The term "transformation" is batted around a lot in health care these days. But leaders at the North Ottawa Community Health (NOCH) System in Grand Haven, Mich., believed their plans to redesign emergency department services could be truly transformational. The 81-bed hospital not only is revamping services in its ED, but also changing how the hospital and other community organizations are collaborating and coordinating services. With these changes, patients can better navigate follow-up care after they are discharged and more effectively manage their chronic diseases.

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Shelleye Yaklin, NOCH's president and CEO, a recent participant in the AHA's Health Care Transformation Fellowship, was working on the ED project during her nine months as a fellow. Yaklin says the hospital is working to create a model that other communities can replicate to deliver better care, better health and lower costs.

Integrating Care to Address Patients' Needs

The ED is a key focus at NOCH, as it is at hospitals across the country. Jen VanSkiver, chief communications officer and director of external affairs, points to a regional United Way study that queried patients who engaged in risky behavior. The question to patients: At what point would you be most likely to make substantive and meaningful change? About 98 percent replied during a catastrophe or true crisis. These patients frequently seek treatment and care in the ED. "To improve outcomes, integrated care starts in the emergency department — to intersect with patients there instead of two or three days later," VanSkiver says.

The ED patient profile at NOCH differs from that of hospitals in major metropolitan areas, VanSkiver explains. "We see a broader mix of issues here." One out of five patients who seek care in the ED does not belong there and should be cared for in a more appropriate setting, she says. This target population typically does not have primary care, lacks health insurance, is not managing chronic diseases, and may have underlying mental health issues. "For a fair amount of our target population, access to basic needs is a primary issue — they cannot fill prescriptions, have transportation challenges or don't have heating at home. These patients cannot get well because they cannot manage day-to-day life," VanSkiver says.

Redefining the Hospital's Role in the Community

Instead of creating a diversionary clinic, NOCH "has opened up our space virtually and physically, to human and social services, as well as mental health agencies," VanSkiver says. The focus is on "reducing duplication and harnessing and focusing expertise already in our community," she adds. "If we set up a separate clinic, it would be grant-funded and compete for grant dollars with existing local agencies. We already have agencies that have developed skill sets and experience and have earned the trust of the community. We don't need to compete with that because, in a community our size, we would hurt those organizations." Yaklin emphasizes, "If we can collaborate, we feel we have a better opportunity — from an outcomes and fiscal and community perspective."

The hospital is focusing on outcomes by collaborating with other community organizations to improve care coordination. "When we start to make transitions — that's where the gaps lie," VanSkiver points out. NOCH is adding social services, working with a community health worker based outside the hospital, and expanding ideas for using the skills of paramedics in more than just field work — by providing follow-up visits after discharge.

Collaborating to Assess Community Health Needs

Since 2012, the hospital has gathered information and analytics to determine what is happening globally in the community and to evaluate available resources. The hospital created a community health needs assessment and final report with two other hospitals in the community, the United Way and the county health department. "Chronic care and access to care caused us to look at the ED. People may not have a doctor, or a doctor is not available. Or they don't have insurance or cannot get to the doctor," Yaklin explains. "The core of everything has been the CHNA." The hospital and collaborating organizations will be completing the second reiteration of the assessment soon.

Hospital leaders and staff have been introspective about their roles in the community, VanSkiver says. "Instead of seeing a patient with a particular illness or injury, we need to see a person in crisis who is looking to get better in every way. So, we must establish pathways. It's not [the hospital's] job to do everything. … With collaboration, we'll be more relevant and be able to walk with the patient longer." She adds, "Ideally we allow ourselves to be in a constant state of change. With the community's support, we will move toward being a steward of population health."

Building Space to Support a New Care Model

The transformation project at NOCH includes designing and constructing a new ED. Building space that supports the new care model has created a challenging opportunity. VanSkiver explains, "We need to create the new model and then hand off that strategy to the architectural team [with the goal] to configure, not a bigger or prettier space, but a space that supports our new model — where the flow of patients and staff is different."


The goal is to create something that could be replicable. Says Yaklin, "Other community hospitals are just like us; the only difference is the culture of the community. If we do the hard work and try to figure out how to break through barriers, we could turn it over to another community hospital." Transformation includes conquering challenges and solving the problems "not only for Grand Haven but for other communities to provide better care, day in and day out."

Connecting with AHA Fellows

As a participant in the 2014–2015 AHA Health Care Transformation Fellowship class, Yaklin appreciated having access to what was happening nationally in the health care field. "[The experience] has helped in moving beyond what's going on in Michigan — beyond using resources available in the state and dealing with our state economy," Yaklin says. The fellowship includes hospital and care system leaders throughout the United States, and connecting with these leaders has helped to "put things in a different perspective for us," she adds.

The fellowship includes three two-day interactive sessions with expert faculty, which highlight innovative models in care delivery, the volume-to-value transition and population health management. Participants can bring a colleague to the sessions; NOCH's chief financial officer attended the fellowship's financial modeling session with Yaklin. In addition, each fellow designs and implements a project.

Though Michigan is a leader in many aspects of quality and patient safety, Yaklin valued hearing about how other communities are connecting and learning about resources that may not yet be available in the Midwest. "We [fellows] heard wonderful ideas and at the same time felt the same frustrations and same pressures inside our industry, while wanting to make a positive difference," Yaklin explains. Although her fellowship class has ended, "I will continue to have access to these people and to the projects of future fellows," Yaklin adds.

Cynthia Hedges Greising is a communications specialist with the Health Research & Educational Trust.

For more information about the AHA Health Care Transformation Fellowship — including podcasts with several fellows discussing their experiences — visit Applications for the 2015–2016 fellowship class are open through June 1, 2015.