This document discusses a program between Sutter Health's Alta Bates Summit Medical Center and local community health clinics to improve access to primary care for patients who frequently use emergency rooms. The program places registered nurses in three Oakland and Berkeley clinics to help establish a primary care physician and ensure follow-up care after ER visits or hospitalizations. An analysis found the program led to a 32% increase in follow-up primary care visits, 17% decrease in ER visits, and 17% decrease in hospital readmissions within 30 days. The program aims to provide more appropriate and convenient care to reduce costs while improving outcomes.

1. Navigating Patients to Better Health
Our hospitals and emergency rooms are open 24 hours a day with
top-notch staff to care for everyone who walks through our doors.
Most days, that includes a lot of people who come to our emergency
rooms for non-emergencies.
Members of our community who are underinsured or uninsured,
homeless or living in poverty, and those with behavioral health
problems, frequently use the emergency room for primary health care.
These patients account for almost half of those making non-life-
threatening visits to the ER.
With the goal of providing the right care in the right place at the right
time, Sutter Health’s Alta Bates Summit Medical Center and the
Community Health Center Network are working together to offer greater
access to primary medical care for patients who often rely on the ER.
Caring for Our Community
Care Transitions Program
Our program places
registered nurses at three
Oakland and Berkeley
community clinics. In this
way, we work to ensure
patients establish a
convenient medical home
where they can make a
follow-up appointment
and get routine care.
Care transitions nurses work
with approximately 3,600
patients a year who visit
the ER or are admitted to
Alta Bates Summit, cared
for and discharged.
altabatessummit.org

2. Caring for Our Community
Steve O’Brien, M.D.
Chief Medical Executive
Tracy Schrider, LCSW, ACM
Administrative Supervisor of Social Work
Data Supports New Approach
In August 2014, the Community Health Center
Network tracked the outcomes of 600 of the
3,600 patients and found that patients in the
care transitions program saw a:
• 32 percent increase in primary
care physician follow up
within 30 days of their first
admission to the hospital.
• 17 percent decrease in ER visits
within 30 days of first admission
to the hospital.
• 17 percent decrease in hospital
readmission within 30 days
of discharge.
“It takes a village to help navigate effective
care and transitions to more convenient and
appropriate settings so that our patients are
well cared for when they are discharged.
“Helping patients get access to community health
providers who can offer a wide range of services—
including preventive care, disease management
and social services for patients—is key.”
“ For a relatively young program, these
findings are remarkable. We’re constantly
looking at ways to provide better care
to patients while controlling health care
costs. This does both and it’s a win-win
for the East Bay community.”

3. Caring for Our Community
Partnering with Federally
Qualified Health Centers
To ensure a smooth transition and continuing care once the
patient is back in the community, Alta Bates Summit Medical
Center relies on long-established relationships with Asian Health
Services, LifeLong Medical Care and La Clinica de La Raza.
These deeply rooted community organizations offer centrally
located, affordable, comprehensive and effective primary and
preventive care. They also provide language translation services
and help identify and remove other barriers to care, such as
substance abuse or lack of transportation or permanent housing.
“Working collaboratively with the
in-patient case managers, I can
help advocate for our patients.
I can let our physicians know, in
real time, that one of their patients
might have a new condition or how
medications have changed.
“Our goal is to facilitate optimal
primary care, health and wellness.
If we get patients plugged into
primary care earlier, hopefully this
will prevent more serious illness
down the road.”
Isobel Harvey, R.N., MSN
Care Transitions Nurse Manager
LifeLong Medical Care
Through its not-for-profit
mission, Alta Bates Summit
and its philanthropic partner,
Better Health East Bay, have
invested nearly $1.5 million
in programs to care for the
neediest in our community.

4. Positive Effects in
the Emergency Room
In the ER, care transitions case
managers collaborate with
medical staff. Once the patient is
discharged, the case managers
help arrange transportation,
determine eligibility for home
health benefits and outpatient
treatments, and explain financial
assistance programs and
community resources.
Most importantly, case managers
help patients make necessary
follow-up appointments.
“This is the best program
that’s been implemented at
Alta Bates Summit in the eight
years I’ve worked here.”
John Mullen, R.N.
Summit ER Charge Nurse
Caring for Our Community
Expanding Community Care
Looking ahead, Alta Bates Summit and its community partners
plan to hire ER patient navigators to assist the R.N. care
transitions case managers. Funded by Sutter Health, the
navigators will work at the health clinics to help even more
patients. Sutter Health is exploring opportunities to expand
this model to other East Bay hospitals and clinic partners to
improve care for the most vulnerable in our communities.
Learn More Online
To learn more about how Alta Bates Summit partners to help
underserved and underinsured residents in the East Bay, visit:
newsroom.altabatessummit.org/
January/February 2015
Alta Bates Summit Case Manager Regina Linder, R.N., helps
connect patients with resources in the community, leading to
better coordination and less frequent use of the ER.