Avoid an ER full of patients on a first name basis
by Cliff Robertson, MD
As much as we want to get to know our hospital patients on a personal level, we don’t want to see them suffering, coming back for the same problem again and again. Seemingly struggling to take advice from the staff and care teams they see.
One of the ways proven to break this cycle is by utilizing the power of a clinically integrated network or CIN. A CIN is a network of hospitals, physicians and advanced practice clinicians who work together with the shared goal of improving the overall care experience in their town or city.
For example, in Nebraska we’ve used a CIN to employ health coaches who can work alongside a clinical care team to help improve care and reduce readmittance for struggling, high-risk patients. These health coaches are employed by the CIN rather than the hospital, which can give them more freedom to focus on fewer patients that have the greatest health needs.
A health coach is generally a registered nurse who is dedicated to exclusively working with a small number of high-risk patients. Working with the clinic staff and the data systems that identify the high-risk patients, they proactively reach out to them to offer assistance. Then they work one-on-one to determine what the exact problems are and how to anticipate and reduce future problems. They can give the care team a clearer insight into why some of these patients might have initially seemed uncooperative or noncompliant. Things like inability to afford prescriptions, trauma related confusion, not having language skills or educational level to make sense of their treatment plans, or simply not accepting that they have real but addressable health issues.
For these patients, the health coaches are invaluable. Rather than spiraling into constant care cycles, these patients reduce their out of pocket costs, spend less time in the hospital and more time being healthy. It’s also a win-win for the hospital. Without CIN help, these patients would require a lot of preventable readmittance care, which creates unmanageable costs to the hospital and community. If we can reduce the amount of intensive care a patient needs by giving them a small amount of support and direction, we can create healthy changes in our patients’ lives at far less cost. With a few small changes, we can radically improve someone’s quality of life and lower their utilization of the entire system.
CIN’s offer us a wider range of tools to achieving a higher of quality care. When the entire healthcare system in a given area is working together to try and improve, it’s much easier to ensure that no matter where a patient is, or what they’re going through, their experience is going to be as good and as cost effective as possible.
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