A New Approach by A New Care Team
By Katherine E. Di Palo, PharmD, MBA, MS, Senior Director of Transitional Care Excellence, Montefiore Health System
Bronx Voice
October 8, 2024
BRONX - Cardiovascular-kidney-metabolic (CKM) syndrome is a health disorder experienced by people who have obesity, chronic kidney disease, heart disease, and diabetes at the same time. People with CKM can experience symptoms including chest pain, shortness of breath, pain in legs while walking, fatigue and an increase in urination.
Within the Bronx, adults with heart disease and diabetes are more likely to be hospitalized compared to other boroughs. Fortunately, there are new drugs that can be used for CKM that improve symptoms, reduce hospitalizations, and reduce the risk of death. However, these drugs are often costly and challenging to access. At Montefiore Medical Center, an innovative new Transitional Care Excellence (TCE) team is piloting a novel approach to improve care for patients with CKM.
A Novel Approach
When patients with CKM are admitted to the hospital for high-risk conditions, a dedicated clinical pharmacist or nurse practitioner meets the patient at the bedside, reviews their current medications and determines a plan to start or adjust medications used to treat CKM. The clinician considers each patient individually and uses an approach specific to them to reduce costs, side effects, and lower the number of medications they need to take, to make it easier for them to stick with the regimen.
For each patient, the clinician screens for and addresses social determinants of health (SDOH) - the conditions in which people are born, live, learn and work. They also consider the age, well-being, and quality of life of each patient.
Examples of SDOH include housing, transportation, language and literacy skills, access to nutritious foods, and income. SDOH contribute to health disparities and inequities. For example, patients who can’t afford or can’t access healthy and fresh foods are less likely to have good nutrition which raises the risk for CKM.
When patients screen positive for SDOH, the Transitional Care Excellence team proactively identifies solutions, like registering for transportation services, enrolling in Montefiore’s financial aid program, working with insurance companies to provide affordable medications, setting up nutritious meals for home delivery, providing access to mobile phones or internet, and referring to additional resources within Montefiore. The team works directly with the patient and family to establish a follow-up plan with primary care providers and specialists and provides education on self-care for CKM.
Once out of the hospital, the same clinician checks in on the patient within two days by telephone to ensure that the patient is on the right track. The team continues to monitor for 30 days and checks in periodically to help navigate care after hospitalization. Patients are encouraged to call the TCE team if they run into any trouble after they leave the hospital.
Testing the Model
To support this extraordinary work, Montefiore Medical Center and Albert Einstein College of Medicine were awarded funding by the American College of Clinical Pharmacy Foundation as part of the Medication Optimization Improving Human Health initiative. As one of only three health systems in the country, Montefiore will study the impact of the TCE team on overcoming challenges that hinder access to new life-saving drugs for CKM. The research team, led by myself, Dr. Ladan Golestaneh, and Dr. Pavel Goriacko, is optimistic that the Transitional Care Excellence model will greatly benefit our patients most in need, and pave the way for a healthier, more equitable future in the Bronx.
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