Winona Health's Community Care Network reaches at-risk residents

AHA News

Minnesota City resident Tom Ailing’s life turned around when he joined Winona (Minn.) Health’s Community Care Network (CCN) program three years ago.

The 64-year-old retiree suffers from diabetes, chronic obstructive pulmonary disease (COPD) and neuropathy – illnesses that used to send him to the hospital’s emergency department (ED) as often as four times a month.

“I used to get pneumonia and COPD attacks all the time and end up in the hospital,” says Ailing, who lives with his black lab Tommy Boy. He says the ED bills added up, and it was stressful and depressing to be sick so frequently.

But Winona Health’s CCN program helped Ailing manage his health conditions and stay healthy at home. The program trains volunteers from Winona State University to be health coaches who make weekly visits to the homes of patients like Ailing. They visit not to measure blood pressure or manage medications, but to offer company, comfort and a listening ear. 

Ailing has been to the hospital only once since enrolling in CCN. He exercises twice a week at Winona Health’s fitness center and sees his doctor for regular checkups. He’s cut his blood pressure in half since joining the program, and says he’s never felt healthier.

“I would be dead without it,” he says. “It’s a great program. I wish I had it years ago.”   

Winona Health launched CCN in 2013 to help patients with chronic illnesses stay healthy and avoid emergencies that can become costly for both the patient and hospital.

Patients at risk for frequent hospital admissions are referred to the free program. “We want to put them back in the drivers seat of their health,” says Winona Health social worker Cassie Boddy, one of Ailing’s original health coaches and a CCN coordinator. For many isolated elderly patients, the coaches are a “familiar face” who help them connect to community organizations or work with them on a plan to start exercising and eat healthier foods.

“When we see the same patient coming back for readmission for ED visits on some level of frequency, something’s happening that we don’t know about,” observes Winona Health President and CEO Rachelle Schultz. “This initiative allows us to see what’s broken outside our walls.”

Through last year, the program trained 42 health coaches who made more than 6,000 visits to 103 patients. ED visits and hospitalization for CCN clients declined by more than 85%. Results like that helped CCN receive the 2016 AHA Hospital Awards for Volunteer Excellence – or HAVE Award – for community outreach and collaboration. 

“Seeing the transformation in the clients is the best part of the program,” Boddy says. “They are healthier, happier and more motivated.”

The program gives the hospital ground-level information, an essential part of population health management, says Marti Bollman, Winona Health’s vice president of primary care clinics.  While the hospital is not reimbursed for the community-based service, Bollman says programs like CCN point the way to the future.

“When you think about value-based payment and the ongoing reforms in health care, you see us moving toward a world where we are going to get paid for quality,” she says. “This program means value for the people in our community. And we see the reward of doing the right thing.”  

Topic: Community Health
Tags: readmissions, population health, Community health, Community Connections, chronic conditions

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