Posts Tagged ‘complex patients’

Severity Index Drives Patients’ Touch Points with Nurse Navigators

August 12th, 2014 by Patricia Donovan

Beyond telephonic outreach, assessment and education, nurse navigators in Bon Secours Health System Advanced Medical Home also manage a case load for face-to-face patient work, explains Robert Fortini, vice president and chief clinical officer at Bon Secours Health System. Here, he describes the process of assigning patients to nurse navigators.

Based on our learning experiences with the Geisinger system, it becomes difficult for an RN to handle more than about 150 patients, depending upon the complexity of the patient.

We also give back-line access, and the RNs all have beepers as well. They have the license to give that beeper number to the more complex patients—the frequent flyers who are going to need more attention. Or they can give that access to our colleagues on the managed care side who might be engaged in managing patients with a severe illness. To our case management team in the hospital, it just allows for more bandwidth and clearer communication across the spectrum of care delivery.

How does a patient get into a case load? It is by the physician’s decision. For example, Mr. Smith has seven different major active problems. He is on 18 different medications, he is 87 years old and he has a touch of Alzheimers. That individual needs hand-holding, so that would be the first way to give the patient case management. We also take referrals from the hospital and from our managed care colleagues. We are also using some predictive modeling tools provided to us by insurers to identify patients who need closer following.

How frequently a patient is touched, brought in for face-to-face care or called on the phone depends on the severity index. We use a tool my colleague designed that will calculate a relative readmission risk index based on several sets of criteria: number of medications, length of stay in the hospital, the acuity level of the patient in the hospital and whether or not they are in intensive care unit (ICU) initially, etc. How frequently they are touched depends on how high up the severity index they are.

Excerpted from: Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination

HINfographic: 7 Care Transition Models for High-Risk Patients

January 21st, 2014 by Jackie Lyons

Many current care transitions models support safer transitions for patients with complex comorbid conditions – initiatives aimed at the patient, hospital, community, or in some cases, a state or region of the country.

One initiative reduced 30-day all-cause readmissions by 21 percent, according to a new infographic from the Healthcare Intelligence Network. This HINfographic takes a high-level look at seven popular care transition programs.

7 Care Transition Models for Complex High-Risk Patients

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Information presented in this infographic was excerpted from: Care Transitions Toolkit. If you would like to learn more about care transitions for complex high-risk patients, this resource includes even more information, including contributions of embedded case managers to care transition management, best practices to improve medication adherence and compliance, health literacy tools to promote behavior change, and strategies for matching high-risk patients with the appropriate clinical intervention.

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HINfographic: The 4 Ws of Home Visits

July 23rd, 2013 by Jackie Lyons

Visiting medically complex patients at home can shed light on health-related issues that might go undetected during an office visit, reducing the likelihood of unplanned admissions or emergency department visits by these patients.

According to a recent HIN survey, 72 percent of respondents include home visits in their care transitions program.

This HINfographic on home visits provides actionable data detailing who conducts the home visits, what happens during the visit, when the visits occur, why they are important and more.

Home Visits blog

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You may also be interested in this related resource: 2013 Healthcare Benchmarks: Care Transitions Management.