Healthcare is a team sport. We know that, particularly when caring for seniors and those with chronic conditions, we provide better patient care when we work collaboratively—from primary care doctors, to nursing teams, to specialists, to support staff.
But there is one area where we could do better—reducing hospital readmissions. The solution? Primary care practices need to take an active role as care managers for their hospitalized patients.
All too often, hospitals are going it alone in an attempt to keep patients healthy and out of the hospital after discharge. Hospitalists don't have easy ways to connect with patients' primary care teams, and they are left to discharge patients into a black hole, wondering who will order essential tests and ensure medications are taken. Hospital and health plan care managers can help, but there is a limit to what they can accomplish without seeing the patient on a regular basis.
As the Chief Medical Officer for ChenMed, a primary care organization that serves low-income senior citizens in nine U.S. markets, what I've learned is that the objectives of hospital-based providers and primary care providers are aligned: we all want to provide patients with the best healthcare possible, and we all want to do so while reducing overall costs. There are several ways we can accomplish this.
First and foremost, primary care providers need to put real resources into transitional care. When it comes to managing patients after discharge from the hospital, primary care has a huge advantage—long-term patient relationships. It's time for primary care to leverage those relationships and become true care managers to help hospitals in their quest to reduce readmissions.
At ChenMed, we tackle this challenge with transitional care teams. ChenMed case managers work in hospitals to help navigate relationships with hospital staff and manage and communicate needs after discharge. Upon discharge, our case managers work with patients one-on-one in their homes. Case managers help them understand their medications and any equipment they need, identify any environmental challenges, ensure their caregivers understand their care plans, make referrals to meaningful community resources, and ensure they are seen by their primary care physician soon after discharge. These team members also report back to primary care physicians and other support staff during weekly meetings, called "super huddles."
We started these meetings just over a year ago, in our South Florida senior medical centers, and we quickly saw evidence of faster interventions and better outcomes. In fact, they were so successful that we have since replicated them across our 39 locations. We've found that putting our doctors, case managers, and other care team members in the same room weekly to discuss the care of each high priority patient is a highly effective way to communicate, identify patient needs, and get at-risk seniors the best possible care. This model of a steady stream of communication and collaboration is one of the reasons ChenMed patients spend 38 percent fewer days in the hospital than the national average.
But transitional care teams cannot succeed when primary care providers do not know when patients are admitted to or released from the hospital. Indeed, tracking patients throughout the healthcare system is one of the greatest challenges of primary care.
We work with health plans to get this information, but working with payers alone is not enough to get it all. Our case managers working in local hospitals identify ChenMed patients and ensure they get care. And supporting all of this is our own technology platform, which tracks patients from the ER to their hospital room. When it's time to be discharged, our transitional care teams spring into action once again arranging everything from transportation to medication and follow-up appointments.
By integrating our case managers into the hospital setting, we are able to work with the team of caregivers at the hospital, help them reduce readmissions, and help us deliver better health for our patients. Now more than ever as the entire healthcare system is moving toward a model that rewards providers who achieve the best care outcomes, this type of collaboration is critical for the health of our patients and the healthcare system.
Gordon Chen is the Chief Medical Officer of ChenMed, a primary care practice providing innovative healthcare to seniors in 39 locations in 9 U.S. markets.
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