In January of 2018, CrossOver launched Bridges to Health, a program serving patients recently discharged from the hospital. At the time, our staff had noticed a pattern: on many days, we’d be running the clinic on our normal primary care schedule, and a new patient would walk through the door in crisis. The patient would be just out of the hospital, most often having been treated for a heart attack, heart failure, diabetes, or blood clots. At discharge, the patient might have been provided with a list of charitable clinics along with a fistful of unfilled prescriptions. Often, these patients were worried about medical bills and medication costs, overwhelmed by the implications of their recent illness and hospital stay, and daunted by the requirements to maintain their health. “They have incredible care in the hospitals, state of the art care,” says Mike Murchie, MD, CrossOver’s medical director, “but if they can’t continue to have their medicine and see a primary care doctor, it literally will all be undone—and undone very quickly. They will end up back in the hospital, which is tragic and costly for their family, and over time, it increases the cost of care for everyone.”
Prior to 2018, when these patients came in, we would find an appointment for them. But these appointments were very time intensive, covering so much complex information. The hospital discharge patients deserved the best of our attention, and our primary care patients deserved a reliable and efficient visit schedule. “There are so many layers that we realized we needed a team approach to our hospital discharge patient visits and a time set aside where their unique needs could be best addressed,” Dr. Murchie says. “So we started Bridges to Health.”
Now, we have developed cooperative relationships with VCU, Bon Secours, and HCA. Their social workers coordinate with ours so there is a smooth transition for the patient from hospital care to care at CrossOver.
Bridges to Health clinics are held once a week at each CrossOver clinic. When these patients arrive at CrossOver, they are cared for by a multidisciplinary team. First, they meet with our eligibility screening team and then with a social worker, who does a full assessment of housing, income, and other needs as well as a depression screening. Then, the social worker takes the patient to a nurse, who does a full medical intake. Next, the patient is seen by one of our clinicians, and before they leave, they receive their medications or prescriptions. We also take care of any labs and referrals needed. We schedule a phone call with a nurse for a week or two after their appointment, “so if someone started on insulin or monitoring their blood pressure, they can report their numbers to the nurse and schedule follow up appointments as necessary,” Dr. Murchie explains. “This saves the patient a return trip unless it’s needed.”
The program has been very effective. Since its beginning, only 3.1% of Bridges to Health patients have had an unplanned hospital readmission within 30 days of leaving the hospital, and only 3.2% have unplanned readmissions by 90 days. And the numbers have gotten even better in recent years. Bridges to Health served 255 patients in fiscal year 2020, and less than 3% of those patients had unplanned readmissions at 90 days after discharge.
“This program has been so helpful,” Dr. Murchie says. “People that are just coming out of the hospital are the most vulnerable for bad outcomes. We often hear from patients’ family members that they were already afraid for their loved one’s health in the acute stage of their illness, but at some point, they realize that improvement is not going to be sustained because of lack of access to care and medication. Finding CrossOver, meeting the team, and accessing care allows them to have hope again.”
Attention CrossOver Volunteers: Are you a CrossOver volunteer who has hit pause on volunteering because of the pandemic? We miss you! If you’re considering returning to the clinic to volunteer, reach out to Rachel Yowell, volunteer manager, at firstname.lastname@example.org to discuss your plans to return. We look forward to welcoming you back!