Page 32 - Layout 1

SAN ANTONIO
MEDICINE

Patient-Centered Transitional

Care Management By Ramon S. Cancino MD, MBA, MS, FAAFP

A patient’s transition from the hospital set-
ting to his or her next setting is one of the
most dangerous times in health care. There
are over 35 million hospital discharges in the
United States every year, and the process of
discharging from a hospital is complex and
1
fraught with challenges. Challenges include
ensuring patients understand why they were
admitted, what medications they should now
be taking and not taking, and scheduling a
follow-up outpatient appointment with their
primary care team. When these or other
components of the discharge process do not
occur consistently, patients may be readmit-
ted back into the hospital. The cost of un-
planned readmissions is $15 to $20 billion
annually. Hospital readmissions following a
2
COVID-19 admission contribute to the cur-
rent problem. CDC investigators found,
among survivors, 9% of patients were read-
mitted to the same hospital within two
months of discharge and 1.6% were readmit-
ted more than once. Hospital readmissions notified, the nurse works with the patient’s elevated blood glucose of 490. The patient
3
are often a sign of system breakdowns and primary care team to develop a transitional had not thought to call her primary care
poor communication between inpatient and care plan, contacts the patient to review post- physician’s office and was planning to go to
outpatient settings. Programs to improve hospitalization instructions including medica- the nearest emergency room. Instead, upon
communication and standardized discharge tions, and schedules the patient for a learning this information, the nurse inter-
processes have decreased hospital readmis- post-hospitalization transitional care manage- vened. She called the patient’s primary care
sion. The UT Health San Antonio Re- ment appointment at their primary care physi- physician to explain the situation, and the pa-
4,5
gional Physician Network (RPN) has cian’s office. Using this approach, we have seen tient was seen and treated in the office the
developed a patient-centered approach. a significant decrease in our readmission rate. same day. Rather than going to a crowded
The RPN developed a data-driven evi- The readmit rate per 1,000 patients dropped emergency room with a long wait time, the
dence-based approach to transitional care from 169 to 152 from 2019 to 2021 after the patient was able to have their medications ad-
management. A team of Nurse Care Managers program was implemented. justed by her primary care team, who she
is assigned to all RPN accountable care organ- There are many examples where patients knew and trusted. Per protocol, the nurse care
ization practices in the community. This team benefit from this approach to transitional care manager followed up with the patient the
of nurses receives an electronic notification management. Recently, after a patient dis- next day with a phone call to assess the pa-
every time an RPN patient is admitted or dis- charged from a local hospital, a nurse called tient’s status. The patient’s blood glucose lev-
charged from a hospital and every time the pa- the patient for a non-face-to-face assessment els were improving, and the nurse took time
tient enters an emergency department. Once where she learned the patient had a severely to provide advice on diet and exercise.

32 SAN ANTONIO MEDICINE • December 2021