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VCU Health program links ER patients with follow-up care

Goal — connect underserved patients with continued services


Jennifer Rodriguez Jennifer Rodriguez was connected to follow-up care after a heart condition sent her to the ER. Her follow-up care was arranged by a new VCU Health clinic called ProPEr Care.

By James Shea

Jennifer Rodriguez felt a pain in her chest while working at home.

“I was just on a Zoom call, and I felt myself get super dizzy,” Jennifer said. “Immediately after that, my heart started racing. It was beating really hard. I continued to be lightheaded and was just generally kind of freaked out.”

Jennifer, 37, told her husband she needed to go to the emergency department at VCU Medical Center. She had experienced heart issues before, but she thought an operation in 2005 had fixed the problem.

By the time Jennifer reached the emergency department, the flareup had stopped. It was hard to diagnose her condition with her heart no longer racing, so doctors kept her overnight for observation.

“They asked me if I had a primary care physician, which I do not,” Jennifer said. “They told me about a clinic that could serve as a stopgap measure — an intermediary between the emergency department and the specialist I would eventually go to.”

ProPEr Care steps in

Jennifer was part of a new program at VCU Health called Providing Post Emergency Care (ProPEr Care). Started in October 2020, the program connects emergency department patients with follow-up services. The goal is to reduce the number of repeat visitors to the emergency department while providing better patient outcomes.

“We created our clinic as a means to ensure that patients who come to the emergency room receive the ongoing care they need, such as making sure the antibiotics they were prescribed are working,” explained Dr. Christina M. Vitto, assistant professor in the departments of emergency and internal medicine. “They are discharged from the ER with antibiotics, and we can then follow up with them in our clinic. We call them or utilize a video chat. We see how things are going and guide them appropriately.”

Vitto placed a follow-call to Jennifer about a week after she was discharged. She asked how she was doing and connected her with a VCU Health heart specialist. Her goal was to make sure Jennifer’s transition out of emergency care was easy and that she got proper follow up.

Keeping the emergency room for emergencies

For many people, especially the uninsured, the emergency room is their primary source of medical care. They visit the ER for a crisis and don’t see anyone after that. Without follow up care, they often land back in the ER. ProPEr Care helps patients access care outside the ER — freeing up the ER for true emergencies.

 “They often use the emergency department as their primary care source because they either haven't been educated to apply for medical insurance and find a primary care physician or they just can't afford medical insurance. Many also have been unsuccessful in finding a primary care physician,” Vitto said.

VCU Health may be the only medical institution in the country that runs a clinic like ProPEr Care, Vitto said.

Case management ensures patients comply with treatment plan, avoiding emergencies

The ProPEr Care clinic operates three days a week. Doctors have full caseloads and follow hundreds of patients. Many of these patients have high blood pressure or diabetes.

“One of the more common follow-up visits is focused on high blood pressure,” Vitto said. “We will often start patients on medications because they have had high blood pressure for a long time. We will arrange follow-up to monitor how their blood pressures have been doing and adjust their medications as needed.”

Patients with diabetes may be put on medication, too, including insulin, or have their medications adjusted. In addition to adjusting medications, the ProPEr care physicians educate patients on managing their diabetes through lifestyle changes.  

Among Vitto’s responsibilities is checking in with patients to be sure they’re obtaining long-term primary care follow-up.  If that hasn’t happened, she will have outreach workers contact the patients to schedule an appointment. She will also refill medications, schedule tests, such as imaging or lab work, remind patients of upcoming visits and help arrange specialty appointments if necessary.  

The process worked well for Jennifer. She connected with a cardiologist and was fitted for a Holter monitor to track future incidents. She and her doctor are working together to determine the source of her heart problem.

“This experience was really nice because it streamlined everything,” Jennifer said. “It made the entire process connected. I really appreciate the care I received. Everybody was so warm and understanding. I never got the sense that anybody wasn’t taking me seriously.”

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