When Akron Children’s Hospital began its Population Health management program in 2017 it was with the vision to develop a family-centered, efficient and outcome-focused care coordination model for the hospital’s highest risk patients.
According to Kris Grayem, vice president of population health, “Our department looks at how we can collaborate with outside agencies and departments within the hospital to get the resources we need for our patients.”
The Population Health team, led by Grayem and Steven Spalding, MD, vice president population health, consists of 5 nurses, 3 social workers and 3 medical assistants, who divide up the patient caseload in Akron Children’s Hospital Pediatrics offices in 32 locations.
According to Kris, the team receives a registry of high-risk patients who have been identified based on a number of factors, including:
- being on Medicaid
- the number of specialists they see
- the number of emergency department visits and hospitalizations they’ve had in the past 12 months
- how many times they miss a scheduled appointment
- whether they have identified social determinants to health – things like lack of access to food, housing, childcare and transportation
“In addition, Anthem, along with some of the managed care companies the hospital contracts with also provide us with a list of their high-claim patients,” she added.
Kris says the idea behind population health is to help remove barriers to care and social determinants to health by connecting clients to resources that can assist them.
One of those resources is Social Worker Zully Nieves-Ramos, who has a caseload of approximately 75 patients at any given time. Zully works with one of the department’s nurses who helps to triage the patient’s medical needs.
“We try to meet our patients and families where they are – we can’t wave a magic wand and get them a job, but we can steer them to the right resources,” Zully said.
That’s what Zully did for 21-year-old patient Jacob Hamm.
“Jacob came on my caseload when he 19 years old. He has Crohn’s disease and had no medical insurance because he was working in the landscaping industry and making just a few dollars over the requirements for Medicaid, which he had aged out of,” she said. “He wasn’t able to get his medications or infusions because he couldn’t afford them.”
Zully relinked Jacob with Lori Taylor, one of the hospital’s financial counselors who had helped him in the past. Lori was able to help Jacob apply for the Hospital Care Assurance Program (HCAP) to help get him assistance with medical bills.
“For a while Jacob didn’t have a phone so Stacey Moreen, his assigned nurse caseworker, would schedule his appointments for him,” Zully said. “Again, this is part of the meeting our patients where they are philosophy.”
In addition to connecting Jacob with HCAP, Zully helped him secure glasses, dental care and counseling services. Jacob is extremely grateful for all they did for him.
“Zully, Stacey and Lori are like moms to me,” he said. “They went above and beyond and helped me get my life back on track when I was feeling really down and I didn’t have insurance.”
Because of the severity of his Crohn’s disease, Jacob requires monthly infusions of Entyvio®, a biologic medication used to treat inflammation, to keep his disease under control. Having recently turned 21, Jacob needed to transition his care to an adult provider who could take over the management of his Crohn’s from his pediatric gastroenterologist, Dr. Kevin Watson.
“Zully and Stacey contacted Summa and helped find an adult GI doctor so I could continue my monthly infusions and not let my health backslide,” Jacob said.
On average, the Population Health team works with a patient for 3-6 months.
“Even though Jacob is no longer one of my cases, he knows he can call me, and I will try and be there for him as a resource,” she said. “In this job, you develop relationships and that doesn’t just stop after discharge. I genuinely care about helping people and seeing them succeed.”