organization delivers care across our
vast service area—sometimes right into
patients’ homes (See the cover story
on p. 4). The health system is also
hiring community health workers and
navigators to give patients additional
guidance in managing their health,
and helping physicians and other
caregivers improve their relationships
with patients.
Navigating chronic disease
Obesity, diabetes, and heart disease are
among the top health issues impacting
the least healthy Americans—and
Texans. In response, Baylor Scott
& White is exploring new ways to
help manage these chronic diseases
and reduce smoking in the state. The
North Texas division has hired 30
about their medications and treatment
plans, to help keep them healthier
and out of the hospital. “There’s no
funding for CHWs right now in many
health plans,” says Dr. Fullerton, “but
they are so effective in improving
outcomes and lowering costs that we
were given grant funding to support
this work. It’s good for us and good
for our patients. If we spend $100 to
help a patient achieve better health
and lower the cost of care by $300, it’s
a good thing to do.”
make parks safer and connected with
churches to enroll people for care,” says
Dr. Fullerton. “We also established
a demonstration kitchen to teach
healthy food preparation and through
the clinic, we are able to partner with
patients to keep their diabetes managed.
A population health focus allows us to
collaborate with community partners
to impact populations, not just one
person at a time.”
Working with at-risk
communities
Hospitals are the most expensive
place to receive care. Because many
readmissions are preventable, Baylor
Scott & White employs transition
coordinators to help people better
manage their daily health issues and
concerns to avoid catastrophic medical
situations that could lead to a stay in
the hospital. Jennifer Reed, system
vice president for Comprehensive
Care Management, oversees a program
designed to ease the transition between
the hospital and the patient’s home or
a long-term care environment.
“Leaving the hospital can be a
dangerous time for patients because
they may need additional education or
assistance with follow-up care activities,
which are critically important to their
recovery,” she says. “That’s why we
have transition coordinators who work
in partnership with physicians and fill
any gaps in care-giving.” Coordinators
contact patients after they leave the
hospital to schedule follow-up visits,
answer questions, and motivate them to
To help improve health in a highrisk, low-income population, Baylor
Scott & White collaborated with the
city of Dallas to build the Diabetes
“A population health focus allows us to collaborate
with community partners to impact populations,
not just one person at a time.”
—Cliff Fullerton, MD, MSc, Baylor Scott & White Quality Alliance president
community health workers (CHWs),
including some fluent in Spanish, to
assist its highest-risk patients: older
men and women on Medicare with
chronic diseases who represent five
percent of the division’s 60,000
patients. CHW staff members work
with these patients to coordinate care
with families, and educate patients
24
THE CATALYST May 16 | sw.org
Health and Wellness Institute in an
urban neighborhood with high levels
of diabetes and obesity—conditions
closely linked to areas with a shortage
of grocery stores and healthy food
options and a lack of safe places to
exercise. (See issue 2