How an Interdisciplinary Care Team Reduces Prolonged Admissions Among Older Patients with Complex Needs

NEJM Catalyst ◽  
2021 ◽  
Vol 2 (9) ◽  
Author(s):  
Kenneth Lam ◽  
Erika L. Price ◽  
Megha Garg ◽  
Nate Baskin ◽  
Megan Dunchak ◽  
...  
Keyword(s):  
Older Patients ◽  
Care Team ◽  
Interdisciplinary Care ◽  
Complex Needs

scholarly journals Improving Palliative Care Chaplain Communication with the Interdisciplinary Care Team Through Implementation of the SBAR Technique (QI606)

2020 ◽  
Vol 59 (2) ◽  
pp. 502-503
Author(s):  
Karen Steinhauser ◽  
Jessica Beliveau ◽  
Artie Hendricks ◽  
Kristen Lakis
Keyword(s):  
Palliative Care ◽  
Care Team ◽  
Interdisciplinary Care

Interdisciplinary Care Team with Pharmacist in a Community-based HIV Clinic

2018 ◽  
Vol 110 (4) ◽  
pp. 378-383 ◽  
Author(s):  
Oh Samuel ◽  
Jacqueise M. Unonu ◽  
Kierra Dotson ◽  
Soon Park ◽  
Richard Parker ◽  
...  
Keyword(s):  
Care Team ◽  
Interdisciplinary Care ◽  
Community Based

scholarly journals GERIATRICS PREVENTABLE ADMISSIONS CARE TEAM (GERIPACT): A HIGH-RISK INTENSIVE AMBULATORY GERIATRICS PROGRAM

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S147-S147
Author(s):  
Stephanie W Chow ◽  
Lizette Munoz ◽  
Susana Lavayen ◽  
Shamsi Fani ◽  
Blair MacKenzie ◽  
...  
Keyword(s):  
Health Care ◽  
Social Work ◽  
High Risk ◽  
Emergency Room ◽  
Older Patients ◽  
Care Team ◽  
Emergency Room Visits ◽  
Telephone Hotline ◽  
Ed Visits ◽  
Preventable Admissions

Abstract The Geriatrics Preventable Admissions Care Team (GERIPACT) is an inter-professional team of 2 clinicians, 1 social worker, and 1 care coordinator, dedicated to offering temporary intensive ambulatory care services to complex older patients at high-risk for incurring expensive health care (ie. frequent emergency room visits or hospitalizations). GERIPACT services include frequent office visits for medical and social work needs, frequent telephone contact, home visits, specialty visit accompaniment, and a 24/7 telephone hotline. Use of this innovative model aims to serve communities lacking in geriatrician and geriatric social work providers, with a main goal of serving the highest risk older population. We reviewed the healthcare utilization of GERIPACT enrollees 6 months prior-to-enrollment and compared with 6 months following graduation from GERIPACT from 2016 to 2018. 78 patients were evaluated, with 49 total ED visits prior to enrollment and 35 post-graduation, saving 14 ED visits for a ratio of 18 saved ED visits per 100 GERIPACT patients. There were 45 hospitalizations prior to enrollment with 29 hospitalizations post-graduation, saving 16 hospitalizations, or 20 hospitalizations per 100 GERIPACT patients. Hospital days were reduced by 237 days post-graduation. An intensive ambulatory program for high risk geriatrics patients may be shown to be an efficient model of care for targeting those older patients who potentially incur greater expenses to the health care system. This focused team may be deployed to primary care communities with complex elderly patients in need of geriatricians and geriatric social workers, and may reduce unnecessary emergency room visits and inpatient stays.

scholarly journals Added Value of Early Consultation of an Inpatient Palliative Care Team in Hospitalized Older Patients With High Symptom Burden: A Prospective Comparative Study

2020 ◽  
pp. 104990912098260
Author(s):  
Myrthe W. Naaktgeboren ◽  
Fabienne J. H. Magdelijns ◽  
Daisy J. A. Janssen ◽  
Marieke H. J. van den Beuken-van Everdingen
Keyword(s):  
Palliative Care ◽  
Older Patients ◽  
Symptom Burden ◽  
Palliative Care Team ◽  
Care Team ◽  
Added Value ◽  
Symptom Improvement ◽  
Period 2 ◽  
The Impact

Background: It is estimated that in 2050 one quarter of the population in Europe will be aged 65 years and older. Although the added value of a palliative care team is emphasized in the literature, the impact of the palliative care team on the symptom burden in older non-cancer patients is not yet well established. Objectives: To structurally measure symptoms and to investigate whether proactive consultation with a palliative care team results in improvement of symptoms. Design: This study has a prospective comparative design. Setting/Participants: Older patients, admitted to a Dutch University Medical Centre for who a health care professional had a negative response to the Surprise Question, were selected. Measurements, Results: In period one, 59 patients completed the Utrecht Symptom Diary (USD) at day one of admission and after 7 days. In period 2 (n = 60), the same procedure was followed; additionally, the palliative care team was consulted for patients with high USD-scores. Significant improvement on the USD Total Distress Score (TSDS) was observed in both groups without a difference between the 2 periods. This study showed an association between consultation of the palliative care team and improvement on USD TSDS (adjusted odds ratio: 4.9; 95% confidence interval: 1.816-13.198), despite low follow-up rate of advices (approximately 50%). Conclusions: This study emphasizes the importance of creating awareness for consulting the palliative care team. Further research should focus on assessing the reason behind the low follow-up rate of the advice given and understanding the specific advices contributing to symptom improvement.

Effects of an Interdisciplinary Care Team on the Management of Alzheimer's Disease in China

2019 ◽  
Vol 45 (5) ◽  
pp. 39-45
Author(s):  
Chunying Chen ◽  
Yingying Huang ◽  
Caixia Liu ◽  
Ying Xu ◽  
Lingyan Zheng ◽  
...  
Keyword(s):  
Alzheimer’S Disease ◽  
Alzheimer's Disease ◽  
Care Team ◽  
Interdisciplinary Care

Implementation of an interdisciplinary care team to create individualized care plans for high risk oncology patients: A model to decrease aggressiveness of care at the end of life and improve cost effectiveness of care.

2017 ◽  
Vol 35 (31_suppl) ◽  
pp. 171-171
Author(s):  
Girish Chandra Kunapareddy ◽  
Joseph Hooley ◽  
Leticia Varella ◽  
Christa Poole ◽  
Helen Tackitt ◽  
...  
Keyword(s):  
Length Of Stay ◽  
End Of Life ◽  
Hospice Care ◽  
Care Team ◽  
Interdisciplinary Care ◽  
Oncology Patients ◽  
Time To Death ◽  
Care Plans ◽  
Individualized Care ◽  
Ed Visits

171 Background: Due to complexity of disease and treatments, oncology patients have among the highest hospitalization rate, especially towards End of Life (EOL). In our cancer institute, just 6% of all discharged patients accounted for >40% of unplanned readmissions, and continue to be highest risk of future admissions, ICU stay, ED visits, overuse of chemotherapy and under use of hospice care. We hypothesized that developing individualized care plans (ICP) for this high-utilization group will provide guidance in the complex care they require to reduce unnecessary and aggressive medical services. Methods: An Interdisciplinary Care Team (ICT) was created consisting of palliative medicine and oncology physicians, social workers, care coordinators, and nurses. On a bimonthly basis, patients with at least two unplanned hospital readmissions over the last 60 days were identified. ICPs were created using a team-based approach with parallel input from patient’s primary outpatient providers. Results: A total of 36 patients, 226 hospitalizations, and 163 ED visits were evaluated over a 6-month period, with an average number of hospitalizations of 1.08 per patient month (ppm). After implementation of ICP, hospitalizations decreased to 0.23 ppm, with an average length of stay decrease from 7.17 to 4.06 days per admission. Average ED visits decreased from 0.58 to 0.34 ppm, and the average number of unplanned readmissions decreased from 0.43 to 0.13 ppm. Of the 10 patients expired since creation of ICP, 8 utilized hospice care, while 2 patients died in an ICU. Average time to death from creation of ICP was 72 days among this cohort, while time to death from last exposure to chemotherapy was 58 days. Conclusions: Creation of individualized care plans for high-utilizing cancer patients decreased number of hospitalizations, ED visits, unplanned readmissions, and length of stay. A dedicated focus from a team of experts, beyond disease biology, on a unique patient situation may result in improved patient experience with decreased aggressiveness of care at EOL and overall resource utilization.

scholarly journals Evaluating integrated care for people with complex needs

2020 ◽  
Vol 26 (1) ◽  
pp. 46-53
Author(s):  
Panagiotis Kasteridis ◽  
Anne Mason ◽  
Andrew Street
Keyword(s):  
Primary Care ◽  
Integrated Care ◽  
Models Of Care ◽  
Care Team ◽  
Future Research ◽  
Complex Care ◽  
Care Needs ◽  
Complex Needs ◽  
Care Models ◽  
Integrated Care Models

Objectives As part of the Vanguard programme, two integrated care models were introduced in South Somerset for people with complex care needs: the Complex Care Team and Enhanced Primary Care. We assessed their impact on a range of utilization measures and mortality. Methods We used monthly individual-level linked primary and secondary care data from April 2014 to March 2018 to assess outcomes before and after the introduction of the care models. The analysis sample included 564 Complex Care Team and 841 Enhanced Primary Care cases that met specific criteria. We employed propensity score methods to identify out-of-area control patients and difference-in-differences analysis to isolate the care models’ impact. Results We found no evidence of significantly reduced utilization in any of the Complex Care Team or Enhanced Primary Care cohorts. The death rate was significantly lower only for those in the first Enhanced Primary Care cohort. Conclusions The integrated care models did not significantly reduce utilization nor consistently reduce mortality. Future research should test longer-term outcomes associated with the new models of care and quantify their contribution in the context of broader initiatives.

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