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Bill Klaproth (Host): This is a special AONL podcast, as we speak with session presenters from the AONL 2022 Conference. With me is Billie Allard, Nursing Administrative Consultant for Population Health and Transitions of Care at Southwestern Vermont Medical Center and Caitlin Tilley, Director of Care Coordination and Blueprint Program Manager also at Southwestern Vermont Medical Center.

This is Today in Nursing Leadership, a podcast from the American Organization for Nursing Leadership. I'm Bill Klaproth. Billie and Caitlin welcome.

Billie Allard, MS, RN, FAAN (Guest): Thank you.

Caitlin Tilley, BSN, RN, CEN, SANE (Guest): Thank thank you. Happy to be here.

Host: So we're going to be talking about community care teams, a breakthrough strategy for healthcare equity. But first off, if we could just hear your experience and how you came to see this problem, maybe that'll kind of give us some background on each of you. So Billie let's start with you.

Billie Allard, MS, RN, FAAN (Guest): So I first experienced this issue when I was the Director of the Emergency Department at a different hospital. And we found that patients with mental health and substance abuse disorder were coming in sometimes three times a day, 20 times a week, hundreds of times over a period of time. And they would say they had chest pain. They had the worst headache of their life. They had abdominal pain. When we would do these very complex, expensive workups, we would have no findings and it almost appeared they wanted attention. They wanted a warm blanket. They wanted a meal. And we didn't really have the resources at our fingertips to do all of those things for them.

We did the best that we could. But as the leader, I felt very unsuccessful. You know, how do we get these patients to say what they really need and how do we meet their needs? Fast forward to, being at Southwestern Vermont, we started a program where we started to follow the pathway of patients and figure out new and different ways to deliver care.

And one of the priority areas that we spoke about was exactly this, how can we help this population? And so, we tried all sorts of things that weren't working, but finally found a strategy called the Community Care Team. And in fact, it was introduced by Middlesex Hospital at a conference years ago, and they had come up with this wonderful plan, which we replicated of hiring a patient advocate for the emergency department that would be there to meet those patients, build relationships with them, have meetings with all of the community agencies and partners across our whole region to figure out who are the people that can help these at risk patients and then putting together a plan for them. And suddenly we stopped having those hundreds, thousands in some cases of visits and we started transforming patients' lives and we started changing the whole feeling of how we were addressing those patients. We did away with all those unnecessary tests, procedures. We found housing. We found ways for them to get food. We got them mental health and addiction, services. And Caitlin could tell you from an emergency nursing perspective, how that really changed how care was delivered.

Host: Yeah, it sounds like so what the care you were providing the care you thought they needed wasn't actually what they were looking for. You were trying to treat them from a medical basis from your training and it kind of actually wasn't what they were looking for. So Caitlin and you were on the front lines of this. Give us your perspective.

Caitlin: Yeah, So my experience is similar to Billie's, but just from a different perspective. So she started noticing this from a leadership role. I saw it from a direct bedside perspective, so I actually have spent most of my nursing career in emergency medicine, about three and a half years ago, after five or six years in the emergency department, I started to feel very frustrated with the inability to sort of meet those needs and Billie happened to have a position available to work with her. And I said, what a great opportunity to find out a way, that I could sort of systemically have an impact. And actually make a change instead of feeling stuck with people who are homeless or have significant financial or food insecurity. When you work in an emergency department setting, they come in, you can address that imminent need, but you never are able to actually fix the long-term problem. And so moving away from that into the population health sector, I was able to sort of focus a little bit more of my time and effort in putting some more work into what that looks like for finding a solution.

Host: Right. So you were seeing kind of the same things Billie was seeing. You kind of just kinda met them and went, hey, right, we're both seeing this. We need to come up with something. Is that kind of kinda how it started yeah.

Caitlin: When I, started working in this avenue, Community Care Team had sort of been established at that point for maybe about a year or two. And we were seeing significant outcomes with that program already. Initially we were seeing a decrease in almost a 35% decrease in overall cost of care. And then the impact we were seeing on emergency department utilization was fairly significant as well and has sustained around a 45% reduction in emergency department visits once they're connected with a healthcare advocate. And it's simply from meeting some of those social determinant needs that are often unmet when you're, you know, you can't engage in higher level treatment when you're worried about where your next meal's coming from, where you're going to sleep that night.

And so we've really worked to build out a community lens, and partnerships with all of our community agencies to make sure that we're able to sort of meet all of those needs one patient at a time.

Host: Yeah, so it sounds like you're not only you're taking care of the patient, which is number one, but it also has benefits for the hospital and the healthcare organization as well.

Billie: I think the population too, that we're reaching are the people that were not being reached before healthcare equity. The neediest people are the people that we were serving. So

Host: Can you talk about that population? Explain it to us a little bit. When you say the neediest.

Billie: They usually were patients with no insurance or Medicaid. They didn't have a primary care physician. They weren't connected with regular care at all. Lots of times they didn't have secure housing. They didn't have workforce training that gave them a job. And some of them were near death. They were addicted, or had mental health disorders. And, you know, I think suddenly we had this window of opportunity to really connect with them. And I think the one thing that was most exciting for me when we first started it was meeting with the community agencies.

We had the first meeting. I'll never forget it. We're from Vermont, so it was like a blizzard and it was the week before Christmas and I thought nobody's going to come. We're starting this wonderful project and nobody's going to come. And everyone came, there was like 30 people, who had trouble even driving there.

And I was so excited and I said, you know, this is great. And why did you come? And they said, because this is like amazing. If we could all be in the same room, these are the same people that were trying to individually help. But if we've got all the people that can surround them with care, we might actually be successful. And so that was the magical beginning. And then the next hurdle was how do we find the funding?

Host: Right. So let me ask you this. And first of all, Vermont should be beautiful this time of year, all the shushing and the shullashing. A little reference there. White Christmas, sorry. Can you explain to us, so you really have done a great job of explaining the issue and what the problem was.

Can you go into a little bit more of the Community Care Team? How was that built in structure? What was the answer to, hey, we think we're treating them for one thing, but they really need another thing from us. The community care team approach was born. What is the community care team approach?

Caitlin: Sure. We kind of touched on it a little bit already that it's not coming from a medical lens. So we hired healthcare advocates who are not necessarily clinical in background, but they have experience working with some of these high-risk populations because it's so important, I think the most important part of the program is the fact that the success comes from somebody who can build those trusting relationships with the individuals. Because the biggest barrier, every step of the way before we got into this work is that the patient ultimately is responsible for their success, their own success. And so by building a relationship with somebody who that person can trust, then allows them to connect with other community resources. So that they can be successful in establishing long-term housing or finding employment, or even just connecting with medical resources so that they can engage in treatment for substance use or mental health disorders.

Oftentimes, especially in a small community, you find that there's sort of a distrust that has developed, based on prior experiences or perceptions of and so our healthcare advocate has been able to build that relationship and eliminate that barrier. The beauty of our Community Care Team is that once a month, everybody comes into the same space and we facilitate a structured conversation around some of the most high risk individuals. They might come up this month, next month and the month after from a followup perspective. But it's what Billie said expecting nobody to show up in the middle of a snowstorm. Everybody continued to show up throughout a pandemic. Things have been remote, not a single month goes by where we don't hold a meeting and have a room, virtual room full of people coming together even if they're not necessarily involved with that individual directly, they're able to strategize and come up with solutions that have worked for other similar types of cases in the past that really don't have a traditional type of approach that you can really get to a solution. These are really, really complex cases, around homelessness.

I think that's the biggest barrier that has been highlighted throughout the pandemic, is just housing insecurity. We don't live in a big city, so it's one of those issues that is sort of under a couple of layers and is not at the forefront in our own community, but it's a huge problem and a very significant barrier to people being able to successfully engage in appropriate treatment plans, being productive with their recovery, contributing to from a financial perspective within their family units. So it's huge.

Host: Yeah. You're finding them the real care that they need.

Billie: Yes. And in some cases, go on to become part of the program and they want to volunteer and they want to help.

Host: They become an advocate for the program.

Billie: Because they recognize what a difference it made in their lives. And I think during COVID, we really saw that a lot of the state agencies just shut down. And so those patients still had those needs. So really, we kind of held it together and continued to meet with the community and to keep them in the loop. And, we also decided to okay, how can we have community care teams for other things? And, I'll get it started but let Caitlinn talk a little bit about, I was rounding with the pediatricians in our community and they told us that they were overwhelmed with the social needs of kids.

We live in a poor community with single family low income housing issues. And they said we can't take care of the health of the kids because there's so many social issues that we don't know what to do about it. So we put our heads together and said, well, let's think about a community care team. And so we created, over the next year, two of those one for birth to age six. And one for age seven to 19. And I'll let Caitlin talk a little bit about what we did with that..

Caitlin: Yeah. So it's been interesting to see that grow because that's a completely different set of community partners. We don't have with our adult community care team, we don't have the school district at the table. We don't have childcare providers. Sort of organically, we started out by seeing some of those, high risk individuals that our adult team was working with that crossover. Right? Because They may be working with a mother with substance use disorder who is at risk of losing their housing or, does not have financial security and then they become pregnant and we're now concerned about her ability to successfully have a child in the community without significant resources for herself in the first place.

And so it really did require a substantial level of partnership with different community partners, but a similar process. And we still continue to tie that back to our adult community care team. It's really neat to see, we have a adult community care team and two pediatric community care teams. And although they're separate programs, they're really partners every step of the way, strategizing how to build those relationships, with community partners, how to build those relationships with the individual that they're working with and sort of troubleshooting some really challenging circumstances. And definitely less than ideal environment.

Host: Well, these programs sound really, really important. And Billie, you were starting to talk about the funding because that is probably what people are going to ask. How did they fund this? So, so let's get to that now talk about the funding.

Billie: So that was the biggest challenge. Once we saw what we could do, we knew that we needed funding and we started to get creative and started looking for grants. And so we, as nurses started writing grants and did get one and got enough funds for three years of the program to be supported. And again, with that patient advocate. That was the biggest cost piece of it. So it wasn't super -

Host: Right. Cause you need to hire a person, an actual patient advocate that's going to service these communities if you will.

Billie: That was biggest piece of the funding. But then of course, that needed to somehow end up in the budget. And so tactically, I really had to start meeting with quality and safety, meeting with the CFO meeting with anyone I could think of that could help me advocate and start to show exactly what we were doing. We started to work with IT, to get data so that we could show exactly what was happening. We kept track of the successes, and then we decided to really seal the deal by having a celebration of the progress that we've made.

And we had patients there and we had care team members there. We had the Medical Director of the Emergency Department telling about how it had transformed care and got rid of our crowded waiting room and waiting time had gone down. And that now doctors didn't feel like they needed to do the medical workup. They could really just hand them over because they knew they were in good hands with our program. And after that, we just kind of slipped it into the budget. It's been there ever since. Then, Caitlin had to help me get funding for the pediatric community care team. And I think now we've proven that we are on the right track.

We are taking care of our community. We're making a difference. And, we are having an easier time dealing with administration, getting some of those programs funded.

Host: It sounds like you built a coalition.

Caitlin: Yeah, I think the other thing that's sort of important to mention, from our perspective, being in Vermont, we do participate in an accountable care organization. So it does give us a little bit of leverage when we're having these financial conversations around it's not great from a fee for service perspective, but in a ACO perspective where you're really looking at value based care and implementing resources in a cost effective way to decrease emergency department, unnecessary emergency department utilization by almost 50% consistently every year. I mean, that's huge.

Host: So there is that benefit there. So you're just really trying to tell the story, but once you do this seems like such an important program. It's easy for administrators and leadership to buy into.

Billie: Yes. And, again, it isn't super expensive, but the benefits are huge. You know, I think we've done presentations at schools. We've gone to the city council meeting. We've tried to get the word out and it started an avalanche of support for other things like, food insecurity. Suddenly we started not wasting any food at the hospital and getting it made into soups and stews and casseroles and delivering it.

We got youth in the schools helping to package that and deliver it. So it really started a movement of the entire community coming together and helping us to make better decisions to take care of people in our community.

Host: Yeah, it sounds like this community care teams model could work in many different cities and places around the country, as someone listening to this says to themselves, yeah, you know what, I'm seeing the same things. I should be looking into this. Where can they start? What should they do? What's your advice, Billie let me start with you..

Billie: I think you start small if you're in a huge community, we've done some presentations at major places. And they found, one neighborhood where they were going to start. And I think you start small and you build that coalition just like you just mentioned. And then it kind of feeds itself and it just takes a couple of committed people to get the ball rolling. I think agencies across the country want to get together. And want to work together. They say it's the best use of their time. This is where they're most effective and get results. So it's not difficult once you bring them to the table. And I think you start small and then just let it build and grow. And a lot of it just builds and grows naturally.

Host: Organically yeah. Caitlin, how about you? What's your thoughts?

Caitlin: I think that the piece of it that's important to remember is that we are somebody who took an idea and replicated it. And so it's a very replicable concept with minimal additional resources. I think the biggest piece around success is having buy-in within your organization. We have a really strong partnership with our Medical Director of the Emergency Department who truly believes in the program. And so that makes it a little bit easier because we're able to have those conversations. We are able to connect with the nurses in the emergency department around how do you identify these high risk individuals and get them connected to.

And I think the other piece of it that's important to think about is just, thinking on that data collection perspective and knowing that even if you're piloting and you're only working with 15 people initially to be able to demonstrate the decrease in utilization the cost savings, and then. just the anecdotal success stories of the program are.

Host: Yeah, as we wrap up and thank you so much for your time. I mean, could you just share a success story with us just to illuminate this for us a little bit more.

Caitlin: Sure. I'm just going to sort of share a COVID related story because we're in the midst of pandemic. But our community care team advocate was working with an individual who at the beginning of COVID was one of those people who was kind of making ends meet, living paycheck to paycheck but was okay and lost their job. And so this is somebody who then started to connect with our healthcare advocate from a financial insecurity perspective, because that sort of domino effect of losing a primary source of income, they were on the verge of losing their housing. They have a family. So Kim, who is our healthcare advocate for the program worked to connect with this person and ended up, they didn't lose housing. They stayed housed. She ended up reaching out to Senator Sanders office and was able to get about $10,000 of back owed unemployment funding so that this individual could maintain housing because it was like this close. It's little things like that, that extra mile that our healthcare advocates always take with every person that they work with that make a huge difference in that person's life.

Host: Well, think about the snowball effect if that person would have lost housing, what that would have led to something else led to something else. So that was huge. So that's a great example. Just having an advocate, speaking on behalf of that, you know, underserved person, what a difference that made in their life.

Caitlin: That's, what they do everyday.

Host: Amazing. Well, gosh, thank you both for your time. I love this conversation. I love the work you're both doing so thank you, both. Billie and Caitlin, thank you again.

Caitlin: Thank you for having us.

Billie: Thanks so much.

Host: And once again, that's Billie Allard and Caitlin Tilley. And for more information, please visit aonl.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is Today in Nursing Leadership. Thanks for listening.