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Posted April 21, 2016

Taking Patient Call Manager to the Next Level

When Sonora Regional Medical Center, part of Adventist Health, started making care transition calls, they quickly realized the benefit and importance of the information obtained in each patient connection. Through the use of Patient Call ManagerSM: The Clinical Call System (PCM), they have maximized their care transition call process to identify new ways to capture and leverage the information it provides. As a result, they have seen a reduction in readmissions and an increase in HCAHPS performance.

Many organizations make follow up calls to patients to ensure a safe transition to home, but the full mileage from this proven tactic is obtained when organizations take action and follow through. Particularly with models like bundled payments and quality measurement for episodes of care like hip and knee replacements, these processes are now more important than ever to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery.

Sonora Regional Medical Center is so dedicated to patient care and the impact PCM has had, they shuffled internal resources to have a singular source for making calls, analyzing the data and suggesting changes to address information obtained. Jody Kaiser, RN, currently serves as the PCM Operator for the Medical-Surgical, ICU and Step-Down units, and oversees all other departments’ use of PCM. In that role, Jody has identified new ways to utilize the software to maximize its potential.

Jody receives a list of discharged patients each day and as a Registered Nurse, clinically reviews and researches each individual inpatient record to ensure all aspects of post-acute needs have been addressed. She then calls the patient and asks them a series of questions in terms of how they are recovering, confirms medications were picked up, ensures follow-up appointments are scheduled, and makes certain all post discharge services have been arranged in order to successfully manage the transition of care to home. Sonora has taken their process with PCM one step further: Jody has added custom fields to document and trend information regarding their hospital stay and transition to home, both shared by the patient on the phone call and discovered during the patient’s chart review. These are customized “internal only” fields Jody has created to maximize each call which is accomplished through PCM’s agility.

For instance, if a patient identifies that they haven’t picked up their medications because the one prescribed isn’t covered by their insurance, Jody then marks that in the system, assists the patient with obtaining new medications, and then can use the data to educate nurses and physicians on asking the right questions to ensure medications are covered prior to discharge. In addition, Jody reviews the discharge paperwork that each patient takes home with them. If there are items missing, for example, the wrong physician listed, Jody notes that as well to track opportunities to improve processes. The report goes directly to the VP of the hospital and Director of the patient care units on a quarterly basis and then staff are educated on opportunities to course correct actions.

“Interventions” completed post-discharge are also tracked by Jody. These “interventions” may include providing additional education, helping to schedule a follow-up appointment, and assisting with medication concerns. On any given day, Jody completes between 25-30 patient calls a day. She facilitates obtaining follow up appointments, arranges home health orders and assists in obtaining appropriate medications. Every quarter, Jody connects with around 960 patients and has never fallen below an 83% patient contact rate post-discharge. Sonora Regional Medical Center is now viewed as the “gold standard” across Adventist Health for completing patient calls, and are looking into adopting the leading practices across the system.

As a result of Jody’s work and the processes in place, Sonora Regional Medical Center has significantly reduced readmissions. Their readmission rate after discharge from hospital (hospital-wide) is below the national rate and have had zero penalties in Value-Based Purchasing for readmissions. Further, on the HCAHPS question “Patients who reported that YES, they were given information about what to do during their recovery at home” ranks Sonora above both the state and national average in top box results.

Through features like serial calls for high risk groups, and color borders that flag patients that have been in your organization within the past 30 days, Patient Call ManagerSM allows you to quickly prioritize which patients need to stay connected with your care givers to ease transitions from your care to home.

PCM represents the next generation of care designed to provide touch points as patients navigate your healthcare system. This software accelerator goes beyond just the care transition call to determine the frequency of connection that will have the biggest impact on reducing readmissions, in addition to the impact individual questions have. To learn more, visit studergroup.com/pcm.

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