Transitioning to Health


Through innovative transitional care programs,
Northwestern Medicine clinicians help vulnerable
patients achieve healthier lives after leaving the hospital.











For some patients, the most impactful medicine comes not from a prescription or a procedure, but from a care plan for after they walk out the hospital doors.

Across the Northwestern Medicine health system, multidisciplinary teams are helping some of the most complex and vulnerable patients transition from acute care settings to healthier lives outside the hospital. The result: improved continuity of care, reduced readmissions, lowered healthcare costs and better outcomes for patients overall.

“These programs are enormously valuable to individual patients and, frankly, to the system as a whole,” says James Adams, MD, chair of Emergency Medicine and chief medical officer at Northwestern Medicine. “Without them, the emergency department cannot address the root causes of these patients’ problems. Only in addressing the root causes can we improve their quality of life, feel satisfied in the care that we provide and, incidentally, optimize healthcare expenditures. Everyone benefits.”

Comprehensive Care for Older Adults

The Geriatric Emergency Department Innovations (GEDI) program launched at Northwestern Memorial Hospital in 2013. Originally funded through a Health Care Innovation Award from the Center for Medicare and Medicaid Services, the program set out to reduce hospitalization of older patients after a visit to the emergency department (ED), and prevent revisits and readmissions.

The team faced a formidable challenge: Studies estimate that up to 25 percent of patients seen in the ED are 65 years or older — a number that’s expected to continue to rise — and roughly one-third of older patients who visit the ED are admitted to the hospital. But hospitalization is often not the best place for patients, especially for older adults.

“Hospitalization comes with risks for delirium, falls and infections — and we really want to minimize those risks,” explains Scott Dresden, MD, director of GEDI and an assistant professor of Emergency Medicine. “We also find that many times our older patients just want to be home. If that’s the right place for them, we want to make that happen.”

As such, the GEDI intervention includes a key new role in the ED: a geriatric nurse liaison. These GEDI nurses (pronounced like the knights in “Star Wars”) meet one-on-one with older patients to evaluate their overall well-being, determine what level of care might best serve them and coordinate their transition to life outside the ED.

Emergency departments weren’t designed for older patients, nor were they necessarily designed to treat all of the underlying issues behind why a patient was there.

“As we see more older adults in the ED, we’re trying to change how we care for them,” Dresden explains. “Emergency departments weren’t designed for older patients, nor were they necessarily designed to treat all of the underlying issues behind why a patient was there.”

But within GEDI, nurses look at the patient as a whole. During a visit, they cover everything from screening for delirium, elder abuse and fall risks, to understanding how the patient obtains groceries and what kind of overall social support system they have.

After the initial assessment, GEDI nurses ensure patients are safe to go home and set up for health going forward — whatever that might entail. A day in the life of a GEDI nurse might include helping a patient obtain a walker, collaborating with physician referral services to set up an appointment with a specialist, procuring forms for handicapped parking or calling a family member to check in on a patient when they return home.

The nurses work closely with dedicated pharmacists — to reconcile patients’ medications, for example — and social workers who help patients understand resources available through their insurance, connect them with home health services or the Department of Aging, and evaluate financial and caregiver strain. Every GEDI patient discharged from the ED or hospital also receives a follow-up call from a nurse.

In some cases, GEDI nurses refer patients to Northwestern’s Home Care program, where clinicians provide vital primary care services directly in an older adult’s home.

Left: GEDI nurses Lisa Lui Popelka, RN, left, and Emily Ruben, RN, right, talk with patient Carol Wittwer at her bedside in the Emergency Department at Northwestern Memorial Hospital. Popelka and Ruben are specially trained to treat older patients and arrange help for them at home. Right: In some cases, GEDI nurses refer patients to Northwestern’s Home Care program, where clinicians like Dwayne Dobschuetz, APN, provide primary care services directly in an older adult’s home. Pictured above: Dobschuetz (left) visits patient Marvin Shimp (right), who has lost much of his vision to macular degeneration. Dobschuetz helps him stay out of the hospital with regular visits to check vitals and answer questions. Below right: Dobschuetz sees several patients in their homes each day, riding a bicycle between stops. Photography by Teresa Crawford

“A lot of older patients who come to the emergency room with vague complaints like fatigue are deep down looking for the support our program provides,” explains Rebecca Zakem, RN, a GEDI nurse. “They often don’t have families or any other way to get help, and that’s really why they keep coming back to the emergency room.”

The program seems to be working: A study published in the Journal of the American Geriatrics Society in January found that GEDI cut unnecessary hospital admissions by as much as 33 percent. Data has also shown that patients seen by GEDI nurses have a reduced risk for 30-day readmissions. Even though the original grant initiated in 2013 has ended, the GEDI program remains a key facet of the emergency department today.

“This program makes a difference, not only in patients not having to return to the ER, but also in giving them such a better quality of life at home,” says Catherine Wilk, RN, another GEDI nurse. “In this work, it’s not about getting patients to the cath lab in time or saving lives from a heart attack. It’s the little things we do that really make people’s lives so much better.”


Transitioning Patients to Primary Care

Older adults aren’t the only vulnerable population requiring a different kind of care than what the traditional ED or hospital is set up to provide.

In fact, research suggests that about one-third of emergency room visits are for care that could be better delivered in other settings. Not only does this contribute to hospital overcrowding and increased healthcare costs, but many patients with complex issues most likely need more comprehensive, continual care.

“Patients who receive primary care in the community have better outcomes and use the hospital less,” says Christine Schaeffer, MD, medical director of the Northwestern Medical Group Transitional Care (TC) clinic and clinical assistant professor of Medicine in the Division of General Internal Medicine and Geriatrics. “So how do we help patients who are currently using the hospital for all of their care feel empowered to use primary care clinics, and receive preventive care so they don’t get sick going forward?”

In 2011, Schaeffer launched the TC clinic to meet the needs of patients recently discharged from the ED or hospital who lack a regular source of primary care, are uninsured, or are overwhelmed by medical conditions or mental health challenges. The clinic does whatever it takes to stabilize these patients, help them transition to partner community clinics and, ultimately, reach healthier lives.

What began as just Schaeffer and a single social worker has grown into a large, bilingual, multidisciplinary team. Staffed with clinicians, nurses, psychiatrists, social workers and health advocates, the clinic is now housed in a new, sunny space across the street from the hospital.

The care plan at the TC clinic is driven by the individual needs of the patient. In many cases, health education is fundamental to a successful transition. “We’re helping people understand and navigate the confusing health system, and teaching them how to advocate for themselves,” Schaeffer says.

There’s an art and a science to caring for these patients. Addressing acute and chronic health issues and connecting patients with a federally-qualified health center in their community is a large component of the process, but a significant portion isn’t strictly medical: It’s helping people find housing, obtain bus passes to get to an appointment, locate a food pantry near their home, and fill out paperwork to enroll in insurance. It’s the combination of these interventions that ultimately sets a patient up for success.

How do we help patients who are currently using the hospital for all of their care feel empowered to use primary care clinics, and receive preventive care so they don’t get sick going forward?

“This clinic sees the most complex patients with great physical and mental health challenges, and low resources,” says Joseph Feinglass, PhD, research professor of Medicine in General Internal Medicine and Geriatrics, who has partnered with the TC clinic to conduct research. “With the clinic’s very refined approach, clinicians can really get to the social determinants of health and bring patients to a point where they’re ready to start taking caring of themselves. These clinicians are my heroes.”

Feedback collected from the clinic’s patients also speaks to the significance of TC. “You worked with me until I was on the proper medication, and kept testing me until I understood my medications,” one woman remarks. “This clinic has kept me alive, [thanks to]the personal treatment and dedication of my doctor,” one man says. “You brought me back,” another simply states.

Research is also demonstrating the large-scale impact of the clinic as it expands over time. In August, Feinglass and Schaeffer published a study in the journal Healthcare that showed, through electronic health records, that patients who visited the TC clinic in 2015 and 2016 had an almost 40 percent decreased likelihood of hospital use within 90 days, compared to patients seen in 2011 and 2012. A randomized controlled trial, recently completed and not yet published, also had promising results: Among patients who are uninsured or with Medicaid, those seen in the TC clinic were associated with a significant reduction in hospital utilization, compared to those who received standard care.


Another specialized clinic, the Complex High Admission Management Program (CHAMP), founded in 2015, focuses on patients who are frequently hospitalized.

“Our patients’ frequent admissions are a sign that the current system of care doesn’t meet their complex medical and psychosocial needs,” says Bruce Henschen, ’12 MD, ’12 MPH, ’15 GME, assistant professor of Medicine in General Internal Medicine and Geriatrics. “We try to design a system of care to address the underlying factors leading to hospitalization.”

Co-led by Henschen and Margaret Chapman, MD, assistant professor of Medicine in the Division of Hospital Medicine, with social workers also on staff, the program is based on a longitudinal, relationship-based care model emphasizing provider continuity, intensive care management and personalized care plans.

Preliminary research shows that the clinic is associated with a 20 to 30 percent reduction in hospital readmissions. The team is currently conducting a randomized, controlled trial to further assess its impact.

A National Model

Though each program serves a unique patient population — and tackles a specific healthcare challenge — CHAMP, the TC clinic and GEDI are united in a core mission: improving the model of care for vulnerable patients.

“We’re all looking for solutions to problems for specific subtypes of patients who the traditional care model didn’t work for,” Schaeffer says. “All of these are novel, cutting-edge programs — and they’ve led to real improvements and advances in care.”

The Northwestern programs serve as models for other medical centers across the country.

“One of our goals is to begin teaching this process to other institutions,” Schaeffer says. “These programs are all part of a national conversation. They’re meshing real science with healthcare to change outcomes — not just for the individual but for the larger system. We’re a great example of how when a university and a health system are paired, really cool things happen.”


We’re all clinicians looking for solutions to problems for specific subtypes of patients who the traditional care model didn’t work for.