At Gundersen Lutheran Health System, executives have put together a program to target the 1 to 2 percent of those most likely to be hospitalized, seen in the emergency department or face other complications. To manage the program, the La Crosse, Wis.-based system is leveraging a feature of their Epic EMR which sifts out the patients most in need of additional care coordination, reports Health Data Management.
Gundersen Lutheran is targeting complex patients with its program, but not just those with medically-complex conditions. They’re also hoping to find patients who, while they might have simpler conditions, live alone or have trouble following sometimes difficult medical care plans. The system is using the EMR first to identify the patients, then to treat them, according to Health Data Management.
To find patients in need of extra care coordination services, Gundersen is using a “tiered scoring” module built in to the Epic platform which includes one component for medical complexity and another to measure psycho-social issues. When clinicians want to refer a patient to the care coordination program, physicians use the Epic scoring tool to see if the patient qualifies. Clinicians can also notify the care coordination team using the Epic system, in three clicks or less, noted Beth Smith, R.N., executive director of patient and family-centered care at the health system.
The patients identified by the scoring model as in need of extra care coordination are farmed out to a group of 22 nurses and social workers, whose job it is to monitor the care of these complex patients who are more likely to face adverse events.
The workload the care coordinators face is intense. Typically, care managers are supervising some 1,700 patients each, who not only stay in touch with patients but also attend office visits and follow through with specialists. Epic plays a role here too, however. Care coordinators get a special tab in the Epic EMR which pulls key elements of the patient’s history into a single view, making it easier to get a sense of the whole patient. Epic also notifies them via a message in the system if a patient shows up in the ED.
According to Health Data Management, this program has helped stabilize hypertensive and diabetic patients, with just under half showing sustained improvements over a two-year period.