Smart thinking and reaching out to a community-based organization (CBO) partner can result in a solution that benefits patients and everyone else involved, as well.
Here’s an example: The case management vice president at Carolinas HealthCare System in Charlotte, NC, read an article about how many people who are eligible for food assistance and other benefits are unaware that they can apply, says Kathryn Harrell, MSW, ACM, social work case manager at Carolinas Medical Center.
“So the vice president approached us, saying, ‘What can we do about this? If people are eligible for benefits, but are not connected, how can we get them connected?’” Harrell recalls.
The case managers knew of a state eligibility tool that could be used to screen people for benefits. They spoke with health professionals in various departments and found that people were receptive to the idea but would say they had neither the time nor expertise to screen patients using the tool, she explains.
“So we reached out to a community partner, Crisis Assistance, and said, ‘Hey, how would you like to help us explore something beneficial?’” Harrell says. “It’s taken us a while to figure out the kinks, but they now help us screen for one benefit: nutrition services.”
The initiative starts with case managers assessing patients, realizing they have limited income and are not receiving food stamps or who say they do not have enough food at home. “I make sure case managers are asking the right questions to identify food insecurity,” Harrell says.
Part of the case manager’s job is to make patients comfortable with the idea of asking for help. “A lot of times, if you say, ‘Hey, are you receiving food stamps?’ they’ll say, ‘No, I don’t want to depend on that,’” Harrell says.
“Case managers will answer, ‘Sometimes it’s just temporary. If you’re eligible, it can help you get through your medical crisis. If you’re eligible, you should get it,’” she adds. “We beat down some of the stereotypes.”
The case manager then refers these patients to Crisis Assistance for an eligibility assessment.
The tool, which is called Benefit Bank, can be used for a variety of benefits. Crisis Assistance had been using the tool with the organization’s clientele and agreed to come into the hospital three days a week to meet with patients at bedside to screen them as well, she says.
The Crisis Assistance representative went through hospital protocols and training. She also helps patients with other social needs, including help with budgeting, utilities, rent assistance, and job searching.
“She has worked at Crisis Assistance for a long time and is a wealth of knowledge,” Harrell says. “She has a certain skill set and knows community resources better than a case manager does because we’re focused on hospital resources.”
“The crisis assistance person also follows up with patients if they’re discharged, and she meets with them in the community,” Harrell adds. “She is available to them by telephone.”
Hospital case managers send her referrals for assessments.
Since initiating the collaboration, the hospital has had hundreds of referrals for food assistance, she adds.
“There are lots of people receiving food stamps, and we track them when they come back to the hospital to see how many referrals are submitted to Crisis Assistance and how many applications were submitted to the state department of social services,” Harrell says. “We see how many were approved and how many were readmitted to the hospital.”
While the initiative’s data is too limited to conclude that the referrals reduced hospital readmissions, it is possible to say that the people who received food stamps did not return to the hospital within 30 days, Harrell says.
“So we like to think we had some impact on them,” she says.
