Team approach improves care coordination

Communication is key to success

Within the first two weeks that WellSpan Health has rolled out its care coordination team model in each physician practice, there’s been a significant success story that would not have been possible before team members at the practice and hospital were working together, says Ann Kunkel, RN, BSN, CPUR, corporate director of care management for the healthcare system.

"We have prevented a suicide and helped families in crisis when neither the physician practice nor the hospital medical team would have understood the whole picture on their own. We have been able to advocate for patients who were being taken advantage of financially and socially, and have been more involved with helping patients understand meaningful healthcare goals," she says.

One of the keys to success is constant communication between the health coaches at the physician practice and the hospital-based case managers and social workers, she says. Each case manager and social worker is assigned to a primary care practice and, with the health coach, coordinates care for all of its high-risk patients. The hospital-based team has a conference call huddle every day with the health coach in the physician practice they support and discusses all hospitalized patients.

Here’s how the process works:

When Ms. Smith, a patient of Dr. Brown’s medical group is admitted, her name shows up on the census of the case manager-social worker team assigned to Dr. Brown. The team visits Ms. Smith, reviews the chart and assesses the reasons for admission, the treatment plan, anticipated discharge date, and discharge planning needs. They discuss Ms. Smith and any other hospitalized patients from the practice during the daily conference call with the health coach at the physician practice. The team members share the information each has about Ms. Smith, her medical history, any comorbidities she may have, what’s happening during the hospital stay, her potential discharge destination, and what she’ll need for a successful discharge. The hospital team updates the health coach each day while Ms. Smith is in the hospital.

The team uses a risk stratification tool, based on utilization and practice data, to identify patients who may be at risk for readmission. Factors include elevated blood pressure, taking more than 20 medications, reported falls, chronic conditions, and utilization issues, such as multiple emergency department visits.

After discharge, the health coaches follow up with the patients by telephone to confirm discharge medications and reconcile them with the medications on the list the office has. They go over the discharge plan, discuss patient adherence, review discharge instructions, and make sure a follow-up appointment is scheduled. The health coach can call on the hospital team if the patient needs extra assistance.

"The hospital staff used to make the follow-up calls but found that patients didn’t make the connection to their physician office. Now they receive a phone call from someone they know in their doctor’s office, and this reinforces the patient-centered medical home environment," says Laurie Brown, RN, clinical director of quality and innovation for WellSpan Medical Group. The hospital team makes the follow-up call to patients whose physician is not part of the medical group.

In the past, the hospital would send patients home with discharge instructions and referrals for community services or applications for assistance and encourage them to follow their treatment plan. "Once they left, we had more patients coming in and we didn’t follow up with those who had been discharged. Accessing resources can be daunting under the best of circumstances, but particularly when someone has just gone home from the hospital. Now the health coach can encourage the patients to follow their treatment plan and get the resources and help they need," Kunkel says.

The initiative has really changed the perspective of staff and patients, says Karen Jones, MD, director of quality and innovation for WellSpan Medical Group. "A social worker shared that prior to this approach, she felt her patients were falling into an abyss when they left the hospital because she never knew what happened to them after discharge," she adds.