Prevention of ED and Hospital Overutilization while Improving Patient Quality of Life

Are you facing the challenges of repeat ED visits, re-hospitalizations, soaring costs due to non-compliance and frustrated healthcare teams from those “non-compliant” patients?   Let’s review a case study and some recommendations that just might help us think differently about our approach.

I remember like it was just yesterday.  I walked into a home, doing a home visit for an elderly woman.   I was working in Palliative Care and Hospice and we had a referral to help this woman manage her chronic diseases without daily calls to the clinic, near weekly visits to the ED recently and monthly admissions to the hospital.  She was labeled as non-compliant and a “difficult patient”.

I knocked on the door and heard a loud voice respond, “what do you want?”  I tried to explain that I was a nurse and that her doctor asked me to come and visit with her.  The response was “ fine, come on in if you think you have to”.

I walked in and went around the corner to see this elderly woman sitting in a chair with a table filled with medication bottles, a nebulizer sitting on another table, a walker next to her chair, and an Oxygen concentrator sitting in the corner.  On the other side of the room was a large crafting table filled with so many crafting supplies and tubs all around the table.

I introduced myself and then was able to focus on the bright pink carpet and sparkling ceilings.  The furniture was all very brightly colored.  I knew right away that I had a spicy patient, with a strong sense of independence. 

The conversation was a little tense at first, but within 20 minutes she was able to see I was there to listen and partner with her to improve her quality of life.  After that initial challenging period, her guard came down and I listened for about 30 minutes to all the challenges she was facing.  Then we were able to move on to discussing her goals for the rest of her life.  She shared how she used to massively decorate for every holiday.  The visual was incredible. 

I’m always amazed at the goals that patients are able to share once they know we are really there for them. 

Her goals were: 

1.     Go to the park again with her grandchildren

2.     Go to Walmart to get more crafting supplies

3.     Once again be able to work on her crafts. 

What was preventing that was the challenges her care regime created for her and the feeling that no one was listening, just prescribing.  She had a regime where almost every hour she had to either take a medication or do a treatment.   We realized that she had been seeing multiple specialties and getting add on to her treatment plan, but no one had looked at the whole care plan from a birds eye view to realize that it was impossible to adhere to this plan and have a life or any rest. 

Over the next couple weeks, we partnered with her physicians, NP, Pharmacy and created a much simpler and effective schedule for her.  Simple things like scheduling meds together when possible, setting up a med planner, simplifying her treatment regime made a world of difference.  We met with her family to review the new plan.  They agreed to support this plan and support her.  Her mood improved greatly and was a true delight to visit with. 

Over the next year her health improved to a very stable state, she visited the ED once and was subsequently hospitalized for a few days. We did visits to brainstorm any challenges she was facing and to verify compliance.   The previous year had been over 20 ED visits and monthly hospitalizations.  This new year she was able to get to Walmart a few times to stock up on supplies, had a schedule with friends and volunteers that helped her organize her supplies and craft with her.  She went to family holidays and grandchildren concerts.   She went to park with her grandchildren several times with the help of her son.  She became near 100% compliant with her care regime.

She passed a couple years later, and I went to visit her near the end.  She was so grateful for all we had done to improve her life and give her precious time with her family, friends and truly enjoy so much time.  The human connection, the ability to hear what the patient really wants, the ability to partner with the patient and various health care professionals to create a care plan that supports the patients’ health and their quality of life. 

An additional bonus is the healthcare costs saved, the burden on the clinics, ED, and hospitalization being dramatically reduced.  This was only one of dozens of case studies where a similar scenario was present. 

So how can we move forward to create these win win situations for our patients, families and healthcare systems.  It is a multipronged approach including such things as:

o   Care Coordination: Employ care managers or coordinators to partner with patients to navigate and provide input into their care, partner to create treatment plans that work for disease management and patients’ lives, create tools to support patients to manage their conditions, integrate remote monitoring when appropriate, prevent crisis, and manage through them when a crisis does occur.  This program is recommended to include visits to the hospital when patient is there, and home visits and partnering with other services they have. 

o   Education and Self-Management Support: Provide resources and training on managing chronic conditions, helping patients to understand the disease process, what a great care plan regime can do, and identifying goals that inspire them to manage their disease(s) well.  If patients understand the what and why behind what we are suggesting they do, the compliance improves.

o   Patient Empowerment: Identify with the patient what matters most to them.  Then engage patients in their own care through goal-setting and self-monitoring tools.  Partner with them to decide on what to monitor, how to manage the prevention and intervention phase.  Engage family or friends when possible so that they have a social and support structure. 

We are here to help you provide coordinated care, partnership, quality and during the process save millions of dollars in healthcare utilization costs and expenses to your system. 

Reach out today to schedule a call so we can explore your current challenges and if a similar program of our own design might solve many of your challenges as well. 

 www.firstqualityconsulting.com