Main content

    Caring for Our Community

    Navigating Patients to Better Health

    Care Transitions nurseOur hospitals and emergency rooms are open 24 hours a day with top-notch staff to care for everyone who walks through our doors. Most days, that includes a lot of people who come to our emergency rooms for non-emergencies.

    Members of our community who are underinsured or uninsured, homeless or living in poverty, and those with behavioral health problems, frequently use the emergency room for primary health care. These patients account for almost half of those making non-life- threatening visits to the ER.

    With the goal of providing the right care in the right place at the right time, Sutter Health’s Alta Bates Summit Medical Center and the Community Health Center Network are working together to offer greater access to primary medical care for patients who often rely on the ER.

    Care Transitions Program

    Our program places registered nurses at three Oakland and Berkeley community clinics. In this way, we work to ensure patients establish a convenient medical home where they can make a follow-up appointment and get routine care.

    Care transitions nurses work with approximately 3,600 patients a year who visit the ER or are admitted to Alta Bates Summit, cared for and discharged.

    Data Supports New Approach

    In August 2014, the Community Health Center Network tracked the outcomes of 600 of the 3,600 patients and found that patients in the care transitions program saw a:

    • 32 percent increase in primary care physician follow up within 30 days of their first admission to the hospital.
    • 17 percent decrease in ER visits within 30 days of first admission to the hospital.
    • 17 percent decrease in hospital readmission within 30 days of discharge.

    "For a relatively young program, these findings are remarkable. We’re constantly looking at ways to provide better care to patients while controlling health care costs. This does both and it’s a win-win for the East Bay community."

    - Steve O'Brien, M.D. Chief Medical Executive

    "It takes a village to help navigate effective care and transitions to more convenient and appropriate settings so that our patients are well cared for when they are discharged.

    "Helping patients get access to community health providers who can offer a wide range of services— including preventive care, disease management and social services for patients—is key."

    - Tracy Schrider, LCSW, ACM Administrative Supervisor of Social Work

    Partnering with Federally Qualified Health Centers

    Through its not-for-profit mission, Alta Bates Summit and its philanthropic partner, Better Health East Bay, have invested nearly $1.5 million in programs to care for the neediest in our community.
    To ensure a smooth transition and continuing care once the patient is back in the community, Alta Bates Summit Medical Center relies on long-established relationships with Asian Health Services, LifeLong Medical Care and La Clinica de La Raza.

    These deeply rooted community organizations offer centrally located, affordable, comprehensive and effective primary and preventive care. They also provide language translation services and help identify and remove other barriers to care, such as substance abuse or lack of transportation or permanent housing.

    "Working collaboratively with the in-patient case managers, I can help advocate for our patients. I can let our physicians know, in real time, that one of their patients might have a new condition or how medications have changed.

    "Our goal is to facilitate optimal primary care, health and wellness. If we get patients plugged into primary care earlier, hopefully this will prevent more serious illness down the road."

    Isobel Harvey, R.N., MSN Care Transitions Nurse Manager LifeLong Medical Care

    Positive Effects in the Emergency Room

    In the ER, care transitions case managers collaborate with medical staff. Once the patient is discharged, the case managers help arrange transportation, determine eligibility for home health benefits and outpatient treatments, and explain financial assistance programs and community resources.

    Most importantly, case managers help patients make necessary follow-up appointments.

    Expanding Community Care

    Looking ahead, Alta Bates Summit and its community partners plan to hire ER patient navigators to assist the R.N. care transitions case managers. Funded by Sutter Health, the navigators will work at the health clinics to help even more patients. Sutter Health is exploring opportunities to expand this model to other East Bay hospitals and clinic partners to improve care for the most vulnerable in our communities.

    "This is the best program that’s been implemented at Alta Bates Summit in the eight years I’ve worked here."

    John Mullen, R.N. Summit ER Charge Nurse