A ‘Below the Surface’ Look at How We Coordinate Complex Care

Transitional Care Services at The Johns Hopkins Hospital

Ms. U was referred to me for transitional care services from the Emergency Department in October 2015. She had presented to the ED after her blood pressure had become dangerously high. The patient confessed that she had run out of her medications one month prior to her visit. Her uncontrolled diabetes led to severe diabetic retinopathy and her vision was significantly impaired. She was evaluated by ED case manager Amy Cammer, who identified many barriers for the patient:

1) She can’t see any of the writing on her pill bottles

2) She has limited knowledge about her medications and only had a fifth-grade reading level

3) She was living alone in a rented room with no family in the state

4) She has no supplies for her glucometer

5) She receives a fixed income (SSDI) and is having difficulty paying for transportation to any of her outpatient appointments

6) She only speaks Spanish. Her medications were filled during her ED visit, a one week pill box was filled, and a referral for Transition Guide (TG) services was placed. It was unclear as to whether or not the patient had a primary care doctor so an After Care Clinic appointment was arranged for the following week.

I met Ms. U in her home for her initial home visit. I am bilingual and was able to communicate directly with the patient. The patient reported that she received primary care at a clinic outside of the Johns Hopkins System. I inquired about her social support system and she reported that her closest relative was her daughter, with whom she had resided with for a period of time, but who lives in out of state. She stated she wanted to have all of her care at Johns Hopkins.

I informed her that she lived within the ElderCare Plus eligible zip codes and would likely qualify for the services of a Medical Day program to assist with transportation, medication administration, and social support. I initiated the referral for two medical day programs that service her area, spoke directly with her primary care provider to obtain referrals for ophthalmology, diabetic testing supplies and an appointment with a mental health provider. I sent a referral to JCHIP because the patient lived within one of the seven eligible zip codes.

She began attending her outpatient appointments and was accepted into the JCHIP program rather quickly. Before attending her first primary care appointment, she was admitted at Johns Hopkins Bayview Medical Center for a condition due resulting from medication non-compliance. After discharge and due to the acuity of the patient’s conditions, skilled home nursing was ordered.

The providers she saw in clinic, Erin Perry, M.D., and Rahul Loungani, M.D., provided detailed emails to everyone involved in her care to provide updates to her plan of care after visits were completed and next steps. Erika Dixon, home care nurse, set up remote-patient monitoring to closely monitor symptoms related to heart failure. Melissa Lantz-Garnish, disease management nurse, monitored to patient’s daily weight, blood pressure and heart rate to assess for acute symptoms that needed immediate medical attention. A pharmacist in the JHOC internal medicine clinic met with the patient regularly to record blood pressures in clinic, provide medication teaching, and fill the patient’s pill boxes based on her most current medication changes. Pharmacist Tara Feller, PharmD, even dropped off the patient’s medications and filled her pill boxes on Christmas Eve, to ensure the patient would have her medications. A Spanish-speaking glucometer, as well as the needed supplies, were also ordered and obtained at a local pharmacy.

Despite our numerous interventions, the patient was admitted for heart failure.After discharge, she was seen in the Heart Failure Bridge Clinic by Johana Almansa, CRNP, where she could receive close cardiology follow-up with a provider that happened to speak her native language.

Her Johns Hopkins Outpatient Center providers gave her the medical records she would need to transfer care and provided a list of those in the area she would be moving to. The patient’s daughter came to pick up the patient, packed up her belongings, and helped her move in with her. I contacted her daughter and provided her detailed instructions about the patient’s current plan of care and how to apply for medical assistance in her state. To date, the patient has obtained medical assistance in her state, established primary care, and is living with her daughter where she received the love and support that she needs.

Each of her providers focused on providing patient-centered care that tailors care to the individual’s unique needs. This type of care provides optimal patient results and despite the complexity of this case, none of this could have been accomplished without the solid and outstanding care-coordination that each of her providers persisted in.

Margaret Elizabeth Arias, M.S., BSN, RN

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