Transcript Preventing Hospital Readmissions

Darius Kostrzewa, MD
Martha Farrelly, NCM
Access to PCPs Office
 Open access/same day appointments
 Expanded office hours
 Educating patients about your availability
 24/7 access to PCP – concierge practice
Role of Nurse Care Manager
 Physician partner
 Patient advocate
 Educator/Life coach
 Resource coordinator
 Liaison
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.
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.
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.”
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.
Hospitalist/Admission/ED
 Communicating with PCPs – exchange of information
on admission and discharge.
 Care Transitions
 Discharge instructions
 Patient Education
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?
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