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In Focus with Heidi Steinhebel

We connected with Heidi Steinhebel, RN,BSN,CCM,CCP, Senior Associate Director of Care Management at IHA, and Clinical Coordinator for the MIRROR-TCM study at Trinity Health-Michigan. Steinhebel shares her thoughts on the importance of equitable access to care, communication and engagement, and meeting the needs of patients across the care continuum.

Q: If you could change one thing about health care, what would it be?

A: I have two things: coverage and mental health. I wish every person had the same opportunities, the same coverage of care. For instance, someone needs a prosthetic leg that costs $80,000 and they have a 20% copay, what is the reality that any percentage of Americans could actually cover that. There needs to be some standardization that everyone has real access to care when they need it. Then I think mental health is definitely an area where the health care system needs to improve.

Q: What do you think are the major challenges affecting the care of complex older adults as they transition from hospital to home.

A: It really is about just that transition. When you think about the inpatient experience that a patient goes through, there’s a lot of things missed in fully preparing patients to return to their homes. Can the patient take care of themself? Is there anyone at home that can help and are they prepared to be of help? Do they really know what to do with their medications and the changes short- and long-term? Are needed services in place? Patients think alright I’m going home, and they think they know what’s going on and the reality is they really don’t. The challenge really is that transition and making sure our patients really do understand what’s going on, and when they say they do, getting that teach back and making them show us that they do know. I think that’s a big component. In general, we need a better system to ensure that patients and their families truly understand what is happening and are able to participate in their treatment and care. We have to be better at what we do. We have to be more diligent. We have to be more caring.

Q: What worries you the most about “at-risk” patients?

A: We continue to learn and refine but my biggest worry is, are we able to meet their needs? It really boils down to how do we figure out who is this population and then how do we best provide services to meet their needs efficiently. This is a challenge for all systems. We all have an algorithm, and sometimes that algorithm works and sometimes it does not. It is like finding that needle in a haystack. Finding a tool that is reliable and consistent in identifying this population. Then when we do identify this population, what resources do we have as an organization or what resources are available in the community, and then there is the cost of those resources. We have patients that have complex needs, whether clinical or social, and we have to find the support.

Q: What impact has the pandemic had on care transitions of this at-risk group and others?

A: We’ve been fortunate as far as our TCM program that we’ve been able to go into the patient’s homes. We also have been able to get into their doctor’s visits for the most part or participate in virtual visits. I think the bigger issue we’ve had is getting into the subacute rehab facility when the patient has a short-stay. Overall as an organization being able to serve our patients in the way that we’re used to serving them and being able to bring them in face-to-face for assessments—being able to see them, getting our eyes on them and doing a good assessment on them, whether it’s in the home, the nursing home or in the office. A lot of our patients are still not comfortable coming in, so we’re still doing a fair amount of virtual visits. Another issue we’ve identified is the loneliness this patient population. If you’ve been in the hospital and you go home and you live alone, during this pandemic you really were alone.

Q: Do you have a large population living alone in your area.

A: We do. It was interesting to see when we started with the TCM program, the first handful of patients to enroll were all men and all lived alone. In addition to those living alone we have a lot of patients that are elderly, and they are the primary caregiver for an elderly spouse who is unable to care for themselves. So, we then have two at-risk patients.

Q: How do you think the TCM program can help to address these challenges?

A: The TCM really gives us a better picture of what’s going on with that patient, whether it’s just the cleanliness and safety of the home, the resources they have, what’s in the refrigerator, what’s in the bathroom, what’s sitting all over the kitchen table, to even how do they get in the house. There’s so much more you can glean from being able to see the patient in their own environment. I know even from our physician perspective, they really feel like if they can get a good sense of the patient in the home where the patient is comfortable and feels confident, it allows them to engage in their care in a different way than a set office visit. The TCM program puts an APRN in the home that can be the eyes of the physician, she helps guide the patient through this journey and also is a conduit for the transferring of information amongst the care team.

Q: How do you think the TCM will advance the mission of the health system? What do you envision for the future?

A: The purpose of the TCM is aligned with mission of IHA and Trinity. We have had similar programs at IHA in the past where a nurse practitioner went out and our physicians really felt that this was a great opportunity for us and could make a difference in our patients lives. We didn’t have data or the metrics from those programs, so I am excited about the data from the MIRROR-TCM project to help us move forward. I’m hopeful in what I hear from the Trinity perspective, that is ‘let’s make this work’. Let’s see if we can make the TCM a successful program and look at how we can roll this out. In the ideal world, I would love to see this program at other Trinity sites across the state of Michigan as well as across the U.S. In an ideal world, the TCM would be rolled out with an even bigger integrated team.


Heidi Steinhebel, BSN, RN, CCM, CCP, is the Senior Associate Director of Care Management at IHA and serves as Clinical Coordinator for the MIRROR-TCM trial based at Trinity Health-Michigan. For the past decade, Steinhebel has led care management programs at IHA to ensure high quality services for patients and families, and leveraged the contributions of a diverse workforce to meet the needs of the greater Ann Arbor community. Prior to joining IHA, Steinhebel worked as a nurse case manager at hospitals, health plans, and community-based organizations.