New ways to provide health care for complex cases

Jerry Krishnan, associate vice president of health affairs at UI Health, and Denise Hynes, professor of public health in medicine.

UI Health and the College of Medicine will develop new ways to deliver health care to patients who have complex medical conditions, using funds awarded by the Patient-Centered Outcomes Research Institute.

The hospital and the college each received $2 million awards from the institute.

The projects, led by Jerry Krishnan, associate vice president of health affairs at UI Health, and Denise Hynes, professor of public health in medicine and VA research career scientist, will aim to reduce hospital admissions, identify and treat complications earlier and encourage patients to take a more active role in their care.

Krishnan’s project, Patient Navigator to Reduce Readmissions or PArTNER, will help patients stick to their treatment plan after they leave the hospital.

Patients admitted to the UI Hospital for heart failure, COPD, pneumonia or sickle cell disease are matched with community members trained to navigate patients through their treatment plan after discharge and help resolve issues that interfere with their care. The project is a collaboration with Elizabeth Calhoun, professor of health policy and administration, and 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 said.

The navigators will identify non-medical problems that might interfere with treatment.

“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,” Calhoun said.

Because the navigators are people from the communities and not doctors in white coats, the patients may be more comfortable asking for help, she added.

Hynes’ project will focus on providing coordinated care to patients with end-stage renal disease. Because these patients often have other chronic diseases that require complex care, they are at 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,” Hynes said.

“Patients typically require appointments with a primary care physician as well as specialists to treat other medical issues.”

Patients will be evaluated during the initial visit, then followed by a team that includes a kidney specialist, primary care physician, advanced practice nurse, dialysis nurse, nutritionist, pharmacist, social worker and 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,” Hynes said.

This integrated approach will help reduce hospital admissions and emergency room visits, she added.

Hynes will collaborate with 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.