KEESLER AIR FORCE BASE, Miss. --
The 81st Medical Group is one of four Defense Department medical facilities participating in the Defense Health Agency’s Readmission Pilot Program.
The core of the pilot program, which began in November, revolves around four components of care in an effort to drive down the readmittance rate for high-risk patients.
To identify those who are at a high risk for readmittance providers use an electronic system that takes into account the patients multiple medical usage such as co-morbidity, (which considers) multiple disease process, lab tests, medication, visits to providers to include the emergency room, said Lt. Col. Debra Zinsmeyer, 81st MDG chief of medical management. “They are not necessarily our 80-year-old patients, but could be a younger person who has a severe disease.”
The DHA program focuses on four components of patient care: medication reconciliation, the completion of an inter-disciplinary team, scheduling a follow-up primary care manager appointment and a home call.
During the medication reconciliation process pharmacists conduct a thorough review of the patient’s prescription record by pulling their history from multiple systems. In addition, they factor in any over the counter medications the patient is taking.
“Patients receive medications from a variety of sources, so it is important the admitting physician is aware of all of the medications the patient is taking to prevent duplication of medications, overdosing or drug interactions,” said Roland Mullins, 81st Diagnostic and Therapeutics Squadron clinical pharmacist. “This provides both the patient and the provider with a complete, comprehensive list of medications that the patient should be taking.”
At discharge, the patient is given printed prescription instructions that include the medication regimen written in simple terms explaining the purpose and use of each medication. In addition, a pharmacist meets with the patient to explain how to properly use each medication and its purpose.
The second component of the program is the completion of an inter-disciplinary review. The review team requires participation of professionals from at least three specialties which can range from dietitians to surgeons.
“(This is) a whole group of people caring for the patient who are meeting to discuss a plan of care,” Zinsmeyer said. “Every morning the chief nurse meets with an interdisciplinary group. In that meeting they discuss what the patient did in the last 24-hours and determine a plan of care.”
The next component of the program is scheduling a follow-up PCM appointment.
“We do this to make sure their primary provider is aware the patient was in the hospital and make sure they put eyes on the patient to see how they are doing,” Zinsmeyer said. “The patient (may of) had some of their medications change while they were here. It is an informative thing for their PCM to know exactly what is going on with their patient post discharge.”
The fourth and final component is the patient call back. The Keesler Utilization Manager calls each high-risk patient within 72 hours of their discharge.
“The utilization manager checks to see how they are doing once they get home,” Zinsmeyer said. “She checks to see if they are able to take care of themselves, have a caregiver, if there are any problems and if they know what medications they are supposed to be taking and when their follow-up appointment is. The patients are very thankful they are getting this phone call because they hadn’t received it in the past. We are finding that the patients actually have a lot of questions.”
The pilot program concludes in May; however, DHA and the Air Force Medical Operations Agency will roll out the program to all bases based on the best practices gleamed from the pilot experience.
“It is still a work in progress,” Zinsmeyer said. “It has been painful, but I think that the patients are very appreciative and they can see we care about them.”