I am a care coordinator. I search out gaps in care and figure out how to reduce them. Right now I am concentrating on readmissions to the hospital within 30 days of discharge. More than 17% of hospital discharges for Medicare patients result in a readmission. I understand from the health care literature that ¾ of these hospital readmissions are avoidable through proper care and prevention. If I do my job well then I can help avoid the need for roughly one in eight admissions of our Medicare patients. To do this I require timely information which only CLG can provide.
My focus on readmissions is important for at least two reasons. One is financial; we do not get reimbursed from CMS for these 30-day readmissions. The other is personal. These readmissions may be for people whose need to be in the hospital can be prevented. If they do get admitted it impacts them and their family. Think of how many people I can really help!
As a nurse, my role with a patient no longer ends when the patient leaves the hospital and gets into the car. I am now calling patients shortly after they are discharged to see how they doing at home. I need to know the level of pain that each patient is having and whether or not they are following the care plan.
Many of my sickest patients are on multiple medications. When discharged from the hospital, they may not know or not remember all the medications they are taking. But when they get home I can go over the medications in their cabinet and make certain that these meds are in line with the discharge plan.
CLG allows me to do even more. In my evolving care coordinator role I am expected to be both a retrospective and proactive problem solver. And I cannot solve problems without access to data and being able to manage that data using CLG. I look at my patients’ risk - using CLG to go back twelve months from the date of admission for each of my patients. I take into account the patients’ age and gender, admissions and readmissions, and history of major diseases like hypertension, diabetes, and chronic kidney disease. Then I use CLG to identify patients with similar risk portfolios, examine which ones lead to healthy and unhealthy outcomes … and try to figure out why.
This information from CLG lets me red flag certain symptoms and situations in a timely way as I prioritize my efforts and initiate discussions with my patients in time to change the course of the disease. I cannot realistically put forth the same effort with every discharged patient. CLG enables me to know who is most likely to get into trouble and who is more likely to be readmitted.
Having the data from the electronic medical record is not enough. CLG helps me pinpoint gaps in care and, for those patients at greater risk, determine what action to take – so I can try to prevent these readmissions. Clinical Looking Glass’ unique ability to track the patient care process retrospectively and use that to inform patient care prospectively helps me focus on the right patients and identify opportunities for improvement in each of their care.
With CLG I go one step further. CLG allows me to look systematically at the cause of these gaps in care to see where we might change our work flow to prevent problems. I can then bring these findings as opportunities for consideration by the others on my care team.
My role is now about improving care and reducing cost; problem solving and preventing for both individuals and groups of patients. I do this by identifying gaps in care and intervening before a patient’s condition worsens to the point where a readmission is required. This is the future of nursing and thanks to CLG I am on the leading edge.