Interprofessional care model shows promise for readmission reduction, ER use

A group of nurse practitioners (NPs) at the University of Arizona College of Nursing aims to improve care for patients whose complex needs put them at high risk for readmission or emergency care through a new bundled-care model, according to Clinical Advisor.

The Health 360 model incorporates a team of three NPs, three physicians, a community health worker, a pharmacist and a full-time registered nurse. The team meets weekly to discuss patients and how to improve care access in a way that prevents readmissions.

The care bundle revolves around the mnemonic "AEI0OU,"  co-developer Paula Christianson-Silva, R.N., told Clinical Advisor, which stands for:

Access to team-based care coordination: Participants must complete a weekly patient team report and ensure all patients and their families know how to contact each member of the team.

Essential basic needs assessment: The team must complete a comprehensive analysis of the patient's health and what he or she needs.

Identification and rectification of gaps in care: The care team notes any major diagnoses in the patients' histories that don't appear in their current problem list, as well as analyzes and reviews any history of abnormal lab results.

0 days without essential medications: Health 360 aims to make refill management for any medication prescribed for ongoing problems as effective as possible, using methods such as internal reviews or post-discharge medication reconciliation.

Occasions for engaging family or close others in supporting patient care: To keep patient's family members and loved ones in the loop during the care process, the care team must have every participant's name and phone number, according to Christianson-Silva.

Utilization of available resources, services and devices: The team must be ready to make referrals to specialists and services, whether they involve home health, nutrition consults, medication management, counseling or home health.

While savings from readmission prevention are difficult to quantify, Christianson-Silva said, preliminary data indicate a steep drop in readmission rates between six months before and six months after they implemented the program.

New healthcare models such as Health 360 emphasize interprofessional and team-based care more than ever before, but experts are concerned medical education doesn't prepare students for this kind of environment, FierceHealthcare previously reported.

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