In healthcare these days, data is king. The primary care offices in Camden, N.J., have access to some of the most sophisticated patient data in the country.
They can track many of their sickest and most expensive patients across the city’s healthcare system, which gives them a better handle on the kind of primary care that will keep them out of the hospital.
But the efforts of the Urban Health Institute – one primary care office in the city – show why for all of data’s promise there are real world limits.
Every morning, a team of nurses, social workers, and healthcare coordinators reviews the patient data that pours in from the city’s three hospitals. If one of their patients has been admitted, they’ll go to that patient’s bedside to set up a primary care appointment.
To do list
Studies show hospital readmissions drop if a patient gets primary care follow-up within seven days of discharge. One of the biggest tests for the healthcare system is how well doctors and hospitals find ways to respond to the lives the data reveals.
UHI’s Amy Kaplan says while the data leads right where she needs do go, she doesn’t know who she’ll find in that room.
“A majority of the encounters [with patients] are not simply: you go in, the phone number is correct, you make the appointment, you leave.”
Often, she says, “it takes digging around, and that takes time.”
Many patients are what are called “poor historians”: folks who aren’t sure which medications they are taking, the name of their doctor, or even their home address. Other patients don’t have phones or are only able to occasionally borrow a neighbor’s phone.
Marcia Johnson (left) and her team of nurses and health workers at the Urban Health Institute
One morning a few weeks ago, the team discussed the case of a patient with a leg wound that required a refrigerated antibiotic. The problem: he’s homeless, so he has no refrigerator.
The solution was to send a homecare nurse to meet him on a street corner a few times a week.
The nurses in the meeting agreed that solution only delayed the inevitable: the guy back in the hospital.
Social worker Marcia Johnson, who oversees the UHI team, knows no amount of data or well-meaning efforts from her staff gets this patient a stable life so he can recover.
“We sit and have these conversations and just kind of think through it,” says Johnson. “Healthcare doesn’t know how to solve some of these problems.”
And while the efforts to help the nearly homeless patient are wholly inadequate to solve all of his problems, it’s a start. It used to be the case that these kinds of patients would just disappear after leaving the hospital.
Thanks to the data they’ve gone from invisible to visible.
This ongoing series on healthcare and data is produced in partnership with Healthy States.