impact on our patients, our partners,
and our medical center. MANJULA GUNAWARDANE:
You feel like you’re supported once you discharge
these patients because there is a clear handoff to
someone who’s really going to pick up that patient. STEPHANIE BROWN: I feel
better as a doctor knowing we have all of these
important relationships. RONN BERROL: We’re now all
talking to one another, and how we develop those lines
of communication was the key and I think is the key to
anyone else who’s trying to replicate some of this.

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