By Melinda Young
Case managers are logistical artists when it comes to helping patients handle care needs during hospitalization and transitions after discharge. But things can get out of control when patients leave the hospital, and transportation is a top obstacle to patients receiving necessary care in the community.
“Rides are difficult, and public transport services are variable,” says Kristin O’Neal, BSN, RN, ACM-RN, CCM, a former transitions of care administrator for a large health system in Norman, OK. “When we started screening patients for social determinants of health at the hospital, transportation was the No. 1 barrier patients experienced.”
Including transportation as a resource at discharge and for follow-up care can produce positive results for patients and health systems, including reducing readmission rates. “From the hospital case management side, we do an amazing job at planning, looking at plan B, and having a plan C, and looking at all of the issues that arise,” O’Neal says. “But things are out of our control when the patient discharges. We don’t know what will happen to the patient, or we do know but there are no resources to help.”
The solution is for health systems to provide free or affordable transportation to patients who need it. Resolving this social determinant of health problem can help care transitions and streamline the discharge process. (For more information, see the story in this issue on how transportation services improve hospital efficiency.)
Transportation programs offer different features, depending on the health system. Some may focus primarily on providing transportation for patients discharged from the hospital. Others may offer transportation services for discharged patients who need a ride to primary care and other appointments.
Transportation services also can help with patients’ medical needs. For example, O’Neal worked with a health system that provided a driver and van for patients discharged from the hospital and for their follow-up appointments and primary care. The service also helped patients who needed daily antibiotics and infusion services for four to six weeks.
Another health system partnered with a transportation agency to create an online ordering platform for non-emergency medical transportation, mostly from the hospital to the patient’s home.
“There’s a whole menu and host of options for patients,” says Molly Shane, MS, BSN, RN, executive director of care management and patient transitions at the University of California, San Francisco (UCSF) Health. “We can help people get to and from procedures and elective surgeries. There are a whole host of opportunities to allow people to get in and out of the hospital environment.”
Patients can schedule companion rides, wheelchair vans, and gurney vans for people who do not require an ambulance but who cannot tolerate sitting in a wheelchair. These include paraplegic patients who are bedbound.
Clients order the transportation service they need online, selecting from different levels of care. “Non-emergency medical transport generally is not covered by insurance carriers. We’ve worked out a pricing structure to help patients connect to this level of care,” Shane says.
Patients pay either through private funds or with a managed care insurance plan, although those are rare. Also, the hospital will support transportation costs for patients who qualify for assistance.
The transportation program has worked so well, the hospital has extended it to other areas of the health system. “Emergency department leaders and others have access to this service to swiftly move patients out of the hospital,” Shane says.
The transportation program has received positive feedback. Both patients and staff have said they are happy with how it works, Shane says.
COVID-19 Spurred Expansion
The pandemic spurred one health system’s transportation program. “The initiative came about during COVID,” O’Neal explains. “We had an opportunity to partner with another department in our health system that provided transportation services for group counseling services for aging adults.”
The project’s initial goal was to transport patients from outlying areas into group therapy sessions within the behavioral health center. When COVID-19 and the nationwide shutdown occurred, patients were no longer attending group therapy in person.
“We had grant funding for this transportation, and there was nowhere to provide [transportation] services,” O’Neal says.
The hospital’s care transitions team worked with the counseling manager to provide transportation for patients who needed antibiotics and follow-up appointments after discharge.
“We always knew transportation was a great need, but we didn’t have the service,” O’Neal notes. “This [grant funding] allowed us to connect those patients with the resources we were recommending post-discharge to optimize their health.”
Patients using the health system’s transportation services have no caregiver support. Some live in rural areas and find it difficult to travel to follow-up medical appointments that are more than an hour away.
“To see that surgeon to check their incision or operative sites was pretty difficult. This transportation program helped patients be able to see those services that were recommended and to have that follow-up,” O’Neal explains.
Before starting the transportation program at UCSF Health, case managers and others had to call transportation vendors to arrange rides for patients after discharge. There was no price consistency or transparency, and arranging these rides was time-consuming.
“We’d call a vendor, saying we need this level of care at this time. They’d say it costs this much, and then the next day, the same thing would be a different amount,” Shane explains. “We didn’t have a way to quantify the number of transports we were doing or any visibility into when they were happening.”
Transportation assistance also is a huge plus from the perspective of patient-centered care. O’Neal recalls her former employer allowed flexibility in patient transportation. If a person wanted to stop at Walmart so they could pick up their prescription on the way home from the appointment, the driver could make this happen.
“They could pick up medication and any home medical equipment that could not be delivered,” O’Neal says.
Patients were satisfied with the service. They knew their drivers, and the drivers were compassionate, sometimes waiting in the car for 90 minutes during the patient’s appointment.
“The drivers got to know patients and developed a rapport with them,” O’Neal says. “For those patients who were not getting out of their house at that time, it removed their anxiety of who this person was.”
The hospital’s transitions of care team would receive important feedback from the drivers. “We had one situation where a patient had to receive outpatient services, and there was an emergent change in the patient’s medical condition,” O’Neal recalls. “Without that driver, I would never have known what happened to them.”
Since O’Neal learned about the patient’s emergency cardiac event from the driver, she could arrange for follow-up care and learn the outcome of the patient’s ED visit.
Discharge rides were a complimentary service. “We screened for eligibility of other resources, like state-funded transportation opportunities, or if the patient was able to pay,” O’Neal says. “If the patient had no funds to pay for transportation, and truly had no one within their circle of support, we would provide this service.”
The transportation service started with discharged patients, who received follow-up care arranged by the case management team. As the program evolved, other clinics and departments in the health system also began to request transportation services.
“There were a variety of drivers and different types of vans. Some had wheelchair accessibility and ambulatory accessibility as well,” O’Neal says.
Providing something as simple as a ride to patients provides so many benefits to a health system.
“There are so many positive outcomes for patients, their health, [finances], and for the hospital because it’s preventing readmissions,” O’Neal says. “We can coordinate with the primary care physician to get the medications patients need. We can get it changed, if needed, because we can have medications delivered to them or give them a ride to pick it up.”
Case managers are logistical artists when it comes to helping patients handle care needs during hospitalization and transitions after discharge. But things can get out of control when patients leave the hospital, and transportation is a top obstacle to patients receiving necessary care in the community.
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