Bartlett Regional Hospital Connecting Patients to Community Support Agencies

Emergency departments exist to serve everyone in need, but caregivers recognize that frequent and repeated users of the ED tend to share common drivers of heavy utilization. Often, the ED serves as a first stop safety net for vulnerable populations if other social services are inaccessible or confusing to navigate.

In 2018, collaborating with community partners to better serve its patients in the greater Juneau, Alaska region, Bartlett Regional Hospital implemented EDIE, an emergency department information exchange system that made possible real-time information sharing that is imperative for coordinated care efforts. When a patient registers, a one-page summary is automatically printed and loaded into the patient's electronic health record. The page includes care recommendations and care coordination notes which are shared with hospitals throughout the state as well as other participating states. The plan of care can be noted and followed through on so care is seamless, consistent and sensitive to social determinants.

In addition, the Bartlett team established a monthly meeting in 2019 to support coordinated care for its multi-visit patients. The meeting loops in a range of service providers — primary care providers, local shelters and housing programs, EMS, fire and rescue, psychiatry, addiction medicine, community case navigators, hospital leadership, and interdisciplinary hospital staff — to identify service gaps and operational barriers to care, and support community and systemic initiatives to best support this vulnerable patient population.

The results demonstrate the value and benefit of this coordinated approach to patient care. Program sponsors report a 44% reduction in rates of repeated ED usage since the inception of the program. Anecdotally, patients have reported improved quality of life and a sense of care and connection from their community.

Another unanticipated benefit was the boost in staff morale. By having a formal process to review, track and update on patients, staff were able to share in the successes — establishing housing, achieving sobriety, reunification with family, finding a job, returning to school, etc. — that helped them feel like the care and attention they provided really does have impact and matter.

This organization participated in the 2024 AHA Dick Davidson NOVA Award application process.