Backus Preventative Medicine Team Breaks Down Barriers to Improve Health

Print icon

Seeking to prevent unnecessary hospital admissions and readmissions, The William W. Backus Hospital created a Preventive Medicine Team (PMT) that is helping people be healthier, happier, and stay out of the hospital whenever possible.

The PMT is designed to support patients who are frequently admitted to the hospital by creating a registry of at-risk patients; utilizing direct hospital interventions; creating individualized transitional care guides that address medical and social determinants of health; and tracking how the initiative impacts the goals of the national healthcare Triple Aim, which includes patient experience of care, resource utilization, and overall health of the population.

Interventions are tailored to the patient and may include:

  • Intensive medication review and bedside medication counseling
  • Healthcare coordination with all providers involved in the patient’s care
  • Identification of any adverse social determinants of health, such as financial or behavioral challenges
  • Screenings for anxiety and depression
  • Supportive counseling and health coaching
  • Referrals to community resources

Initial results have been remarkable and the team believes successful transitions of care will heighten the patient experience, improve patient care, and lower avoidable medical costs. The first cohort of patients reported an improvement in quality of life related to their healthcare. In addition, there was a 73 percent reduction in the total inpatient/ observation encounters and a 43 percent reduction in length of stay.

To be considered for the registry, a patient must have had three or more inpatient or observation admissions to a Hartford HealthCare (HHC) acute care hospital in the previous six months. The team also considers referrals from hospitalists and other HHC partners for admitted patients at Backus Hospital with high risk for readmission and complex social issues.

Once placed on the registry, the team completes a comprehensive assessment to identify clinical, behavioral, social, and/or logistical issues that may contribute to frequent admissions and challenge a successful transition from the hospital setting to home.

After completing the assessment, the team collaborates with hospital-based caregivers and the patient’s family, primary care provider, and any other specialists, community providers, homecare agencies, and pharmacies involved in the patient’s care. A Transitional Care Guide is created and embedded in the patient’s medical record so Backus Hospital clinical staff can take a consistent approach to registry patients coming into any HHC facility for care.

Once discharged, the team participates in each patient’s transition to home with phone calls, home visits, and coordination with medical and community providers. The team meets regularly with other care coordinators to discuss mutual patients.

What's New

Dancing with the Stars

Watch Your Step: It’s Stars Dancing for Parkinson’s May 10

They’re doctors, administrators, corporate organizers – and now they’re dancers as part of the second annual Stars Dancing for Parkinson’s fundraiser to benefit the Chase Family Movement Disorders Center at the Hartford HealthCare Ayer Neuroscience Institute. “I’m no dancer – I’m not even sure I have rhythm!,” said Donna Handley, president...

Windham Gets Advanced Hip and Knee Certification

Windham Hospital has earned The Joint Commission’s Gold Seal of Approval® for Advanced Certification for Total Hip and Total Knee Replacement. The advanced certification is for Joint Commission-accredited hospitals, critical access hospitals and ambulatory surgery centers seeking to elevate the quality, consistency and safety of their services and patient care....

More Advanced Heart Procedures Now Available at Backus Hospital

The Hartford HealthCare Heart & Vascular Institute continues to add more advanced procedures for cardiac patients in eastern Connecticut. Dr. Paras Bhatt, Medical Director of Electrophysiology in the East Region, inserted an implantable biventricular defibrillator in an 80-year-old patient who had ischemic cardiomyopathy (weakened heart muscle) at Backus Hospital on...

Men: ED Treatment Sound Too Good To Be True? It Probably is.

If you were among the 50 percent of adult males between the ages of 40 and 70 with erectile dysfunction, would you pay thousands of dollars for shock-wave treatment, which has uncertainties about long-term effectiveness and safety? Would you be concerned that it is not FDA-approved? You should be. More...