Community Connections Program in partnership with Humana makes a difference
Yolanda Rodriguez, 46, had been in and out of Community Regional Medical Center’s emergency department several times a month for a year. She had poorly managed diabetes made worse by mental health issues and living on the streets.
 

Community Regional social worker Xochitl Valenzuela took to Fresno’s streets to find her — in an encampment with an open wound on a foot that had been amputated.

“Yolanda has no family support. She eats when she can. She was living in a place with a lot of violence. Her medications would be stolen,” said Valenzuela. “We partnered with the Fresno County Department of Behavioral Health to find housing and financial resources and link her to mental health help.”
 

And she was folded into Community’s new Diabetes Medical Home, which provides a team-based approach to caring for patients with psychosocial concerns. It’s part of the Community Connections program at Community Regional, which partners with community-based organizations to help uninsured or underinsured patients with chronic diseases to improve their quality of life and reduce avoidable trips to the emergency room. In its first six months, the Diabetes Medical Home reduced emergency department visits for patients in the program by 74%, reduced hospital admissions by 64% and cut by more than half the hospital stays of those who are admitted.
 

The hospital-based Community Connections program’s mission is to provide quality comprehensive care coordination and outreach services to Community Regional patients to promote wellness, and help restore health, with excellence, compassion, and competence. The majority of the patients served are vulnerable populations with problems of chronic disease, homelessness, substance abuse, and mental illness. Many patients find themselves using the hospital as their safety net when they have trouble accessing primary care physicians. Many lack reliable transportation, have little education and find barriers navigating complex medical and social services systems.
 

In September 2012 a generous gift from the Humana Foundation enabled Community Connections to expand staffing and additional resources in the form of a medical home concept to serve the diabetic population whom have multiple and/or frequent emergency department visits and inpatient stays. Humana Foundation’s gift provided for a nurse practitioner dedicated to the diabetes population with specific attention to:

• Expedient and frequent access to primary care services
• Proactive identification and education of high risk diabetic patients within the hospital
• Linkage to the Diabetes Medical Home and Diabetes Care Center

The gift also provided for a social worker and an outreach specialist to assist with a variety of psychosocial needs such as:
 

• housing
• transportation
• insurance
• mental health
• social services
• public benefits
• depression/anxiety screenings
• monthly home visits for supportive services

This multidisciplinary approach has had a significant impact on reducing visits, inpatient stays, and improving the lives of patients. Since Humana’s gift Community Regional has seen the following results among patients enrolled in the Diabetes Medical Home:

• 27% drop in emergency room visits
• 64% drop in admissions to the hospital
• 65% drop in inpatient days

But the numbers don’t tell the real story about the difference this gift is making. Valenzuela was also able to help Yolanda find a stable living situation, help her find transportation to her appointments and keep up regular contact.  Housing one homeless person for a year can save Fresno taxpayers $11,872, say Fresno City officials, who estimate the city’s 14,000 homeless cost the community about $80 million in resources each year. Finding Yolanda a home, is also helping her stay out of the hospital.
 

“Yolanda’s had mental health issues for 20 years or more. We can’t just discharge her and say 'Call your doctor and make an appointment' like we do other patients,” Valenzuela said. “We’ve become that family support system that’s missing. If she would’ve had support 10 years ago, she probably wouldn’t have had that foot amputated.”
 

Erin Kennedy reported this story. She can be reached at MedWatchToday@CommunityMedical.org.