Example Scenario Shows the Benefits of Care Coordination
A patient suffers a dangerous fall over the weekend and is rushed to the hospital, where the health plan provider is contacted as treatment begins. After a hospital doctor treats the patient for a broken hip, an IntegraNet Health hospitalist is assigned to the patient to provide personal attention to the hospitalized patient. The hospitalist is responsible for checking on the hospitalized patient at least daily, speaking with the patient’s family as desired, coordinating with needed specialists and reporting progress to the patient’s primary care physician. This last aspect relieves the primary care physician of the time and financial constraints of making hospital rounds, yet allows the primary care physician to remain knowledgeable about the patient’s condition and treatment. Health plan providers also appreciate the hospitalist’s role as research shows that hospitalists reduce the length of stay and treatment costs as well as improve the overall efficiency of care for hospitalized patients. When the patient is ready for discharge from the hospital, the hospitalist makes the arrangements for proper discharge at the correct level of care. Additionally, the hospitalist provides all necessary referrals to IntegraNet, in-network specialists and supplies an IntegraNet Health case manager with updates on patient needs and progress.
A care coordinator is then assigned to check on the patient’s wellbeing and determine if a medical home specialist is needed. If a medical home specialist is not needed, the care coordinator will continue to check in periodically by phone with the patient and will report back to the primary care physician. The patient feels good about the level of care being delivered, the physician is able to use his/her time efficiently and effectively, and the health plan provider incurs lower costs when patients receive the medical help they need without return visits to the hospital.
If a medical home specialist is needed, the care coordinator makes all the arrangements.
A medical home specialist is a home-based nurse or nurse practitioner who works closely with the assigned patient and the primary care physician. Within one week of hospital discharge, the medical home specialist begins visiting the patient to assess the home environment, perform a physical exam, review medication, educate the patient on needed care procedures and evaluate overall home care needs. HRA, care plan, HEDIS and 5 Star measures are communicated to the primary care physician by the medical home specialist, ensuring diligent care of the patient. A follow-up visit with the primary care physician is also recommended. Home visits continue until the medical home specialist and the primary care physician believe the patient is no longer in needed of such care.
The medical home specialist improves overall patient health by regularly monitoring patient progress, providing continuous feedback to the patient’s physician(s) and allowing the physician to devote more time to office patients. Both patients and health plan providers benefit from consistent patient monitoring, continuous communication with the physician(s) and fewer repeat visits to the doctor’s office. If you are interested in becoming part of the IntegraNet Health system as a physician, health plan or patient, please contact us for more details. Better medical care is just a call away.