UI Health and the UIC College of Medicine have each received a $2 million award to develop innovative new ways to deliver healthcare to patients with complex medical conditions.
The awards are from the Patient-Centered Outcomes Research Institute, and are two of the four total awards given by the institute in Chicago this year.
The projects, led by Dr. Jerry Krishnan, associate vice president of health affairs at the University of Illinois Hospital & Health Sciences System, and Dr. Denise M. Hynes, UIC professor of public health in medicine and VA research career scientist, are designed to reduce hospital admissions, identify and treat complications sooner, and provide opportunities and support for patients to take a more active role in their care.
Krishnan’s project, called Patient Navigator to Reduce Readmissions, or PArTNER, will help patients stick to their treatment plan after they leave the hospital. Patients admitted to UI Health for heart failure, COPD, pneumonia or sickle cell disease, are matched with local community laypeople trained to navigate patients through their treatment plan after discharge and help resolve any issues that may interfere with their care. The project is a collaboration with Dr. Elizabeth Calhoun, UIC professor of health policy and administration, and Dr. Mark Williams of Northwestern University.
“The patient ‘navigators’ are at the core of our program, and are there to serve as a liaison between the patient and the hospital and help the patient progress through their treatment plan once they are discharged,” Krishnan says.
The navigators will identify non-medical barriers that might interfere with the continuum of care.
“Sometimes patients don’t come to their appointments because they can’t get a ride, or they’re embarrassed that they can’t remember how to take their medication,” said Calhoun. Because the navigators are people from the communities and not doctors in white coats, the patients may be more comfortable asking for help, said Calhoun.
Hynes’s project will deliver efficient, coordinated care to patients with end-stage renal disease. These patients often have other chronic diseases that require complex care and are at a high risk for emergency room visits and hospitalizations.
“Patients with end-stage renal disease may require dialysis up to three times a week to replace their lost kidney function,” says Hynes. “Patients typically require appointments with a primary care physician as well as specialists to treat other medical issues.”
Patients will be evaluated during an initial visit, and then followed by a team including a kidney doctor, a primary care physician, an advanced practice nurse, a dialysis nurse, a dietitian, a pharmacist, a social worker and a health promoter.
“We will use the patients’ regularly scheduled dialysis visits as our opportunity to meet with the patient and coordinate any additional care, schedule any additional specialist visits, as well as offer educational sessions for family members and caregivers,” says Hynes. Hynes believe that this more integrated and coordinated delivery of care, which brings together many needed providers and services, will also help reduce hospital admissions and emergency room visits.
Hynes’ project is in collaboration with Dr. Jose Arruda, professor and chief, section of nephrology and medical director of the UI Health dialysis unit, and the Fresenius Medical Care Chicago Westside dialysis unit. The project will also use resources at UIC and UI Health’s Center for Clinical and Translational Sciences Biomedical Informatics Core, the Midwest Latino Health Research Training and Policy Center, and UIC’s Institute for Health Research and Policy.
Krishnan’s collaborators include Northwestern University, COPD Foundation, Society of Hospital Medicine, the University of Illinois at Urbana Champaign, Veterans Administration, University of Illinois Sickle Cell Patient Council, Academy Health, National Jewish Health, Howard University, Social Work Policy Institute, Baystate Medical Center, Olmsted Medical Center, University of California at San Francisco, Respiratory Health Association of Metropolitan Chicago, and Mended Hearts.