Keys to Managing Transitions of Care
To implement these programs, Jung says coordination with primary care physicians is paramount, but has yet to be fully realized. It's an ongoing process, the focus of constant discussions. "We need to talk with them and coordinate with them—that this patient is going to be discharged," he says.
While Sarasota Memorial has case managers on staff, Jung says that leaders realize the importance of case managers also working out of the primary care physician offices. Still, there are kinks to work out, particularly related to fiscal incentives for physician groups. Case managers "probably need to be in primary care offices, but we need the incentive between the two, to work together to make it worthwhile," Jung says. That means diving a bit "into the weeds," as they discuss revenue codes and fiscal returns, he notes.
Once a patient is discharged from the hospital, "we need to talk with [the physicians] and coordinate with them," Jung says. "That promotes the clinical integration piece that payers are going to look for as well. Everyone needs to be around the table and discuss information about people who are discharged."
Keeping an eye on quality measures is a constant. "Our readmissions rate is pretty stable and we're focusing on it," Jung says. "We remain competitive, and we are starting to push this transition case manager program."
The general feeling at Sarasota is, "let's do this—we're good at it, and let's see if we can remain good at this."
(To learn more, tune into a HealthLeaders Media webcast, "Patient-Centered Care Transitions for Better Quality, Costs and Readmission," on Wednesday, May 29, 2013, with speakers Fred D. Jung, RN, PhD, CPHQ, executive director of quality and patient safety for the Sarasota Memorial Health Care System and Kathleen M. Martin, RN, BSN, CCM, CPC-H, VP of Patient Safety and Care Improvement for Griffin Hospital, in Derby, CT.)
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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