We had a very productive telephone meeting regarding one of our member’s patient care opportunities this morning. The combination of Lightbeam’s data and the ability to collate with the EMR data really illuminated some opportunities for care coordination. Everyone was motivated to work together. Drilling down on individual patients locally, especially the high utilizers, is invaluable.
The two specific patient cases were interesting in that they were both very sick patients, but had very different healthcare barriers:
Patient 1. An end-of-life patient who had multiple admissions, but only 3 visits to her primary care provider.
This patient would have likely benefited from some care coordination between the discharge Planner at the hospital and the outpatient Care Coordinator to facilitate better follow-up with their PCP. This may have led to more in-depth discussions about end of life, Hospice, etc. Even if the patient or family was not interested in palliative care, it would have at least allowed for closer follow-up between hospitalizations for preventative care, medication compliance or dosing adjustments, etc. All of which could have improved the stability of this patient’s health and comfort in the months leading up to her death.
The other patient was very different, but also very sick.
Patient 2. A chronic disease patient (COPD) who had seen multiple physicians, but was, nonetheless, admitted 8 times for COPD in the first 9 months of 2014.
The opportunities for care coordination here are certainly different, but equally important and achievable. The outpatient chart review was interesting: showing yet another admission since data collection in the spreadsheet. In this subsequent admission, the patient refused follow-up in the 3 days of respiratory worsening leading up to admission. The opportunity for a Care Coordinator to be collating all the discharge information, specialist care/recommendations, communicating with the patient and PCP with the goal of breaking down barriers to outpatient care access or novel methods for and outpatient action plan (ie corticosteroids) or redirecting care away from the ER when appropriate are obvious.
There seem to be many windows of opportunity that were identified and taking the Lightbeam data back to the Care Coordinators, hospital discharge planners and associated PCPs at the local level seems to be an actionable way to improve the patients’ care and also decrease costs.
Paul Krause, MD
Chief Medical Officer