Success Stories

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