Executive Summary

At-risk patients who are being discharged from Torrance (CA) Memorial Medical Center are referred to the Care Coordination Clinic for follow-up care and/or receive care coordination services from an ambulatory care manager.

• At the Care Coordination Clinic, a physician or nurse practitioner reviews the discharge plan, reinforces discharge education, conducts medication reconciliation, and communicates with the patient’s primary care physician.

• Patients are usually seen at the clinic only once, then followed by an ambulatory care manager unless they are having home health services. Then the care manager picks up after the patient is discharged from home health.

• The Care Coordination Clinic also sees patients who have not been hospitalized, but who have been referred by the emergency department staff or community physicians because their chronic conditions are deteriorating or they need palliative care.

 

At Torrance (CA) Memorial Medical Center, patients who are at risk for readmissions are referred to the health system’s post-discharge Care Coordination Clinic for follow-up care and/or receive post-discharge care coordination services from an ambulatory care manager who may be an RN or a social worker.

Early in the hospital stay, the hospital’s unit-based case managers administer a readmission assessment tool, based on the Project BOOST program1 and adapted to the Torrance Memorial Health System’s needs. Patients with two or more risk factors are referred to the Care Coordination Clinic. As soon as the hospital case managers know the expected date of discharge, they set the follow-up appointment for the patients to see a clinician within 72 hours of discharge, says Carol Ecklund, RN, MN, AOCN, director of medical management at Torrance Memorial Medical Center.

When patients visit the clinic, a physician or nurse practitioner reviews their plan of care, conducts medication reconciliation, and reinforces the education they received at discharge.

“Discharges are so stressed and hurried that the patient can’t absorb all the information they receive. We fill in the inevitable gaps that occur. The clinic visit is like a second discharge day,” says Ujjwala S. Dheeriya, MD, medical director for Supportive Care Services at the 446-bed hospital.

Patients who are seen at the clinic are followed in the community by case managers and social workers in the hospital’s post-discharge Ambulatory Care Management program or are receiving home health services.

“Having a case manager and a home health nurse both following them is too much for the patient. If patients have home health services, that agency does the case management and if needed, hands the patients off to the case management when they are discharged from home health,” Dheeriya says.

The care coordination team works closely with patients’ primary care physicians and gets buy-in from the physicians before scheduling a clinic appointment.

“We communicate back and forth with the primary care physicians and specialists, if appropriate, and keep them in the loop. If they are receiving home health services, I keep the home health staff informed as well,” Dheeriya says.

When patients come into the clinic, Dheeriya conducts a thorough review of the hospital stay, conducts medication reconciliation, and reviews the discharge instructions with the patient.

“We take a patient-centered approach and use motivational interviewing to include the patient and caregivers. If the patient’s condition is complex and he or she does not have a coordinated plan, we set a follow-up appointment. Most patients go back to their primary care physician after one visit,” she says.

The ambulatory case managers make about 80% of their contacts by telephone and make home visits when they feel the patient needs it. They may accompany the patients on their appointments at the Care Coordination Clinic. “Their job is to pick up the ball and make sure whatever care plan is developed in the hospital is followed as they transition back home and back to their primary care providers,” she says.

Most of the patients the ambulatory case managers work with have had multiple hospitalizations. Sometimes they are people who are not high risk enough to be referred to the clinic but have a limited need, like a transportation issue, Ecklund adds.

The ambulatory case managers coordinate care between multiple practitioners, help patients connect with community programs and services, educate them on their conditions, and help them follow their treatment plan.

Patients who receive case management through the Care Coordination Clinic or from ambulatory case managers have not necessarily been hospitalized. “There may be patients in the community that we identify as having decompensating health. We try to intervene to prevent hospitalizations or to get the right plan of care in place so they don’t deteriorate further,” Ecklund says.

Some patients are referred to the clinic after an emergency department visit, she says. Others are there for palliative care.

Physicians also can refer their program to the clinic for follow-up if their illness is causing significant suffering or is terminal, Dheeriya says. For instance, a physician may refer a patient who is close to end-stage chronic obstructive pulmonary disease but still wants treatment, or someone receiving chemotherapy who needs pain management.

“We transition them to a supportive care model that meets their needs before hospice is appropriate and helps them avoid hospital admissions,” she says.

Reference

  1. Project BOOST (Better Outcomes by Optimizing Safe Transitions) is a series of interventions to improve the hospital discharge process. For more information, visit www.hospitalmedicine.org.