Navigating the health care system can be complex and challenging for anyone. It is particularly difficult for patients who lack basic resources, such as food, transportation and housing, or who have multiple health needs. Pair these challenges with a shortage of primary care, like in Butler County, and many in the community end up receiving care through hospital emergency departments. Fueled by a one-year $205,000 bi3 grant from TriHealth Bethesda Butler Hospital completed a planning process, to better understand the needs of its patients and explore solutions that would improve health and healthcare in the region.
The planning process included three areas of work:
- Needs Assessment- Partnering with Primary Health Solutions, a community health center, Bethesda Butler Hospital administered a Social Needs Survey. More than 400 patients responded to the survey. Identifying access to affordable food, unstable housing, paying for healthcare and transportation as top social needs. Data were gathered on an additional 100 patients who were high utilizers of healthcare (patients who had 2 hospital admissions or 3 emergency room visits in the last six months). These patients accounted for 25 percent of emergency room visits and the majority were covered by Medicare or Medicaid.
- Research-The team also explored different models of care for complex patients. Through the planning process, three best practices were identified: 1) Partnership with a Federally Qualified Health Center; 2) High-touch in home/community intervention; and 3) a Community connection center. Based on their learnings, the Bethesda Butler team piloted a volunteer-run Community Connections Desk in partnership with Miami University. The pilot utilized trained students to screen patients for social needs and help link them to community resources. In 12 weeks, more than 1600 patients were screened, 43 percent of which identified an unmet need. Those identified with unmet needs were connected to community-based organizations for services. The pilot generated many learnings around patient needs and procedures for referring to community resources. The need for more training and support around trauma informed care was identified as a key area of work.
- Pilot and best practices-The final phase of work focused on targeted community engagement efforts. Bethesda Butler team members reached out to a variety of Butler County organizations to identify resources for patients and build referral relationships. Hospital staff are now members of local coalitions seeking to address the social determinants of health.
Learnings have been shared at multiple conferences including the Ohio Hospital Association, the Emergency Nurses Association and the National Center for Complex Health and Social Needs. The project continues to inform discussions within TriHealth around meeting the needs of the Medicaid population and population health. Because of this work, Bethesda Butler has been chosen as TriHealth’s pilot site for the federally-funded Accountable Health Communities (AHC) effort being led by The Health Collaborative.