Program focuses on elderly with highest risks
Program focuses on elderly with highest risks
Patients are carefully screened
Carle Clinic Association in Mahomet, IL, carefully screens the patients who are chosen to participate in its Partners in Care case management program. The typical patient has two or more chronic conditions, such as congestive heart failure, diabetes, cancer, stroke, or coronary artery disease, and takes at least five medications daily. Patients have limitations in activities of daily living (such as walking or feeding themselves) and instrumental activities of daily living (cooking, driving, and shopping), as well as a history of previous hospitalizations.
Over time, the practice has automated its identification system to identify patients at risk who should be referred to the program. "We are continually refining and automating our clinical records and triggering systems," says Cheryl Schraeder, RN, PhD, FAAN, who heads the health system research center.
Medicare patients who have seen a family practice or an adult medicine physician more than four times a year are referred automatically to the program. Patients also are referred to the program directly by physicians. Once referred to the program, a patient receives a 50-item questionnaire that gathers information such as demographics, medications, current health conditions, and prior health care service utilization.
The information from the questionnaire is entered in a computer database that classifies patients into risk categories based on their response to certain questions. For example, a patient who has positive responses to three of 13 "trigger" questions initially is given a status of "At Risk." A nurse, known as a Nurse Partner, conducts a second, more detailed screening either during an office visit or over the telephone. Using this information, the nurse and physician determine the patient’s final risk status.
Participating patients are given a medical assessment by the physician to determine current and potential medical and psychosocial needs. Then, the patient, physician, and nurse develop a coordinated health care plan that includes medical services, community services, and assistance from family, friends, and neighbors.
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