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As a result of a patient-centered medical home pilot program based around preventive and coordinated care, Bend (OR) Memorial Clinic's hospital admissions and emergency department visits dropped for Medicare Advantage members of PacificSource Health Plans.
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When patients who have a high risk of rehospitalization are discharged from Bayada Home Health Care's home health services, the Mooretown, NJ, home health company calls them monthly for the next year to find out how they are feeling and whether they need assistance or additional services that will help them avoid another hospital admission.
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When the Bend Memorial Clinic receptionist offered a 90-year-old patient a brochure describing the clinic's medical home model and a letter introducing the nurse care management program, the patient angrily threw the materials back.
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Georgene Siemsen, MS, RN, GNP-BC, visited the home of a 74-year-old patient at Bend (OR) Memorial Clinic because of concerns that she was not refilling her medication consistently. Inside, Siemsen found a disorganized collection of old bottles, expired prescriptions, and multiple refills of the same medications.
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When you meet with patients in person, you can find out information, determine their level of understanding, and develop rapport much better than just talking to them on the telephone, says B.K. Kizziar, RNC, CCM, CLCP, a case management consultant based on Southlake, TX.
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With surging demand from patients with both medical and mental health needs, and continuing pressure to reduce costs, ED managers have a full plate of concerns to contend with.
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As payers and providers alike begin to recognize the value of care coordination, case managers are being given more and more responsibility.
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Getting an entire staff of physicians, nurses, and techs to do things differently is never easy, but you can clear away hurdles by giving them the ability to formulate some of their own solutions.
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While the Centers for Disease Control and Prevention (CDC) in Atlanta has been calling on EDs to routinely test patients for HIV since 2006, the practice is hardly widespread.
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Northwestern Memorial Physicians Group in Chicago is partnering with Walgreens to counsel patients with chronic illnesses on their disease and medication and to support them in following their medication regimen. So far, patients in the pilot have increased their medication adherence on five different drugs by 5%.