PP108 – The Advanced Care Providers Role in Case Management-Multidisciplinary Approach to Navigating High Risk Populations in the Community
Advanced care providers play an important role in providing a robust transitional care management program. This presentation will focus on how advanced care providers innovate and utilize their expertise and experience as clinicians to provide outstanding care and outcomes outside the concrete walls of the acute care setting for high risk patients such as cardiac surgery patients and patients with chronic conditions. The audience will have the opportunity to experience what it is like to not only care manage high risk chronic patients, but also develop an understanding of what it is like to step into the world of the high risk patient in their home setting, no matter where they call home. Through a robust transitional care program with the help of analytics, our ACP’s have provided over 10,000 touches for cardiac surgery patients in any place where patients may call home (cars, homes, boats, shelters, and even the streets). Every touch enables our multidisciplinary team to identify adverse events, medically optimize, refer to wellness programs, and improve the overall patient experience. By providing care with ACP’s, the readmission rate for the Follow Your Heart patients which includes CABG and Valves has decreased from 15.2% in 2016 down to a present rate of 11% for this high risk population. Case Scenarios along with patient experience videos will be presented.
1. Understand the role of the ACP for effectively care managing and effectively addressing both medical and social issues for the high risk cardiac surgery patient population and chronic patient in the community
2. Learn how providing a robust transitional care program that utilizes a multidisciplinary approach can lower the overall readmission rate for high risk populations
3. Engage leaders to create a true transformation through innovation and utilization of analytics for care managers by expanding care outside of the hospital walls to keep patients engaged and connected