What We Tried

Sakakawea Medical Center (SMC) and Coal Country Community Health Center (CCCHC) work together to provide care coordination for all patients.  Each day, the clinic receives a list of patients discharged from the Emergency Department (ED) and Hospital.  Someone at the clinic is assigned a patient to contact them for follow-up.   A report is also run monthly to identify all patients that have presented to the ED more than two times.  This report is used to help determine care coordination follow-up and aims to reduce the number of ED visits by contacting the patient and looking for alternatives to care other than the ED.  Care Coordinators from both SMC and CCCHC meet once a month to talk through patient scenarios and develop procedures to assure coordination is running smooth.

If a patient presents to the ED without a primary care provider, the ED Care Coordinator contacts the patient to set them up with a primary care provider to assure they have made their follow-up appointment.  If a follow-up appointment needs to be made, the ED Care Coordinator helps make that appointment for the patient.

Upon admission to SMC, patient-specific coordination of care begins.  The Nursing Care Coordinator reviews each patient’s chart daily, assessing for educational opportunities for patients, continuity in the plan of care and potential discharge needs.  Each patient is visited by the Nursing Care Coordinator throughout their hospital stay to review their plan of care, answer questions and address any educational needs that may arise.  These visits cultivate a relationship between the Nursing Care Coordinator and the patient and opens the door for clear, honest communication.  The goal of the Nursing Care Coordinator is to inspire patients to take ownership of their health through education and empowerment.  In order to adequately prepare for each patient’s transition out of the hospital, staff participates in daily discharge planning.  This meeting is multidisciplinary, including nursing, rehabilitation services, social work, pharmacy, dietary services and our facility’s in-house physician.  Once discharge is planned, this team rounds on the patient, allowing the patient to ask questions and have their discharge concerns addressed prior to their transition in care.  The Nursing Care Coordinator works to ensure each patient’s discharge from Sakakawea Medical Center is successful.  This is done through patient education, medication reconciliation, scheduling appropriate follow-up, making referrals to community services, making post-discharge phone calls to patients and providing the patient’s primary care clinic with a warm hand-off.  The Nursing Care Coordinator schedules each patient a follow-up appointment prior to discharge.  If appropriate, a Transitional Care Management visit is scheduled.  Once discharged, each patient’s records are faxed to their primary care clinic.  These records include pertinent diagnostic reports, provider progress notes, discharge paperwork, a reconciled medication list and a transitional care worksheet.  The transitional care worksheet is a document our facility has created that provides the patient’s primary clinic the information needed to ensure a smooth transition from inpatient to outpatient care.  Within two days of discharge, the Nursing Care Coordinator contacts each patient by phone to assess their health status post discharge.  The Nursing Care Coordinator reviews plan of care, the patient’s medication regimen, red flags in reference to the patient’s diagnosis and reminds the patient of their follow-up appointment.  If any questions or concerns arise following this call, the Care Coordinator at the patient’s primary care clinic is made aware.

A team-based approach is used to facilitate enhanced care coordination for our patients at the primary care clinic. RN Chronic Care Coordinators (CCC) review all transitional care documents prior to the patient’s visit to ensure all pertinent information is communicated to the provider for follow up as identified. Upon arrival for a post-hospital discharge appointment, RN CCC’s review each patient’s medication list and red flag identifiers per diagnosis along with any follow-up diagnostic testing identified post discharge. In addition, patients receive education regarding advanced directives with requests or wishes documented in the electronic medical record and shared within the medical neighborhood. Additional needs identified with patients include community and home based services, ongoing self-management needs and goals including the development of an interdisciplinary plan of care. Patients can enroll and receive education about our medical neighborhood’s community care coordination program. Within this model, a RN visits each patient within their home to assess ongoing community and home based services and coordinates services as needed. Each patient receives weekly phone calls from RN CCC’s and/or the RN Community Care Coordinator to review their plan of care with an ultimate goal of keeping each patient healthy in their home and reducing overall readmission rates, improving overall health outcomes and patient/ family satisfaction.