Successes From the Care Management Team

Baptist Health’s PHSO interdisciplinary care management team efforts are centered around improving the patient’s physical and mental health while promoting wellness and autonomy through advocacy, communication, education, and identification of service resources.

The team manages patients through post-hospital discharge, referrals from primary care providers, and risk-stratified Epic reports for patients with complex conditions—and creates a plan of care that is specific to the patient needs.

The team members will then monitor this plan closely ensuring that all steps are being implemented correctly. Across the health care continuum, patients are routinely transferred from one service to another. Because patient care is often fragmented, duplicative, and sometimes disorganized and improperly planned, the risk of medical errors increases as the patient's exposure within the health care system increases.

The PHSO care management team bridges that gap from inpatient to the outpatient setting by creating a plan of care that is specific to the patient’s needs. Team members will then monitor this plan closely ensuring that all steps are being implemented correctly.

Reviewing medications and making sure the patient understands the appropriate medication regime they are to be on is crucial in post-discharge care management. Studies have shown that more than 40% of medication errors are believed to result from inadequate medication reconciliation in handoffs during admission, transfer, and discharge with 20% to result in patient harm.

By having a team available for outreach to patients at discharge, these caregivers are able to review medications with the patient and families in hopes of reducing these percentages that can cause life-threatening harm to patients.

Here is a success story from one of the care managers in the PHSO that exemplifies the difference this care management team is making and the complexity some patients are experiencing upon discharge,

A patient said he was very tired and fell asleep in his chair last night and slept 15 hours. He is still tired and feeling fatigued. Upon med review, we noted he is still taking meds that are no longer on his profile while also taking new meds that were prescribed upon discharge.

The patient said he has been taking those meds for years, so we reviewed the discharge med list from hospital admission and compared with the skilled nursing facility med list. We then informed him that those meds he states he is still taking are not on his list from the skilled nursing facility.

The care manager then reviewed his prior hospital admission from where he had bypass surgery and informed him that those meds were actually from the discharge at that time. However, the patient went straight to the skilled nursing facility upon discharge. The patient said, “Oh, that explains why they weren’t giving those to me while I was there.”

According to the patient, he has been away from home for a month and a half. Upon discharge from the skilled nursing facility, he said he was home 10 hours when he suddenly developed a heart issue and had to be readmitted. He did not look at his recent discharge list and just resumed his prior meds and added the new ones on top of it.

This patient has had three discharge med lists with changes over the course of two months. We strongly reinforced to the patient to only take what is on his discharge med list from most recent hospital admission and to please not take two beta-blockers stressing the importance of it possibly dropping his heart rate dangerously low.

We stressed again to only take meds from the last hospital discharge for his safety. He said he understands, will only take meds prescribed, and expressed his thanks for the follow up.