Fully-integrated care is the wave of the future in healthcare, and one health system has used it to cut emergency room visits and improve medication management for heart failure patients, according to a blog post at NEJM Catalyst.
Leaders at Danville, Pennsylvania's Geisinger Health System sought to build on the system's record of care integration and coordination to address emergency and inpatient care for heart failure patients, write Geisinger's Sanjay Doddamani, M.D., Janet F. Tomcavage, R.N., and John B. Bulger. Nearly 5 million patients in the United States have heart failure and it costs the healthcare system $32 billion per year, according to the article.
The organization began to consider every unplanned admission for acute heart failure that required only diuretic therapy for treatment as a sentinel event. From there, system leaders developed a central urgent heart failure clinic, offering onsite review of each patient's care plan, coordination between nurse navigators and community nurse case managers, and medication management.
Each team member coordinates care according to a methodical assessment and care algorithm, communicating face-to-face, through electronic medical records, by phone and in monthly meetings. When team members communicate with this kind of regularity, it lessens the risk of care and communication gaps, according to the post. These multidisciplinary teams include nurse navigators, nurse case managers and pharmacists, all of whom operate in their distinct spheres while each serving the broader aim of integrated care.
Preliminary metrics indicate Geisinger's approach is bearing fruit, according to the post. Last year, it saved the system $240,000 in ED visits, with 28 percent of hospitalized heart failure patients avoiding emergency care. The system is still crunching the numbers on medication management, but thus far, monitoring of renal function and potassium is up from 41 percent to 80 percent.
To learn more:
- read the post