Our flagship Care Transitions Initiative is a three-tiered intervention for the health system designed to enhance care coordination and improve patient experiences throughout their health journeys.
The Care Transitions Initiative is comprised of the following components: Community Referral Coordinator Program, P.U.L.S.E. Model, Transitions of Care Task Force, and the ELC CHW Maternal Health Initiative.
Community Referral Coordinator Program
The Community Referral Coordinator (CRC) program is a patient-centered intervention where trained staff work with patients and community members to assist in understanding and navigating their healthcare.
The goal is to enhance access to a primary care home and health resources for patients regardless of their ability to pay. While our focus is on serving underinsured and uninsured patients, we work with all patients in need of a medical home.
“I had no idea how to navigate healthcare services to get what I needed. With IHN’s help, I am enjoying time with my family in better health. IHN is a blessing, and I’m truly thankful.”
– Byron Witherspoon, CRC Patient
How It Works
Community referral coordinators are members of the IHN team who work on-site in the hospital. CRC staff meet with patients in acute hospital settings to assist in navigating to outpatient care, often connecting them from inpatient units and emergency departments with a primary care home for follow-up, outpatient, and preventative care.
Our dedicated CRCs often provide education around the availability of care services, help patients find primary care homes, and help with scheduling follow-up appointments and arranging transportation as needed. They’re also equipped to connect patients to medical and social service resources to assist with system navigation, as appropriate.
CRC Program History & Growth
The CRC program began in 2007 in two hospitals through grant funding, and in 2014, we transitioned to a contract-based model. We’ve since expanded to 10 hospital sites with 12 full-time hospital-based CRCs and two community-based CRCs.
The CRC program celebrated 15 years of operation in 2022, during which our team surpassed 200,000 total patient encounters. We also joined 165 other community-based organizations in training and onboarding to the St. Louis Community Information Exchange, designed to streamline and strengthen the region’s health service ecosystem.
Over the years, we’ve seen an upward trend in appointment show rates for patients connecting to primary care homes after a hospital emergency department visit or inpatient stay. The show rate was 29% in 2009 and had more than doubled to 64% by 2021.
15,000+
Patients served at 10 hospital sites and in the community in 2023
97%
Self-pay/uninsured patients received health coverage assistance in 2023
76%
Patients who did not have a primary care provider in 2023
P.U.L.S.E. Model
The P.U.L.S.E.™ Model is an educational framework used to help patients understand the levels of care available in their community, as well as when and how to engage with those systems. The acronym stands for:
- Primary Care
- Urgent Care
- Live Well
- Specialty Care
- Emergency Care
This model is the second component of our initiative, and through it, we aim to reduce non-emergent use of emergency departments and low acuity re-admissions, ultimately improving the efficiency and effectiveness of our healthcare system.
Transitions of Care (TOC) Task Force
The third and final component of our initiative is the Transitions of Care (TOC) Task Force. Formed in 2013, this cross-functional group of providers and health leaders focuses on strengthening collaboration by addressing policy and practice issues from a system’s perspective in order to improve care transitions across the healthcare system.
The TOC Task Force collaborates to improve care transitions across the community with the goal of promoting high-quality, safe, and efficient patient transitions of care between a hospital (inpatient or emergency department) and an outpatient setting. This includes coordinated appointments and transfer of important clinical information.
Meeting quarterly (with smaller workgroups meeting more often as needed), the TOC Task Force includes membership of all IHN board organizations and providers, CRC team members, and other key partners in the areas of behavioral health and social services.
ELC Project
At the heart of the St. Louis Integrated Health Network (IHN), we are committed to advancing health equity and improving well-being through increased access to health and social services. One of our key initiatives in this mission is the Epidemiological and Laboratory Capacity Community Health Worker (ELC CHW) Initiative, a program specifically designed to support at-risk pregnant individuals.
Collective Impact
Since its inception, the Care Transitions Initiative has made significant strides in advancing health equity and improving wellbeing, including:
- Enhanced continuity of care, ensuring patients receive consistent, coordinated care regardless of ability to pay
- Improved electronic communications and processes among safety net providers caring for the same patients, reducing duplication and improving patient outcomes
- Defined a TOC standard of care for the region to ensure patients consistently receive quality care, regardless of provider
Through the Care Transitions Initiative, we’re leveraging the common interests, resources, and expertise of our members to optimize health outcomes and eliminate health disparities.