Culbertson Memorial Hospital issued the following announcement on Oct. 28.
Culbertson Memorial Hospital recently started a new Care Coordination program that has already begun improving the care patients receive. The program decreases Emergency Room readmissions, increases patients’ understanding of chronic conditions, improves self-management and helps patients understand the importance and proper use of their medications. One of the components is called Transition Care Management (TCM), and it helps patients after hospital discharge.
“Transition Care Management involves contacting patients when they are discharged from the hospital to see how they are doing and whether they understand their instructions,” said Kristen Campbell, RN, Patient Care Coordinator at Culbertson Memorial Hospital. “If they seem not to be improving or have symptoms that show they need to see the doctor sooner, I am able to communicate with the doctor to get them treatment faster so they do not end up back in the hospital.” TCM also involves coordination with the pharmacist at the hospital if the patient is taking complex medications, has an extensive medication list and/or needs services from the pharmacist.
Another component is Chronic Care Management (CCM). “We are currently focusing on our traditional Medicare patients, but in the future, everyone in our clinics will be able to utilize this service. It is currently done on a case-by-case basis if the patient is not covered by traditional Medicare. The provider and Care Coordinator will look at patients who are having difficulty managing their health, frequently in the ER and/or need extra education. The Care Coordinator will provide education about the patient’s chronic conditions, medications and any other health-related questions they may have. Together, the Care Coordinator and patient develop goals to handle his or her chronic condition. Patients receive a printed care plan every month that will list the set goals and how they are doing at progressing through those goals.” A CCM patient receives a visit at the clinic or the home and/or will receive a monthly telephone call from the Care Coordinator, who will then give the provider monthly updates on the patient’s progress.
The program is especially helpful for patients who do not have family nearby. Care Coordinators are able to go to patients’ appointments with them and offer help with other things, such as clarifying medical jargon.
Some examples of how Care Coordination has already begun helping patients:
A patient became more compliant with his medications due to the increased understanding of his need for medications and weekly reminders/check-ins.
A patient was on a fluid restriction protocol and was drinking from a 12-oz. glass rather than an 8-oz. glass and was not aware of the difference or that other foods that melt into liquid were considered fluid and should be tracked. This helped manage the patient’s congestive heart failure and has kept the patient out of the hospital.
A patient was still running a fever after discharge from the hospital with a diagnosis of pneumonia and did not want to reach out to the doctor because he had an appointment a few days later and did not want to bother the staff. The Care Coordinator was able to talk with the provider and continue medications prior to the patient’s next office visit. Without this intervention, the patient could have become sicker and been re-admitted to the hospital.
Patients feel they are in control of their health and understand they play a major part in improving their chronic health conditions.
The Care Coordinator also works with the Emergency Room Nurse Manager on patients who are frequently in the ER. Campbell said she checks to see if a patient has a primary care provider and is able to set the patient up with one if needed. If the patient does have a provider, and the visit was for a non-emergency, she contacts the patient to find out why the Emergency Room was utilized instead of the clinic. “This will help the patient avoid unnecessary wait times that they would find when utilizing an Emergency Room visit as well as unnecessary costs,” she explained.
If you or a loved one could benefit from this program, call 217-323-2245 and ask for Kristen Campbell, email Kristen at kcampbell@sdcmh.org or your family healthcare provider.
Original source can be found here.
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