For Roscoe Lees, pain is an ever-present companion.

“A lot of times it’s excruciating,” the 62-year-old man said, sitting in the living room of his north Billings home. “I’m on pain management now, but there are times when I don’t even bother for it won’t do anything.”

In the past that pain has frequently driven Lees, a Montana native and Vietnam vet, to visit the St. Vincent Emergency Department for relief. His frequent visits flagged him as a candidate for a one-year pilot program that seeks to help individuals stay healthy and find appropriate care for their medical needs.

Jennifer Hough, clinical lead nurse for the Care Transition Team of the Adult Alliance of Yellowstone County, first reached out to Lees in May. Her goal was to see how she and the other two members of the team could help him.

They focused both on pain management and his undiagnosed PTSD, for which they connected him with a VA counselor.

“Our goal is to identify why a patient is using ER or hospital services quite a lot and see if we can assist them with choosing alternatives that would be better for the circumstances they have at that time,” Hough said.

Lees, who lives with his wife, Donni, and Dusty, their 9-year-old Chihuahua, served five years in the Navy. Afterward, he worked at a series of jobs, severely injuring his back at a construction site.

That and other medical problems forced him to undergo 15 surgeries. 

He agreed to meet with the Care Transition Team to see if they could help him with his chronic pain. Hough worked with him, as did the team's two community health workers who at that time were both military veterans. The team worked to get Lees plugged into the VA system where appropriate.

The trio also helped him find a social outlet with other vets.

“I’ve pretty much become a hermit,” Lees said. “I see my kids, my friends and my grandkids, and that’s about it. I don’t really do much.”

Hough also helped apply for financial aid to decrease some of Lees’ medical bills, and the team helped him know his own boundaries.

“I have learned to know ahead of time when I’m doing too much,” Lees said. “These guys have pushed me to realize maybe I should stop sooner.”

How it works

The Care Transition Team was created in February 2017 and began working with clients in April 2017. The pilot project is one of three in Montana coordinated by Montana-Pacific Quality Health in Helena.

The projects are funded by Centers for Medicare and Medicaid Services and the Robert Wood Johnson Foundation. Mountain-Pacific contracts with CMS to work on a variety of health care-related projects to improve lives of Medicare beneficiaries.

The Kalispell project started enrolling patients in October 2016 and the Helena project, in January 2017. As of January, the Billings team had worked with 32 people ages 29 to 79, 53 percent female and 47 percent male.

The Care Transition Team continues to take referrals. All of the clients to date have had insurance, Hough said, including Medicare, Medicaid and Blue Cross Blue Shield.

Potential clients are identified by St. Vincent Healthcare, Billings Clinic and RiverStone Health. To be chosen for the program, All those who qualify have made five ER visits and two inpatient hospitalizations within the past six months.

RN care managers or coordinators at the hospitals contact those patients to see if they would be interested in meeting with the Care Transition Team to help them with their situation. If they agree, Hough contacts them to set up an intake session.

She and the assigned community health worker meets with them in their home and they chat. Hough notes not only their health needs but other issues making their lives difficult.

Those issues, called social determinants, have to do with struggles over such things as housing, transportation, utility payments, food, medication and care costs, literacy and emotional support.

A lack of medication makes it hard for them to control their diseases. A lack of transportation might compel them to call an ambulance when they need medical care.

“We create individual care plans to work with these people who have been referred to us,” Hough said. “Our hope in doing that is with each and every identified need met, their stressors will decrease and they will be able to focus on themselves.”

For instance, on the non-medical side, if a client is having trouble finding housing, it might be a matter of helping them apply for subsidized housing and then getting them help to move their belongings. Or maybe their health is suffering because they’re not able to afford nutritious food and one of the community health workers can plug them into a local food pantry.

Meeting clients in their homes helps Hough and the two community health workers more easily identify other needs. Over time, trust develops and issues can be ferreted out.

“It is their safe haven, and we’re invited into that place, so we’re respecting them, getting to know them and better assess their needs by being present in the moment with them,” Hough said.

And as the relationship develops, Hough or her co-workers can offer their clients tips on ways they can boost their own health.

“We talk about what is healthy diet, exercise for their current disease, ask if they’re taking meds like they’re supposed to and what can we do that will allow them to be better about taking their meds,” she said.

Part of the education also has to do with the best ways to manage their medical problems and develop a relationship with the care coordinator who works with their primary care physician. In that way when a medical problem comes up, the client can call that care coordinator for advice on seeking the proper level of care, rather than heading to the emergency room.

The work of the Care Transition Team with a client can last anywhere from two weeks to six months, Hough said. When the client has arrived at a good place, the team hands them off to the care coordinator.

“We check in with the (care coordinator) to see how the client is doing and we reach out to the clients to see how they are,” Hough said. “Some of them even reach out to us to see how we’re doing because we’ve established that relationship.”

Working together

St. Vincent Healthcare, Billings Clinic and RiverStone Health all are supportive of the pilot project. The three organizations have been members of The Alliance since 1994, which seeks to create and sustain innovative programs that address community-wide health issues.

Since 2005 they have partnered to do community health needs assessments. Out of the 2014 assessment, access to health care services was seen as an area of opportunity, said Shawn Hinz, vice president of Public Health Services at RiverStone.

“Part of that access to care was making sure individuals are connected with primary care,” Hinz said.

The Care Transition Team pilot project is a natural outgrowth of that, she said. For people who “shop for the wrong level of care because they have access 24 hours a day at the emergency room,” the Care Transition Team can help solve the problems that keeps a client from access to primary care, a more effective and less expensive alternative.

RiverStone Health offers its own care management services to high-risk patients. High risk is defined by the number of chronic diseases they have, their use of the hospital ER and other social determinants that affect their lives.

Unlike the Care Transition Team, said Breann Streck, RiverStone’s Special Projects director, RiverStone’s care managers don’t go into clients’ homes. And Hough and her coworkers can spend more time with their clients.

“Also, there’s not a mechanism in place for us to obtain ER utilization rates,” Streck said. “So the pilot project is helping bridge that gap.”

Eventually, she hopes a health information exchange will be in place between RiverStone and the two hospitals so the health center can better identify at-risk clients.

At Billings Clinic, registered nurses and social workers called care managers work with primary care physicians and their patients deemed high risk for overusing the ER and hospital.

When the Care Transition Team began its work, the hospital secured permission from some of the patients they work with to give to the team, said Amy McManus, RN care manager.

“It’s hard for us to see what’s going on in their home environment,” McManus said. “I’m on the phone with them and I’m at their appointments sometimes if they want me there, but I can’t meet them at home.”

Once the team transitions the patient back to their primary care physician’s care manager, whom the patient already knows, “they feel safe to continue working with me,” she said. She also has quick access to the patient’s primary care physician and can set up an appointment.

“Eventually they become more empowered,” McManus said. “They learn along the way how to work within the services they have to move forward in their own self-care. So it’s a really positive thing for the patient.”

St. Vincent Healthcare has care coordinators at each of its internal medicine and family practice clinics in its system. Like McManus, Rebecca Anderson, RN care coordinator at St. Vincent, spends much of her time on the telephone managing patients.

“It can be months to a couple of years I’ve been following people,” Anderson said. “They’ll call me and ask questions about medications, questions about instructions from physicians.”

Or maybe the patient will leave the office, forgetting to ask a question and they’ll call Anderson and ask her to check with the doctor. Helping a patient work with a primary care physician, rather than seeking emergency care, is a better use of services.

And working with the Care Transition Team has helped facilitate that process.

“We’ve seen a decrease in the use of the ER for most of all the patients that we have referred to the Care Transition Team,” Anderson said. “They focus on the whole person, and they are definitely making an impact.”

Members of The Alliance are evaluating the results and holding conversations about the direction to take once the pilot project ends in May, said Luke Kobold, director of strategic planning at Billings Clinic.

“At least from the anecdotal responses it’s been positive,” he said. “It’s an area of high need for our patient base and anything that can help us, we’ll look at.”

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