After discharge it has often been up to the patient to adhere to medication regimens and alert their physician to any complications or confusion, but patients don’t always have the tools or circumstances to make this an easy task. Learn how a new transitions model helped one patient take charge of his health and better understand and adhere to his care plan.
The SafeMed model was developed at the University of Tennessee in partnership with Methodist Le Bonheur Healthcare in Memphis. It was designed with the strengths of primary care in mind and relies on a collaborative team effort from physicians, pharmacists, nurses and community health workers to form a support network for high-risk and high-needs patients as they transition from the hospital to the outpatient setting.
Helping one patient take charge of his health
Mr. S had multiple chronic conditions—coronary artery disease, congestive heart failure, chronic kidney disease, hypertension, and a history of depression and cocaine use.
He was initially admitted to the hospital because his automatic implantable cardioverter-defibrillator kept firing, causing severe emotional and physical discomfort.
Social risk factor screening indicated that he had low to moderate social support at home. Mr. S was on Medicaid and received government disability assistance. His complex medical history and lack of social support made Mr. S an obvious candidate for the intensive care transitions services provided by the SafeMed program and he was enrolled.
Over the next three days of his hospitalization, the SafeMed team—which included a nurse practitioner, a pharmacist, a pharmacy technician and a licensed practical nurse community health worker—worked to develop rapport with Mr. S and assess his unique needs.
Because of his limited income, cost was a major barrier for Mr. S’ medication adherence, the pharmacist learned. So the pharmacist and the pharmacy technician helped Mr. S simplify his medication regimen, made sure he was paying the lowest possible cost for his medications and reviewed his plan following discharge.
When he left the hospital, they gave him a patient-friendly medication list describing each of his medications.
The team learned that, because Mr. S had many negative health care experiences in the past, he didn’t feel comfortable describing why it was difficult for him to follow medical advice and felt judged when he talked to medical professionals.
The nurse practitioner and the community health worker counseled him on how to share his concerns with his physicians and worked closely with him to prioritize, schedule and arrange transportation for his outpatient visits following discharge.
They also gave him educational materials, including a congestive heart failure symptom tracker to help him know when he needs to contact the physician. At discharge, the nurse practitioner worked with the pharmacist to complete a brief SafeMed continuity of care document to send to his primary care physician and cardiologist before his follow up appointments.
Staying involved through the continuum of care
The community health worker visited Mr. S in his home and reviewed his patient-friendly medication list and congestive heart failure symptom tracker. She learned that Mr. S did not have full comprehension of the self-management care guidelines he had been given in the hospital.
They discussed his care plan in greater detail along with his health goals, which included outpatient medical follow-up as a priority and diet and exercise as secondary goals.
In a bi-weekly case review meeting to discuss Mr. S’ needs and care plan, the community health worker met with the entire SafeMed team to refine the approach to Mr. S’ care. The team decided that the community health worker should attend his outpatient cardiology follow-up visit to assist him in communicating his concerns to the physician.
This support made Mr. S more comfortable discussing issues regarding the circumstances that led to his defibrillator’s repeated firing and he revealed to the cardiologist that it always occurred during sexual activity.
The cardiologist was able to fine-tune the device in response to Mr. S’ activity level to help him avoid future unnecessary shocks.
Because the SafeMed team facilitated communication between Mr. S and his Medicaid case manager, he was able to get the assistance he needed with medications and home services. With the help of counseling, ongoing education and a supportive care team, Mr. S is meeting his health goals, attending his follow-ups, walking in his neighborhood and exercising daily for cardiac rehabilitation.
The SafeMed team helped him speak up for himself and get the care he needed most, Mr. S said. He looks back positively on the experience.
Mr. S was not receptive initially, according to the SafeMed team. But, once he understood that the SafeMed team members were there to help him, he was able to take the actions he needed to gain control of his health and avoid further hospitalization.
Implement the SafeMed model in your practice
A new module on using the SafeMed model for transitions of care approach is one of eight new modules recently added to the AMA’s STEPS Forward™ collection of practice improvement strategies to help physicians make transformative changes to their practices.
The University of Tennessee Health Sciences Center contributed this STEPS Forward module after winning the AMA-MGMA Practice Innovation Challenge. The module can help practice teams implement the SafeMed model, which enables them to work closely with patients to build strong relationships that make it easier to coordinate and manage their care.
Thirty-five modules now are available, and several more will be added later this year, thanks to a grant from and collaboration with the Transforming Clinical Practices Initiative.
AMA Wire® explores many of the other STEPS Forward modules, including why your practice needs a health coach and four questions to ask to find out if your patients have unmet needs.
