{"id":1082,"date":"2021-09-01T08:29:02","date_gmt":"2021-09-01T13:29:02","guid":{"rendered":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/?page_id=1082"},"modified":"2021-09-01T08:31:06","modified_gmt":"2021-09-01T13:31:06","slug":"success-stories","status":"publish","type":"page","link":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/success-stories\/","title":{"rendered":"Success Stories"},"content":{"rendered":"<h4>Mrs. B: General care management\/ care plan development\/ outreach support<\/h4>\n<ul>\n<li>Community Provider Patient<\/li>\n<li>10+ ED visits per month<\/li>\n<li>Multiple problems ranging from GI to mental health<\/li>\n<li>UT Health RPN Care Management team started to engage the patient because of high ED visits identified using claims data<\/li>\n<li>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<\/li>\n<li>Team met with the patient at the PCPs office to develop a plan<\/li>\n<li>Care Manager started reaching out the patient weekly, including a few home visits, to check in and follow up on any lingering challenges<\/li>\n<li>If there were any new issues or challenges, the patient was scheduled for a home visit<\/li>\n<li>Patient was started in a palliative care program last fall<\/li>\n<li>\u00a0Patient has now started with hospice<\/li>\n<\/ul>\n<h4>Mr. S: TOC led to immediate clinic visit related to medication error\/ prevented return to ED\/IP<\/h4>\n<ul>\n<li>Community Provider patient<\/li>\n<li>Experian notification prompted care manager to outreach patient for a transition of care call<\/li>\n<li>Patient had just been discharged from the hospital and patient\u2019s medications had been changed at the hospital<\/li>\n<li>Patient\u2019s sugar was 490 and was about to go to the emergency department<\/li>\n<li>Care manager called the clinic and the clinic saw the patient the same day and adjusted the patient\u2019s prescriptions<\/li>\n<li>Care manager checked on the patient the next day and sugars were a bit high but very acceptable<\/li>\n<li>Patient continued to follow up with care manager and PCP to ensure sugar levels were kept in check<\/li>\n<\/ul>\n<h4>Mr. M: Care Manager pre-surgery planning identified SDH need preventing readmit following surgery<\/h4>\n<ul>\n<li>Community provider patient<\/li>\n<li>Patient was spotlighted to care manager because of high cost\/ utilization over previous few months<\/li>\n<li>Patient had multiple ED visits\/ IP admits related to GI\/ abdominal issues<\/li>\n<li>Care manager worked with patient before a planned hernia surgery to establish meals-on-wheels for the patient following surgery<\/li>\n<li>By establishing support before surgery, the patient was able to receive support immediately following discharge<\/li>\n<li>This reduced the stress on the patient and the patient\u2019s family<\/li>\n<li>The patient has had no return ED visits or IP admits since the surgery<\/li>\n<\/ul>\n<h4>Mr. C: Care Manager engages patient\/ PCP\/ patient\u2019s family to support and maintain care plan<\/h4>\n<ul>\n<li>Community Provider Patient<\/li>\n<li>Patient has CHF with lingering issues related to UTI, urine retention, fluid retention<\/li>\n<li>Patient had multiple admissions over a few months averaging at least 1 admit per month<\/li>\n<li>Team engaged with patient and engaged with patient\u2019s PCP<\/li>\n<li>Care manager spoke with patient\u2019s family<\/li>\n<li>Supported a patient with palliative care transition<\/li>\n<li>Weekly care manager calls to proactively support patient concerns\/ anxiety<\/li>\n<li>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<\/li>\n<li>Calls have been backed off to monthly and patient is getting better outcomes<\/li>\n<\/ul>\n<h4>Mrs. K: Care Manager determines underlying Social Determinates of Health concern that triggered ED visits<\/h4>\n<ul>\n<li>Patient of community provider<\/li>\n<li>Patient had multiple ED visits but never seemed to have good outcomes<\/li>\n<li>Outreach by care manager determined that patient was having trouble with social determinates of health<\/li>\n<li>Care manager connected the patient to meals on wheels to provide support<\/li>\n<li>Patient now has a more stable home situation and has significantly reduced ED utilization<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>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 [&hellip;]<\/p>\n","protected":false},"author":352,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1082","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Success Stories - Regional Physician Network<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/wp.uthscsa.edu\/regional-physician-network\/success-stories\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Success Stories - Regional Physician Network\" \/>\n<meta property=\"og:description\" content=\"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 [&hellip;]\" \/>\n<meta property=\"og:url\" content=\"https:\/\/wp.uthscsa.edu\/regional-physician-network\/success-stories\/\" \/>\n<meta property=\"og:site_name\" content=\"Regional Physician Network\" \/>\n<meta property=\"article:modified_time\" content=\"2021-09-01T13:31:06+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"3 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/wp.uthscsa.edu\\\/regional-physician-network\\\/success-stories\\\/\",\"url\":\"https:\\\/\\\/wp.uthscsa.edu\\\/regional-physician-network\\\/success-stories\\\/\",\"name\":\"Success Stories - Regional Physician Network\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/wp.uthscsa.edu\\\/regional-physician-network\\\/#website\"},\"datePublished\":\"2021-09-01T13:29:02+00:00\",\"dateModified\":\"2021-09-01T13:31:06+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/wp.uthscsa.edu\\\/regional-physician-network\\\/success-stories\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/wp.uthscsa.edu\\\/regional-physician-network\\\/success-stories\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/wp.uthscsa.edu\\\/regional-physician-network\\\/success-stories\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/wp.uthscsa.edu\\\/regional-physician-network\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Success Stories\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/wp.uthscsa.edu\\\/regional-physician-network\\\/#website\",\"url\":\"https:\\\/\\\/wp.uthscsa.edu\\\/regional-physician-network\\\/\",\"name\":\"Regional Physician Network\",\"description\":\"Regional Physician Network\",\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/wp.uthscsa.edu\\\/regional-physician-network\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Success Stories - Regional Physician Network","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/success-stories\/","og_locale":"en_US","og_type":"article","og_title":"Success Stories - Regional Physician Network","og_description":"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 [&hellip;]","og_url":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/success-stories\/","og_site_name":"Regional Physician Network","article_modified_time":"2021-09-01T13:31:06+00:00","twitter_card":"summary_large_image","twitter_misc":{"Est. reading time":"3 minutes"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/success-stories\/","url":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/success-stories\/","name":"Success Stories - Regional Physician Network","isPartOf":{"@id":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/#website"},"datePublished":"2021-09-01T13:29:02+00:00","dateModified":"2021-09-01T13:31:06+00:00","breadcrumb":{"@id":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/success-stories\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/wp.uthscsa.edu\/regional-physician-network\/success-stories\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/success-stories\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/"},{"@type":"ListItem","position":2,"name":"Success Stories"}]},{"@type":"WebSite","@id":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/#website","url":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/","name":"Regional Physician Network","description":"Regional Physician Network","potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"}]}},"_links":{"self":[{"href":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/wp-json\/wp\/v2\/pages\/1082","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/wp-json\/wp\/v2\/users\/352"}],"replies":[{"embeddable":true,"href":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/wp-json\/wp\/v2\/comments?post=1082"}],"version-history":[{"count":0,"href":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/wp-json\/wp\/v2\/pages\/1082\/revisions"}],"wp:attachment":[{"href":"https:\/\/wp.uthscsa.edu\/regional-physician-network\/wp-json\/wp\/v2\/media?parent=1082"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}