Baylor University Medical Center (BUMC)
Dallas, TX
1025 staffed beds
STEEEP
Efficient - The VPN has reduced rehospitalizations and uncompensated costs.
Equitable - The program provides quality health care to patients with limited or no insurance and with limited access to follow-up treatment.
Patient Centered - Patients receive regular home visits from clinicians and are connected to community social services if needed.
Team Members
Christopher Berry, MD
Family Medicine Physician
Adam Chabira
Director, Office of Health Equity, Baylor Health Care System
Vanessa Lopez
VPN Enrollment Coordinator
Tina Thomas, RN
Nurse Practitioner
James Walton, DO
Vice President and Chief Health Equity Officer, Baylor Health Care System
Michelle Zamorano
Medical Assistant and Community Health Worker
Making Health Care Equitable: Baylor's Vulnerable Patient Network
The Problem
Some patients seen at Baylor University Medical Center (BUMC) for trauma and chronic conditions such as heart failure, hypertension and stroke need follow-up care at home after discharge, but they have no medical home and no insurance.
The Solution
Baylor’s Vulnerable Patient Network (VPN) provides home-based primary care and social support services to uninsured and underserved patients with complex medical and social conditions. Hospital social workers and rehabilitation staff identify patients who might need the services, and a VPN enrollment coordinator verifies eligibility. Physicians, nurse practitioners, medical assistants and community health workers visit patients’ homes to provide medical services, coordinate care and give social support to patients.
The Results
With access to quality medical treatment and care, patients receive the follow-up health care they need, learn to take charge of their own health and manage their medications, and are less likely to return to the hospital or emergency department. The combination of providing medical care and social services has reduced avoidable hospital utilization and uncompensated costs. A recent analysis of congestive heart failure patients in the VPN compared hospital utilization and uncompensated costs six months pre- and post-enrollment. Emergency department visits decreased 26 percent, admissions decreased 63 percent, and uncompensated costs decreased 53 percent (more than $200,000).
Background
In 2002 James Walton, DO, began what he calls “building a solution” for ongoing care of underserved patients discharged from Baylor hospitals. As a trauma center, BUMC serves patients with major neurological trauma. Walton’s first VPN patient was a 16-year-old boy who was visiting the United States and broke his neck. In 2002 Walton made his first house calls to this patient and several similar patients, all of whom needed intensive medical care but had difficulty obtaining care in a traditional ambulatory clinic. Then Walton’s patient clientele grew to about 30 patients. “We gained respect with our trauma hospital,” he says.
Walton started seeing one to three patients each week, and that number grew quickly. After five years, Walton wanted to expand the program. In 2007 Baylor hired a nurse practitioner, Tina Thomas, RN, and, in 2008, another physician, Christopher Berry, MD—both to help Walton. Today Thomas, working closely with Berry, sees between 70 and 80 patients each month. The VPN currently includes one homeless patient, who is seen at a homeless shelter to help control his asthma. “We go just about anywhere,” says Walton.
The VPN provides as much care as patients need but does not bill patients. With clinicians providing primary care and preventive services, patients are less likely to return to the hospital or emergency department. And with good primary care, patients are better able to manage their chronic health conditions. The program has been effective in reducing rehospitalizations—both ED utilization and inpatient admissions—and uncompensated costs.
The VPN program works closely with community partners like the Dallas County Medical Society, Project Access Dallas, and Central Dallas Ministries to help stabilize patients’ social issues like housing, hunger, and transportation.
Principles of Performance Excellence
Perfect the Patient Experience
According to Thomas, the VPN’s nurse practitioner, “We try to take care of patients medically, socially and emotionally.” On the first home visit, Thomas explains to patients that she will be their primary care provider. Also during that visit, she gets patients’ medical history and background and reviews a list of things they need to do, such as scheduling follow-up appointments or filling prescriptions.
Thomas works with a medical assistant and visits patients regularly—some once a week and others once a month, depending on their needs. The medical assistant holds state certification as a community health worker and serves a dual role by also addressing social issues that may affect the patient. Patients are referred to a social worker when needed to help access other community services.
Thomas does everything from managing patients’ medications to treating multiple chronic conditions, such as congestive heart failure and physical disability. The home visits provide support and ensure better compliance by patients. “I love it,” says Thomas. “Patients look forward to my visit.” Thomas says she gets to know patients and their families and they know to call when they need her. She recalls one of her patients, a 24-year-old woman who is a quadriplegic. “She knew we were coming by every two weeks to see her,” says Thomas. “We helped her navigate the health system.” (This patient’s story is discussed in more detail below.)
Remove Waste
The VPN has helped reduce costs associated with avoidable hospital utilization. According to Adam Chabira, director, BHCS Office of Health Equity, “The ED is costly and ineffective, but not as costly as admitting patients to the hospital. Our program can more than pay for itself.” Walton adds, “We are improving transitions of care and shaving days off hospital admissions.”
Create a High-Reliability Culture
According to Chabira, a unique component of the VPN is its multidisciplinary team, including physicians—who oversee the team; nurse practitioners—who handle the day-to-day work; and medical assistants—who address social issues and know other services offered by community organizations. “We have medical and social expertise on our team,” says Chabira.
“The work is and can be challenging, but I have enjoyed it,” says Berry, the physician who joined the VPN team in 2008. Berry shared what he called a “typical story” that illustrates the needs addressed by the VPN. A young woman broke her neck in a pool accident. She arrived at the hospital, was resuscitated and treated, but after that there was “nothing,” says Berry. She had no insurance, no support, and no help at home to recuperate. If not for the VPN, she might have become sicker or gotten pneumonia, Berry believes. “We were going out, seeing her, and caring for her. Her disability disqualified her for insurance. We got our community health worker and social workers involved and played a critical role in getting the medicine and supplies she needed.” Through the VPN, this patient also received home nursing support and housecleaning help at home. The patient has not been back to the hospital for over a year, and Thomas continues to see her every two weeks.
The VPN also has become closely allied with BUMC’s Heart Failure Clinic, which provides follow-up after discharge and telephone management for patients with heart failure. Many of these patients are members of vulnerable populations. “We are wrapping a nice envelope of support around [all] these patients,” says Walton.
Berry says that despite the help provided by the VPN, there are still tremendous challenges in treating patients with serious medical conditions who have difficulty complying with treatment. One heart failure patient that Berry and Thomas visited was receiving free medications and help managing his medications—including help from Thomas putting the medicine in pill boxes—but the patient still was not complying with treatment. The patient seemed resigned to being ill with the attitude “this is just my lot,” says Berry. “We have not solved that problem,” he adds. “There is so much more than the medical system is designed to provide. I would like to see more collaboration with some of these community organizations on attitudes and lifestyles.” According to Berry, “There are folks who respond well to what Tina [Thomas] provides, enough to lift them up to where they can get on with their lives. But for other people, what we offer through medical services does not address most of their problems.”
Continual Improvement
Berry looks for further collaboration between hospitals and community agencies to serve patients in need. “Medicine is a little arrogant,” he observes. “We think it is our job to fix everything. We need to give up some responsibility [for helping patients] to other organizations that are more qualified to do it.” Berry sees opportunities to provide patients with daily life skills classes—teaching basic skills like filling pill boxes and paying checks—and getting people together to create a sense of community, so they do not feel so alone. The VPN provides a start in that direction.
