For many North Carolina residents – about 40 percent or roughly 4 million people – prefer the pace of a small town and the space to spread out. They reside in one of the state’s 80 counties classified as rural – a population density of 250 people per square mile or less.
But when it comes to healthcare, rural areas often have bigger challenges to face, such as an increased rate of chronic diseases, higher numbers of drug and alcohol use, and other issues that lead to a higher mortality rate than metropolitan areas.
So how can the healthcare industry help tackle this gap? How can patients who are further from brick-and-mortar healthcare facilities better connect with their providers and care teams? How can clinicians better monitor what is happening – in real time – with their patients? And ultimately, how can help our rural communities be healthier?
These are the kinds of questions that Atrium Health’s Alisahah Cole, MD, vice president and system medical director of community health at Atrium Health and Kevin Lobdell, MD, director of regional CVT quality, education and research, are helping to answer. And to help facilitate solutions to these gaps, The Duke Endowment, one of the nation’s largest private foundations with assets of $3.5 billion, has provided grants totaling $1.8 million to the Atrium Health Foundation earlier this year. The grant will help fund three to address population health, pediatric dental care and a novel approach to virtual cardiac care called Perfect Care: Personalized Cardiac Care and Collaborative. This pilot project will utilize technology to help eliminate disparities in follow-up care following heart surgery. The first-of-its-kind program will eventually be rolled out to six Atrium Health hospitals.
Dr. Lobdell answered some questions about how this novel approach to recovery care will be a game-changer for cardiac patients.
Question No. 1: Once a patient leaves the hospital after a cardiac procedure, what are their typical steps for follow-up care?
Lobdell: Traditionally, a patient would be directed to schedule a follow-up appointment with their primary care doctor and/or cardiologist. Additionally, they would follow-up with the surgeon in two-to-four weeks for an office visit.
Q2: With the Perfect Care pilot, how will their care be influenced?
Lobdell: We will schedule a series of postoperative active monitoring or virtual visits that will be personalized to a patient’s specific risks and needs – while passively monitoring their heart rate, blood pressure, oxygen saturation, steps, sleep, weight, etc. The passive monitoring, via a “digital health kit” will also be tailored to their personal risks and needs. ‘
Q3: This novel cardiac care initiative will bring post-operative care to people who traditionally encounter barriers to care. What is your vision for this project?
Lobdell: As a result of routine active and passive monitoring, we will be providing proactive, personalized care to the patient, therefore reducing their burden of traveling to and from appointments. This will also allow our experts to care for more patients and learn faster. We believe this is central to patient-centered, high-value care and builds a culture based on continuous improvement.
Q4: How will patients be involved with their care?
Lobdell: Perfect Care will have a patient and family advisory focus that shapes our educational efforts, engagement, activation and development of patient-reported outcomes – which include pain control, sleep, activities of daily life, returning to work, etc. This advisory will help our teams learn and improve with our patients and families.
Q5: Virtual care is expanding nationally. In what ways will our teams use virtual care to help patients?
Lobdell: Perfect Care’s active monitoring will fill gaps in the continuity of care through all phases, providing a peri-procedural home that doesn’t exist in today’s episodic care model while affording us the opportunity to passively monitor with novel biosensors to detect patterns of risk – for example weight gain, which may suggest fluid retention. As we learn from both modes of monitoring, we will be able to tailor our efforts to reduce risk of complications and readmissions to improve each patient’s recovery.
Q6: How is this cardiovascular care initiative different from others across the country?
Lobdell: This is the first time a healthcare organization is integrating all of the components of Perfect Care. Atrium Health has all these components, and the grant enables us to aggregate them into a novel, learning, peri-procedural home.
Q7: When will the pilot launch?
Lobdell: We’re aiming for the first quarter of 2019 and will scale to other locations as soon as possible.
Dr. Cole discusses how hospitals and healthcare systems need to invest in their communities if they want to make an impact in improving the health of their patients.
Q8: This initiative is one of several other community health initiatives. As a system, how is Atrium Health improving care for all patients?
Cole: In addition to the world-class clinical care we provide, we are aiming to enhance our community’s health by reducing tobacco use, facilitating improved access to care – through pilot programs like Perfect Care – participating in the improvement of social and economic factors, and improving mental health awareness and education. We are truly committed to no longer just focusing on illness and disease, but health and wellness. That requires our healthcare system to deliver care holistically, not only for our patients, but our communities at large.
Q9: What are some other areas that health systems can help reach patients in their communities?
Cole: We look at ways to extend care outside our hospital walls, because as we have uncovered, a person’s socioeconomic status, health behaviors and physical environment can attribute to 80 percent of their health outcomes. For example, the Atrium Health Foundation received a grant to help set up mobile “food pharmacies” which will help provide patients with easier access to healthier foods and education about food tailored to specific medical conditions. We know that medically-tailored meals can help patients achieve an enhanced quality of life, reduce healthcare costs and reduce unnecessary hospitalizations.
Q10: How can access to food improve a community’s health?
Cole: In 2016, Atrium Health partnered with the North Carolina Institute for Public Health to conduct a Community Health Improvement Plan study to examine what social determinants of health affected the immediate areas we serve. We uncovered the biggest need was to address food insecurity. Food plays such a major role in health, affecting things from academic performance and mental health utilization in our children, to chronic medical conditions in adults. In order to holistically address food insecurity, we recognized that collaboration is critical. Together with the Mecklenburg County Health Department and Novant Health, we formed the One Charlotte Health Alliance. Through this collaboration, we have committed to addressing some of the most critical needs our community is facing, including food and access to more primary care.