Care Coordination

Goal: Enhance care coordination / navigation across the community

With success in connecting pregnant women and patients with chronic conditions to primer care, the Emergency Department Care Coordination (EDCC) initiative is focusing on the most frequent users of the ED, many of whom have behavioral health disorders. Expanding our focus on ‘super utilizers’ includes collaboration with the Community Justice Council and its pilot program to prevent incarceration among those most likely to offend due to mental illness or substance use.

• Year to date in 2016, ED to medical home patient referrals are 23% higher than the previous year.
• The ‘show rate’ for patients keeping a scheduled primary care appointment increased from 39% in 2014 to 47% in 2015.
• Average days from an ED visit to a primary care appointment decreased from 11 in 2014 to 6 in 2015.

Robert’s Story

Robert had tooth pain for a few months, but with a low income and no insurance, he thought he had no option other than living with the pain. He was used to ‘toughing it out’ with some problems, but eventually the pain became unbearable.  He was not able to eat or sleep and was in danger of losing his job, because he couldn’t focus on his work.

When Robert finally sought help at Columbia St. Mary’s he was referred to the St. Elizabeth Ann Seton Dental Clinic, as part of the Partnership’s ED Care Coordination initiative.

Fortunately, Robert was able to secure an Urgent Care visit the next day and had a badly infected tooth extracted. He was so thankful for the prompt and free dental care that he received, he asked for clinic flyers and business cards so he could pass along information to others in need. “If it weren’t for you, I would have lost my job,” he told clinic staff.  “I want everyone to know about this program!”