Preventing Hospital Readmissions
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
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
? Simple diagnosis-specific instructions reviewing
what to do, when to do it, and who to call.
Meet my Friend
82 year old female
Primary caregiver for spouse with advanced Parkinson
History of anxiety/depression
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 population is huge challenge.
When help is offered, it is either too expensive or not
These patients need a lot of reassurance, repeated
contact in order to trust us and trust our
Role is to educate, advocate and coordinate needed
resources to keep patient out of ED.
Communicating with PCPs – exchange of information
on admission and discharge.
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
Could telemedicine work for these patients?
Standards of Care in PCPs Office
Setting up standards for CPE
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