Hospitals in pursuit of excellence

Pushing the Hospital Walls

Extending services beyond the hospital walls to its most vulnerable patients?that is the goal of Baylor University Medical Center?s Vulnerable Patient Network (VPN). Prior to discharge from the Dallas-area hospitals, staff identifies patients with serious medical and social conditions who may have difficulty accessing follow-up care and lack insurance. Patients receive regular home visits from a nurse practitioner who does everything from managing medications to treating multiple chronic conditions like congestive heart failure and severe physical disability. Social workers step in as needed to help these patients access other community services. This combination has been successful in reducing avoidable hospital utilization and uncompensated care. The VPN started with Jim Walton, D.O., who was making house calls to 30 patients. Today nurse practitioner Tina Thomas, RN, working closely with Christopher Berry, M.D., visits and treats nearly 80 patients a month. Dr. Berry sees opportunities for further collaboration between the hospitals and community agencies to serve patients in need. "We're wrapping a nice envelope of support around these patients," says Dr. Walton, Baylor's chief health equity officer.