"bundle" interventions to solve problems that impede access to care?

As a case manager in a busy ICU-cardiac ICU, I hear a lot about the use of "bundles" for particular conditions, such as sepsis and ventilator-associated pneumonia. A bundle is a protocol that employs a number of interventions to treat or prevent a specific cluster of symptoms (the combination produces better outcomes than any one intervention can). Bundles are usually created to address specific physiologic aspects of acute, life-threatening conditions, but recently I began to wonder whether the bundle concept could be used for critically ill patients who have socioeconomic barriers to postdischarge treatment. Might we also "bundle" interventions to solve problems that impede access to care?...

...Of the nearly 35 patients a month who receive cardiac stents in our hospital, two to four are underinsured, uninsured, or homeless. Colleagues on other units have told me they care for many such patients as well. So I decided to develop a "medication access bundle" for underinsured patients requiring cardiac stents and postdischarge clopidogrel. The bundle addresses a cluster of social symptoms-little or no insurance; an inability to buy medication; undocumented immigration status; and such obstacles to follow-up as homelessness, transience, or the lack of a phone-and presents solutions to fit the circumstances.

The bundle involves four interventions. First, case managers work with attending physicians to find physicians in the community who will see low-income patients on a sliding scale and accept clopidogrel shipments for them in 90-day increments for a year. Second, the case managers use the protocol I developed to fill out the necessary paperwork and fax it to our hospital's medication assistance program, which forwards it to the drug's manufacturer. (Applications for more than 400 medications are also available at www.needymeds.org.) Third, we give patients a free 30-day supply of clopidogrel and, through the manufacturer's representative, arrange for the patient to receive an additional 14-day supply-thus providing adequate coverage until the mail-ordered prescription arrives. Fourth, upon discharge, we give the patient the medication, follow-up physician information, and written instructions.

This bundle was put into action in the discharge planning department. After approval from the director, I gave the department an in-service training and became the point person for this particular bundle.
There are scores of medical conditions complicated by socioeconomic issues. Perhaps the bundle concept can be used to open up more avenues of care to these patients.