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Cynthia
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Currently, our care managers work to identify the patients that have been using the ED or hospital frequently and pair them with a PCP office when possible. They then stay in contact with them providing education, coordinating care and services. The care management department has a clinical pharmacist and social workers and nurses to support the patients. They provide this care in several languages and attempt to engage them in way that work best for them, via phone, using Skype, meeting them at the doctor’s office.
Be Careful of hiring friends, unfortunately this sounds like a tough situation. It may be best to meet with them individually and then together. Hopefully a happy balance can be obtained to meet the goals of the work that is needed get done. It will be important to be direct and you may want to involve someone from your human resources department to help mediate and review the hospital policies.
Currently, most of our patient education happens when the patient comes to the office for a visit. There are opportunities for patients to attend diabetes classes if they’ve been diagnosed as a diabetic. We also have care mangers that provide patient education. In addition there are many community health fairs and we have a team called “BP ambassadors” that attend the health fairs and set up tables at stores, malls, or health fairs to provide checking of BP but also patient education. I believe we have opportunities to improve how we’re providing patient education.
So, we have started doing mini-pilots with innovative ways to service the community like doing telephone visits, virtual visit and group visits. As we work in a fee for service model these types of visits work well in a population health/value based world but in our current fee for service world we’re unable to bill for many of these services however we are learning from them and soon we’ll understand if there’s benefit in other ways such as cost savings programs or reduced ED visits. Time will tell……….