Mrs. B: General care management/ care plan development/ outreach support

  • Community Provider Patient
  • 10+ ED visits per month
  • Multiple problems ranging from GI to mental health
  • UT Health RPN Care Management team started to engage the patient because of high ED visits identified using claims data
  • Team was able to use Experian notifications to identify when the patient went to the emergency department and follow up with the patient following the visit
  • Team met with the patient at the PCPs office to develop a plan
  • Care Manager started reaching out the patient weekly, including a few home visits, to check in and follow up on any lingering challenges
  • If there were any new issues or challenges, the patient was scheduled for a home visit
  • Patient was started in a palliative care program last fall
  •  Patient has now started with hospice

Mr. S: TOC led to immediate clinic visit related to medication error/ prevented return to ED/IP

  • Community Provider patient
  • Experian notification prompted care manager to outreach patient for a transition of care call
  • Patient had just been discharged from the hospital and patient’s medications had been changed at the hospital
  • Patient’s sugar was 490 and was about to go to the emergency department
  • Care manager called the clinic and the clinic saw the patient the same day and adjusted the patient’s prescriptions
  • Care manager checked on the patient the next day and sugars were a bit high but very acceptable
  • Patient continued to follow up with care manager and PCP to ensure sugar levels were kept in check

Mr. M: Care Manager pre-surgery planning identified SDH need preventing readmit following surgery

  • Community provider patient
  • Patient was spotlighted to care manager because of high cost/ utilization over previous few months
  • Patient had multiple ED visits/ IP admits related to GI/ abdominal issues
  • Care manager worked with patient before a planned hernia surgery to establish meals-on-wheels for the patient following surgery
  • By establishing support before surgery, the patient was able to receive support immediately following discharge
  • This reduced the stress on the patient and the patient’s family
  • The patient has had no return ED visits or IP admits since the surgery

Mr. C: Care Manager engages patient/ PCP/ patient’s family to support and maintain care plan

  • Community Provider Patient
  • Patient has CHF with lingering issues related to UTI, urine retention, fluid retention
  • Patient had multiple admissions over a few months averaging at least 1 admit per month
  • Team engaged with patient and engaged with patient’s PCP
  • Care manager spoke with patient’s family
  • Supported a patient with palliative care transition
  • Weekly care manager calls to proactively support patient concerns/ anxiety
  • Patient would be scheduled for a clinic visit if the patient was having any new concerns or issues that could have resulted in a low complexity ED visit
  • Calls have been backed off to monthly and patient is getting better outcomes

Mrs. K: Care Manager determines underlying Social Determinates of Health concern that triggered ED visits

  • Patient of community provider
  • Patient had multiple ED visits but never seemed to have good outcomes
  • Outreach by care manager determined that patient was having trouble with social determinates of health
  • Care manager connected the patient to meals on wheels to provide support
  • Patient now has a more stable home situation and has significantly reduced ED utilization