Reducing Inpatient Readmissions and Unnecessary ER Visits through PCMH

1. Reducing Inpatient Readmissions and Unnecessary ER Visits through PCMH Darius Kostrzewa, MD Martha Farrelly, NCM

2. Access to PCPs Office • Open access/same day appointments • Expanded office hours • Educating patients about your availability • 24/7 access to PCP – concierge practice

3. Role of Nurse Care Manager • Physician partner • Patient advocate • Educator/Life coach • Resource coordinator • Liaison

4. Current System • We receive an e-mail every morning with list of patients seen in the ED and those admitted . • Wade through Meditech to determine what was done for patient and where they are now. • We do not get notification of patient transfer to another hospital or notice of death. • Daily list of discharged patients would be helpful • Access to any physician/nurse ED notes.

5. ED Follow Up • Call patients seen in the ED. • Often need to ask them what they were told to determine what their problem was. • ED or triage notes would be very helpful • Discharge instructions with current meds and any new scripts patients are leaving the hospital with. • Discharge instructions need to be specific and legible!!! • ? Simple diagnosis-specific instructions reviewing what to do, when to do it, and who to call.

6. Meet my Friend • Shirley B • 82 year old female • Primary caregiver for spouse with advanced Parkinson Disease • History of anxiety/depression • Multiple medications • Complicated family dynamics • Frequent emergency room visitor • “I was tired, I had a headache, my kids weren’t around, so I called the rescue.”

7. Geriatric Patient • Geriatric population is huge challenge. • When help is offered, it is either too expensive or not convenient enough. • These patients need a lot of reassurance, repeated contact in order to trust us and trust our recommendations. • Role is to educate, advocate and coordinate needed resources to keep patient out of ED.

8. Hospitalist/Admission/ED • Communicating with PCPs – exchange of information on admission and discharge. • Care Transitions • Discharge instructions • Patient Education

9. VNS • Direct communication with NCMs definitely improves continuity of care. • We receive list of mutual patients, discharge instructions of new VNS clients • Opportunities exist to improve home care services. • ? Respiratory program for COPD patients similar to CHF protocol. • Could telemedicine work for these patients?

10. Standards of Care in PCPs Office • Setting up standards for CPE • CSI measures • End of life issues – most healthcare dollars spent in last years of life. • How do we keep elderly at home? • Family meetings/list of patients living alone. • NCM geriatric assessments