Care Coordination Services Make the Difference for Patients

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By Jeanine M. Tome, MSN, RN-BC, ACM, CPHQ

Our hospital patients are whole beings with different parts impacting their recovery and return to health.  Health systems also are whole entities with many different parts acting together or separately, which can impact a patient’s return to health.

At Saint Vincent Hospital and throughout the Allegheny Health Network we want that impact to be a positive one!  To do so requires that all of the caregivers act not as individual entities, but connected with a goal to insure safe, quality care in a complex and rapidly changing environment. 

One of the largest efforts underway at Saint Vincent involves Care Coordination Services.   These efforts have had a significant impact, especially on caring for patients who do not have a primary care physician.

With the implementation of the Affordable Care Act, it is important to transition a patient’s care to better ensure they, too, will take part in their overall health. 

Our Care Coordination Services works to match a patient with a primary care physician (PCP) in the Saint Vincent Medical Group for any follow up care.  This effort began in the Emergency Department (ED) where many patients seek care because they do not have a PCP.  A care coordinator is able to work with the patient to identify a PCP and then schedule a follow up appointment prior to their discharge from the ED.  We have found that we have impacted about 60 patents per month that are now seeing a PCP.

Our care coordination teams have focused also on our hospital in-patients where we have assisted more than 250 patients per month transition to a primary care office for follow up care.  For patients that have a PCP, we work to schedule the follow-up appointment with the physician.  

This now insures that all patients being discharged from Saint Vincent are referred to a Primary Care Physician who can follow their care in the way more closely required by the Affordable Care Act. 

We have expanded the Care Coordination services to prevent many other patients from falling through the health care cracks.

The Saint Vincent Family Practice Residency program has established a Transition Care Clinic to see patients weekly after transition from acute care.

Our Regional Home Health has worked with Care Coordination to establish a Transition Home Visit (THV) for patients who may need some extra care onsite when leaving the hospital. If appropriate, after this one- time visit, a patient can be referred for home care services. 

Transfer Center Nurses have relocated to the hospital to join Care Coordination to work 24/7 to evaluate medical necessity for patients transferred from our regional sites.  In addition, three Saint Vincent physicians expanded their Physician Advisor role to 7 day coverage to support the Care Coordination team in determining medical necessity. 

Care Coordination Services implemented a “Lay Navigation” program in July to work with Community Health Net (CHN) and the Saint Vincent Emergency Department to support follow-up care and assist with many real barriers to care such as transportation and child care.  The Lay Navigators are part of a research study to examine how these roles can impact care in our community. 

Our primary goal has always been the health and wellbeing of our patients.  Our focus today, however, must include coordinating that care across the full healthcare spectrum in order to better ensure the health of all of our patients. 

Jeanine M. Tome, is Vice President, Continuum of Care, for Saint Vincent Hospital.