Care Management

Nurse navigators help manage patients with chronic conditions such as diabetes, heart failure and COPD in longitudinal care management in order to improve outcomes and reduce serious events and hospital utilization. They work with high-risk patients associated with particular payer plans who receive primary care through Temple Physicians, Inc., Temple Faculty Physicians, and providers that are part of the Temple Integrated Care Network.

After hospitalization or emergency room visits, nurse navigators help high-risk patients in our primary care networks manage their transition back to primary care—even if those patients were admitted to a hospital outside of Temple Health. Navigators schedule follow-up visits with primary care offices, provide medication reconciliation, screen for social determinants of health that could impede treatment adherence, and connect patients with community health workers to gain access to additional needed services. Some nurse navigators work specifically with patients involved in Medicare bundled payment programs through Temple Center for Population Health’s CMS ACO REACH, meeting patients at the hospital and working with them for 90 days post-admission.

The main goal of our community health workers is to reduce readmissions throughout the hospital system by providing holistic support for patients with high utilization. They reach out to patients who have been admitted to the hospital and who meet specific criteria—for example, patients who have multiple recent readmissions, or who have significant socioeconomic barriers to health as noted on a social determinants of health survey—to help address the challenges they face. They build relationships, visiting patients at the bedside before discharge, and when possible following up with home visits. Patients may have difficulty sharing concerns with their providers, and CHWs provide a caring presence who can help solve problems a patient may not discuss with a physician.

Open five days a week, the Multi-Visit Patient Clinic piloted in 2020 to address high rates of readmissions among patients with congestive heart failure. Now, this official program has expanded to patients with other chronic conditions who have had more than three hospital visits in a three-month period. Deploying community health workers, clinicians, hospitalists, and social workers, the clinic uses a multidisciplinary approach to address the needs of chronically ill patients. Patients with behavioral health challenges are matched with a social worker, and all patients are connected with a community health worker to connect them with additional assistance if needed. The clinic team helps manage and coordinate care and provides a warm handoff to transition the patient back to their primary care provider. For 90 days post-hospitalization, patients in the program have access to assistance such as transportation to physician appointments.

Since the clinic opened, patients enrolled in the Multi-Visit Patient Clinic have seen a 48% decrease in readmissions and a 42% decrease in visits to the emergency department. The clinic is now being scaled up to care for additional patients.

Behavioral health services can help patients with behavioral health issues to lead fulfilling lives and manage their other health conditions. The Center for Population Health employs a licensed clinical social worker (LCSW) to help make that connection. This social worker coordinates with Temple Physicians, Inc., practices to identify patients with diabetes and other chronic conditions who are also dealing with behavioral health issues such as depression, anxiety, and post-traumatic stress disorder (PTSD). Patients receive a referral to a behavioral health provider or a brief therapy intervention provided by the licensed clinical social worker, with oversight from a care team of psychiatrists and psychologists. While the patient population is small, the program has already seen improvement in patient health questionnaire scores relating to depression, and is scaling up to assess and connect with additional patients. The Center also works to coordinate additional behavioral health referrals for patients in Temple Family Physicians and Temple Physicians, Inc., practices.

Temple is dedicated to ensuring that our patients have access to high-quality options for post-discharge care. The Temple Post-Acute Care Collaborative is a referral resource used by our nurse navigators and hospital case managers to direct patients to trusted partners during discharge planning. The Collaborative comprises skilled nursing facilities and home health agencies, and which meet certain quality measures. Within the Collaborative, our CMS Preferred Provider network includes providers with a CMS star rating of 3 or higher. Providers who do not fall within the Preferred Provider group may still qualify to be part of the Collaborative based on other quality criteria. Members of the network meet routinely to collaborate and discuss shared initiatives and challenges.

Patients in Medicare Fee-for-Service plans under Temple’s Direct Contracting Entity also have access to Care Management Home Visit and Post Hospital Discharge Home Visit benefits if they meet certain requirements. They may also be eligible for a waiver that allows for short-term skilled home health services even if they are not homebound or rehabilitation at a skilled nursing facility without a preceding hospitalization.

Healthy Together Mobile Health Vehicle

The Temple Center for Population Health partners with community and faith-based organizations in selected neighborhoods to provide health screenings, education, and connections to community resources through its mobile health vehicle. Along with screenings and education on the basics of blood pressure and stroke prevention, our team of community health workers introduces additional important health topics every month, such as chronic disease prevention and management, health screenings, gun violence prevention, and support for addressing social determinants of health.

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Fox Chase Cancer Center’s Office of Community Outreach

Fox Chase Cancer Center’s Office of Community Outreach offers cancer-related patient education, a community speakers bureau, and a mobile cancer screening clinic. Their Lippincott Resource and Education Center provides patients and families with a wealth of information about cancer, cancer care, and survivorship, available in multiple media, with health educators to help patients find what they need. The Speakers Bureau offers free educational sessions on cancer topics, in English and Spanish, to groups located across multiple local counties. The Fox Chase Cancer Mobile Screening Unit partners with community organizations to offer neighborhood cancer screenings throughout Southeastern Pennsylvania and parts of New Jersey.