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Transitions of Care Case Report: A Patient Experience with the SafeMed Model at the University of Tennessee

Mr. S* was one of the first enrollees in the University of Tennessee/Methodist Le Bonheur Healthcare SafeMed program.

A 58-year-old Caucasian, Mr. S had multiple chronic conditions, including coronary artery disease, congestive heart failure (CHF), chronic kidney disease and hypertension, along with a history of depression and cocaine use. He was initially admitted to the hospital because his automatic implantable cardioverter-defibrillator kept firing, causing him 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 a clear candidate for the intensive care transitions services provided by the SafeMed program. He met the program eligibility criteria and expressed interest in participating. Over the next three days of his hospitalization, Mr. S was visited by the SafeMed program's lead nurse practitioner (NP), lead pharmacist, a pharmacy technician, and a licensed practical nurse (LPN) community health worker. This team worked to develop rapport with Mr. S and assess his needs.

The pharmacist learned that because of his limited income, cost was a major barrier to Mr. S's medication adherence. The pharmacist and pharmacy technician helped Mr. S. simplify his medication regimen, made sure he was getting his medications at the lowest possible cost, and reviewed his plan for obtaining his medications following discharge. At discharge, they gave him a Patient-Friendly Medication List describing each of his medicines.

The team also learned that Mr. S had numerous negative healthcare experiences in the past with specialists and primary care physicians. He didn't feel he could talk to a care provider without being judged about why it was difficult for him to follow medical advice, nor did he feel that they understood his situation. The NP and LPN community health worker counseled him on how to share his concerns with his physicians and worked with him to prioritize, schedule, and arrange transportation for his outpatient visits following discharge. They also gave him educational materials, including a CHF Symptom Tracker to help him know when to contact the doctor. At discharge, the NP and pharmacist completed a brief SafeMed Continuity of Care Document/Discharge Summary and faxed this information to his primary care provider and cardiologist before his follow-up appointments.

Soon after Mr. S. was discharged from the hospital, he was mugged, resulting in a brief rehospitalization for a concussion and a broken leg. The SafeMed team was immediately alerted of his readmission via the daily eligibility report and Mr. S's team members visited him once again.

A few days after his second hospitalization, Mr. S was visited in his home by the LPN community health worker. The community health worker reviewed his Patient-Friendly Medication List and his CHF Symptom Tracker. When she employed teach-back techniques, she found that Mr. S had only a fair level of 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. Mr. S identified outpatient medical follow-up as a priority, with secondary diet and exercise goals.

After the initial home visit, the LPN community health worker met with the entire SafeMed team at their bi-weekly case review meeting to discuss Mr. S's needs and care plan. The input of the lead physician, NP, and pharmacist helped to refine the approach to Mr. S's care. Most importantly, the team decided that the community health worker should attend Mr. S's outpatient cardiology follow-up visit to assist him in communicating his concerns to the doctor. This 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 the firing always occurred during sexual activity. As a result, the cardiologist was able to fine tune the device in response to the patient's activity level to help him avoid future unnecessary shocks.

As part of Mr. S's ongoing care plan, the SafeMed staff facilitated communication between Mr. S and his Medicaid case manager. As a result, Mr. S was able to get the assistance he needed with medications and home services. With the help of concentrated counseling, ongoing education, and a supportive care team, Mr. S is now meeting his self-identified health goals: attending his scheduled follow-up appointments, walking in his neighborhood, and doing daily exercise for cardiac rehabilitation.

Mr. S. looks back on his SafeMed experience positively, remarking that the SafeMed team helped him speak up for himself and get the care he needed most. The SafeMed staff was encouraged by their breakthrough with Mr. S. They noted that, like many of the medically and socially complex patients who participate in the program, Mr. S. was not very receptive to help initially, 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.

*Disclaimer: The protected health information regarding Mr. S. in the case study above has been modified to protect patient privacy.

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