What It Is

The Care Transitions Initiative is a three-tiered intervention for the health system. It is comprised of three components:

Community Referral Coordinator (CRC) Program

P.U.L.S.E.™ Model

Transitions of Care (TOC) Task Force

Goals

Enhance access to a primary care home and health resources for all patients regardless of ability to pay
Reduce non-emergent use of emergency departments and low acuity re-admissions
Enhance continuity of care
Strengthen communications and processes among safety net providers caring for the same patients

Impact

16,384

patient encounters by the CRC team

9,029

patients scheduled for appointments

53%

For all appointments scheduled, 53% of appointments were kept

$8.4

Cost savings of $8.4 million in CY2017

811%

Return on Investment when savings are compared with budget of CRC Program

23%

Reduction in Non-emergent ED Utilization (over 5 ½ year period)

FOR PATIENTS

Community Referral Coordinator (CRC) Program

Community Referral Coordinator (CRC) staff meet with patients in acute hospital settings to assist in navigating to outpatient care. CRCs connect patients from inpatient units and/or emergency departments of hospitals with a primary care home for follow-up and preventative care. The program focuses on serving underinsured and uninsured patients; however, works with all patients in need of a medical home. Community Referral Coordinators are employees of the IHN who work on-site in the hospital. The CRC program started in 2007 in 2 hospital sites through grant funding. In 2014, the program transitioned to a contract based model and by 2019 has expanded to 9 hospital sites with 12 full-time hospital-based CRCs and 2 community-based CRCs.

P.U.L.S.E.™ Model

The P.U.L.S.E.™ Model is an educational framework used to assist patients/community members to understand the levels of care available in the community and when and how to engage. The P.U.L.S.E.™ acronym stands for: Primary Care, Urgent Care, Live Well, Specialty Care and Emergency Care.

CRC Team Retreat group photo — At the annual CRC Team Retreat in December 2018

FOR THE HEALTH SYSTEM

Transitions of Care (TOC) Task Force

The Transitions of Care Task Force is a cross-functional group of providers and health leaders serving the safety net. The TOC Task Force collaborates to improve care transitions across the community. The Care Transitions Initiative was designed so that family-level engagement can inform systems level change efforts, and vice versa.

The goal of the St. Louis area Transitions of Care Task Force is to promote high-quality, safe, and efficient patient transitions of care between a hospital (inpatient or emergency department) and an outpatient setting including coordinated appointments and transfer of important clinical information. The Transition of Care taskforce meets 5-6 times yearly and 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.

CRC Program Metrics