Like a director coordinating his cast, officials at Regions Hospital, a HealthPartners hospital, have perfected the care plan, a set of directions for the care team. Instead of ordering their actors to exit stage right, or whisper, to assure the integrity of the show, the care plan informs members of the care team throughout the organization how to best respond to a patient, so that key goals for his diagnosis, disease or needs are maintained, says Joshua Brewster, Regions’ director of care management.
The core example of the work that we’ve done is in what we call ‘care plans.’ There are two settings for them: one is using the data for few patients, or 1 percent of the patients that were coming here and overutilizing the ER and being admitted. It was led by our hospitalist, who put together written care plans that we focus on that are communicated to the patients. For those familiar faces that come here often, the plans state how we as a hospital are going to manage them when they come into the ER looking for admission.
Care plans are directions to the care team. For example, if the patients presenting often ask for narcotics, this is how we are to respond. We’ve also done a lot of work in terms of our plan of care and how we communicate what’s happening for patients throughout the entire organization. So when the patients are in front of them, the hospitalist knows exactly what the key goals are around a certain diagnosis or disease or patient’s needs. We have made sure that those are very visible in our charts and we have found great success in that. But it’s also been a good tool for us to communicate with each other as to where we would put key information and how we could collaborate in care for these patients that come through the different care settings.
Rethinking Readmissions: Patient-Centered Collaborations in Care Transition Management examines the data analytics driving the CMS Care Transitions Demonstration Project as well as some home-grown programs that are supporting patients’ seamless transitions back into their communities.