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Medical home model helps DP process with care
Point person or EMR keeps all providers informed
Here's a common hospital discharge scenario: the patient is ready to be discharged home, and the hospital has a discharge planner or case manager who is prepared to call the patient's primary care physician (PCP) to discuss the patient's post-discharge care. But who does the discharge planner call? And will anyone respond to the call?
"Everyone in a typical doctor's practice is busy; and they might be a little annoyed, because they don't have time for this; and they don't have a system in place to handle it," says Marjie Harbrecht, MD, CEO of Health TeamWorks, formerly the Colorado Clinical Guidelines Collaborative (CCGC) of Lakewood, CO.
This is where the patient-centered medical home model can greatly benefit discharge planning. With this model, there is a person to call a primary care case manager or care coordinator. And chances are that the care coordinator might even call the hospital discharge planner first.
"The medical home sets up a specific contact system, so each person has been assigned to someone who can check this log to see who has been in the hospital and emergency room," Harbrecht says.
The hospital discharge planner can tell the medical home coordinator about the patient's discharge, the hospital team's chief concerns, and the need to have the patient seen by a provider soon after he or she returns home, she adds.
Harbrecht and other experts discuss these ways the medical home model can enhance care transition and the hospital discharge process, and how hospitals can make the most of these transitions with or without assistance from medical home providers:
Create tools to improve communication between the hospital and medical home/PCP.
Physicians sending patients to the hospital will want to communicate some specific details about the patient's case, but it's often unclear how they might do so, Harbrecht notes.
"Who is the patient, his or her demographics, histories, medications, allergies, etc.?" she says. "And how do you contact me and send information back?"
Also, there might be times when the PCP doesn't know the patient has entered the hospital, and the hospital doesn't know where to send results.
TeamWorks created some tools to help with these communication issues.
One is a wallet card for medical home patients. They receive a handout that says, "You're now part of a medical home, and here's what it means; here's how to reach us after hours, and if you do have to go to the ER, call us first to see if we can help you through that," Harbrecht says.
Patients keep these cards in their wallets or purses, so they'll have it to show hospital staff their PCP's name and their health coordinator's name and contact information.
Another tool is a fax referral form that is available for these care transitions:
- PCP to hospital - direct admit;
- hospital to PCP;
- PCP to ED;
- ED to PCP.
These one-page fax forms have spaces for all essential communication about the patient, including the following information:
- patient name;
- patient date of birth;
- dates of hospitalization;
- hospital name;
- attending physician/hospitalist;
- reasons for hospitalization;
- discharge diagnoses;
- key lab/imaging results;
- new medications/immunizations;
- procedures done;
- pending lab/imaging results;
- recommended follow-up (including specialists contacted);
- provide discharge summary if available.
Provide electronic communication processes.
"One challenge is how to get succinct communication back and forth between the busy emergency department and the primary care physician and back," says Tina M. Snapp, RN, BSN, CCM, continental division director of case management of Hospital Corporation of America of Denver.
One method is to provide PCPs with access to the hospital's computer system and electronic medical records for their patients.
This way they can check their patient's lab test results at the time they have the patient sitting in the exam room waiting for them.
"Through our information system, we set up a remote access for the physician group, so they can go online for information," Snapp says. "We have a website called healthonecares.com, and doctors can go online with access codes, and if these are tagged to their patient, they can see the test results."
Insurance company nurses also can access this system when they're primary payers, she adds.
Work with medical home care coordinators.
Medical home care managers provide complex case management for patients, Snapp says.
"From the discharge perspective, we know the primary care office, and we can call different care coordinators in the offices, and information will go over to them," she says.
"It's set up in our system that discharge summaries and information is faxed over to the primary care office too," Snapp says. "So, they know what happens in the course of hospitalization."
It can be a relief to hospital discharge planners to have a point person to call about a patient.
"It's still our responsibility, but the difference is we have somebody to call and say, 'This person is very high risk and has been here several times, so would you please make sure you get the patient in your office right away,'" Snapp explains.
"Before, you might call the doctor's office and leave a message that goes into oblivion," she adds. "But now, there's someone at the doctor's office who's responsible for this call, and that's a huge difference."
Case managers and social workers have a tremendous opportunity to be a positive force in care transition through the medical home model, notes Robyn Golden, MA, LCSW, co-founder of the National Coalition on Care Coordination in New York City and director of older adult programs at Rush University Medical Center in Chicago.
Medical home care coordinators regularly call patients to make certain they are adherent to their medication and doctor visits and to see if they have any symptoms that might lead to an ED visit.
"They talk to patients all the time, making sure things are going okay," Golden says. "They're the contact person."
Robyn Golden, MA, LCSW, Co-Founder, National Coalition on Care Coordination in New York, Director of Older Adult Programs, Rush University Medical Center, 710 S. Paulina St., Suite 422, Chicago, IL 60612-3814. Telephone: (312) 942-4436. Email: Robyn_L_Golden@rush.edu.
Marjie Harbrecht, MD, Chief Executive Officer, Health TeamWorks formerly Colorado Clinical Guidelines Collaborative (CCGC), 274 Union Blvd, Suite 310, Lakewood, CO 80228. Email: email@example.com. Website: www.healthteamworks.org.
Tina M. Snapp, RN, BSN, CCM, Continental Division Director of Case Management, Hospital Corporation of America, 4900 South Monaco St., Suite 380, Denver, CO 80237. Email: firstname.lastname@example.org.