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.