Care Transitions Prime Opportunity for Patient-Centric Case Management

Hospital-to-home or hospital-to-nursing home transitions offer a wealth of opportunity for intervention, the first being medication management and medication reconciliation, say Doreen Salek, director of business operations of health services, and Janet Tomcavage, RN, MSN, vice president of health services for Geisinger Health Plan. Following up with patients on home health and durable medical equipment is also key to successful patient-centered care.

There are five core components to our medical home initiative, the first one being the concept of patient-centered care. When we talk about patient-centric care, we talk about getting the patients—particularly Medicare patients—and the families actively engaged in education, decision-making and understanding their plan of care. One of the first things that we emphasized in this component was the development of a team at each primary care site that would start to understand where patients were. We have a monthly team meeting made up of the case manager and the provider, and we try to include all providers at the site. They may rotate through each month, and all providers may not attend, but there’s always provider representation.

We have nursing from the office, we have front desk or the phone people who do a lot of the office work flow. Each month, one of the first things that we do is review every admission to the hospital to see if there were missed opportunities or if we could have done something differently, but we also look at what happens from hospital to home.

We started our first site in January 2007. We found out that the hospital-to-home or hospital-to-nursing home transitions offered a wealth of opportunity for intervention, the first being medication management and medication reconciliation. We realized that we didn’t have discharge information in a timely manner. We realized that there would be discharges home with no follow-through on home health or durable medical equipment (DME) delivery. Or we realized that there were people discharged home who wanted to go home, but once they got home realized that they could not manage at home independently and needed to be in a nursing home for some rehab or continued therapy. We used these monthly team meetings to talk about enhanced opportunities. That was when we started to realize that we needed to be better connected with hospitals. We pushed the envelope with our participating hospitals to make the connectivity between inpatient care management and the case managers that were out in the clinic site.

We also looked at the electronic medical record (EMR) to determine if there was opportunity to get connected to hospital EMRs and move that to the clinic site. Many community hospitals were very willing to give the practice access to their census list or to a summary so that you could see at least a limited view of the inpatient stay. All those things helped us enhance that transition from hospital to home. Early notification about admission and the ability to see in real-time what was being done; outcomes from some test results, medication changes, etc. were key things that we realized early on were very helpful in this process.

Source: Care Transitions Toolkit

Care Transitions Toolkit

Care Transitions Toolkit examines current and emerging trends in care transition management, providing actionable data and case studies from industry thought leaders on key elements of their care transition programs.

This entry was posted in affordable care act, Care Coordination, Care Transitions, Case Managers, Case Managers and the Patient Experience and tagged , , . Bookmark the permalink.
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