Open Forum

Good Morning,

We have a CM team that completes the call and then schedules the patient if they are not scheduled.

Thank you,

Linda

Linda Postula, MHA, BSN, RN

Chief Nursing Executive, Faculty Practice Plan

Office: 314-362-1092

Cell: 618-304-8495

At UCM, we have a dedicated Population Health Nurse Navigator team that completes TCM calls for our entire system, including OON, and a Care Coordination team that focuses on the 10% most at risk within our ACO. We have escalation pathways for different practices and a separate one for our OON discharges. The team does what they can to remedy the patient's issues and will escalate more complex needs as needed. We make 3 attempts to reach the patients across 2 days, leave messages if needed, and send a MyChart message after 3 attempts if they have an open account. We have a set Epic template to ensure consistency in calls and capture all of the questions, we also added an "attestation" within a telephone encounter that we document if we are unable to reach the patient, which helps us track. Even for those patients that we don't reach, if they have a UCM PCP we ensure that they have an appointment within 7-14 days. We track any issues identified during the call, i.e. didn't pick up meds, no wound care instructions, DME not delivered, etc.

In addition to doing TCM calls, we've set up a dedicated Post-Discharge line that gets answered by our Pop Health team. This is provided to all patients at the time of discharge and they can call with questions or needs when they aren't sure who to call or if they don't have an established in-network PCP that can answer questions. This has been an invaluable addition to our 30-day readmission work. We track the calls so that we can trend the questions and issues patient report, similar to TCM calls.

We recently implemented TCM calls and our discharge line at our community hospital and within the first 2 months saw a around a 25% decrease in readmissions. I think the most essential part of this work is actually speaking with the patient and assessing how they are managing at home, ensuring all meds, DME, etc. have been received, that home health has contacted them if ordered, etc. and then helping the patient to get those things they need or answer questions – these are the things that we have seen bring patients back to the ED and often readmitted.

Sarah L. Kundrat MSN, RN, NEA-BC

Executive Director, Ambulatory Nursing

Associate Chief Nursing Officer

UChicago Medicine

I love that we are bringing up this topic and there are others to collaborate with!

My team supports 33 primary care offices and 4 hospitals (2 are small). In most we have a nurse care manager and social worker (some do have more than one office but all offices have support) embedded. We have a centralized team of MSWs, RNs, MAs, and support staff. Our structure is: 4 RNs and 4 MAs making calls to hospital and ED discharges, 1 RN calling peds, and our MSWs call discharges with behavioral health needs but also deploy to offices to assist with assessments. We prioritize based on high risk diagnosis then risk score, and we omit patients based on criteria we developed (surgical, OB, TEE, and some others). Our hospital TOC calls are only for our primary care attributed patients. We are in the 90^th percentile of completing our TOC calls. We also have 2 part time RNs who share the load of calling our attributed patients who are discharged from an external hospital system.

One area we have challenges in is capturing SNF patients when they discharge back home and behavioral health patients discharging from an inpatient facility. Another challenge we have is demonstrating impact on readmissions (capturing actual data). If anyone has a dashboard in Epic I would love to hear more about this!

I am interesting in learning more from others and improving ambulatory care.

Ashley Rosa, MSN, RN

Manager Ambulatory Care Management

Bronson Healthcare Group