By Marnie McAllister, Record Assistant Editor
A new program offered by KentuckyOne Health is reaching out to people from low-income neighborhoods who struggle with multiple health problems.
Among them is Carrie Brown, an elderly widow living alone in South Louisville. She had a series of falls a few months ago and landed in a local hospital operated by KentuckyOne.
Upon release, she would have had to fend for herself at home and, perhaps, fallen again, KentuckyOne officials said.
Instead, KentuckyOne’s Health Connections Initiative sent a team of four — a registered nurse, licensed practical nurse, social worker and a community health worker — to visit Brown regularly for a 90-day period.
“I’m doing better now,” Brown said in during an interview last week in which she also noted that she has heart trouble. “These social workers, they’re the sweetest things that ever was. They’d tell me to do things, like breathe in real hard and breathe out when I was retaining fluid and couldn’t hardly breathe. And it helped,” she said.
The Health Connections team also coordinated Brown’s follow-up care with a physician who adjusted her medication. One medication, it turned out, had been making her sleepy and unsteady on her feet. She’s not falling anymore and she hasn’t returned to the hospital, Brown said.
Brown and 72 other patients who participated in the recent eight-month trial period of the program “saw dramatic improvements in rates of depression, confidence in their ability to manage their health and connection to a medical home,” according to a news release from KentuckyOne.
“Only six patients were readmitted to the hospital compared to 26 the year before,” the release said.
KentuckyOne Health announced in mid-August that the program — which is free — will continue operating full-time for the next three years thanks to a grant from Catholic Health Initiatives. The Catholic health care system is funding the program with a $1.5 million grant from its Mission and Ministry Fund.
Alice Bridges, KentuckyOne’s vice president of healthy communities, said the program is expected to serve about 524 people during the three-year period.
She sees it as part of the faith-based mission of KentuckyOne, which combines Jewish and Catholic heritages, to care for the “whole person,” she said.
“We really have a moral imperative to do this,” said Bridges. “It really is grounded in Catholic social teaching. Barriers to good health go far beyond medical conditions, so our program looks at what (patients) need for their whole health.
“They may need help with transportation, applying for disability. They may need help getting meals on wheels” or finding a primary care physician, she noted.
Patients are selected for the program after being admitted to one of KentuckyOne’s two local hospitals — Jewish Hospital and Sts. Mary and Elizabeth Hospital. A computer program analyzes multiple factors in the patients’ lives, such as how often they are admitted to the hospital, how much support they have at home and where they live.
The program is available only to those who live in West Louisville and South Louisville, and for a good reason, said Bridges.
“Neighborhood is more of a predictor of health outcome even than genetics,” she explained. “Even when you adjust for socio-economic status — take that out of the picture — neighborhood is still a predictor” of health, Bridges said, citing statistics from a 2013 report issued by the Louisville Metro Department of Public
Health and Wellness’ Center for Health Equity.
According to the report, “You’re going to live about 13 years less on average in West Louisville and South Louisville than if you live in some other neighborhoods,” she said.
These areas also have the most frequent users of the emergency department and outpatient services at local hospitals, she added.
That’s partly because many patients don’t have a primary care physician, according to Dr. Valerie Briones-Pryor, medical director of KentuckyOne’s Hospital Medicine Service Line.
“We do such a good job at the hospital and they do so well,” she said of the patients she sees at Sts. Mary and Elizabeth. “And then they come back. And we think, ‘What happened? You were doing so well.’ ”
She started a transitional clinic at the hospital to help bridge a gap she observed in follow-up care.
“We’ve done so much to try to improve patient care outside the hospital,” she said. “With the way health care is changing, we really have to be with patients … in that transition period when they leave the hospital and before they see their primary care physician.
“Everything is coming together at the right time,” she said. “The transition clinic acts as a safety net for the HCI (Health Connections Initiative) team.”
Dr. Briones-Pryor has seen the effects of the program on her patients first hand.
“All of them wished the program went beyond the 90 days. You could tell they were energized by that team and felt they had the tools to continue on with the work the team had shown them,” she said.
There are currently two Health Connections teams, one for South Louisville and one for West Louisville. The team members come from VNA Nazareth Home
Care, which Bridges said, “is the champion” of the program.
Both teams include a non-medical person called a community health worker who is key to the program’s success, said Bridges.
“This is a respected person from their (the patient’s) neighborhood and they break down the inherent power relationship between health care workers and patients,” Bridges explained.
Bethany May, a community health worker on the South Louisville team, said “it’s the best job I’ve had in my life. It’s so fulfilling, it’s so touching to see your work in action. You see the effects on” the patients.
She visits Carrie Brown about once a week and she attends doctors appointments with her.
Before an appointment, May said, she helps the patients prepare questions, and afterward, she makes sure her patients understand the doctor’s instructions.
And sometimes, she added, “you’re just there for support, to be a friend by their sides.”
