By LYNN LOFTON
Often patients are released from the hospital with a fistful of instructions and a bagful of medications. What then? For more than two years Memorial Hospital at Gulfport looked for ways to do more care coordination to help patients have better followup and quality of life and to prevent having to re-enter the hospital.
“Care coordination has always been very important to us, and we had put in the budget to hire two more staff members for this purpose,” says Melody Griffin, director of case management. “In January, Medicare came up with such a program because they too are interested in giving better wellness and helping patients not re-enter the hospital.”
Thus was born RevUp, a Medicare-covered program designed to help patients between regular physician visits. Medicare patients with two or more chronic conditions have access to a personal
RevUp Health Coach, a registered nurse, to discuss the maintenance of their conditions and assist with medication monitoring. Memorial began the program in May and is the first facility on the Mississippi Gulf Coast providing it.
“At this time we’re targeting Medicare patients because we seldom see Medicare patients who do not meet the criteria of having two or more chronic conditions,” Griffin said. “We’ve enrolled 900 patients since May and feel some of those have avoided being re-admitted.”
A chronic condition is a health condition that lasts more than 12 months. For example, many Medicare patients have diabetes and hypertension, or a combination of obesity and arthritis. Much of the RevUp program is focused on education and lifestyle changes.
Case managers provide coaching for patients, give education and counsel about the proper way to take medications. If there’s a problem, the case manager can get the patient in to see a physician quickly, often heading off more problems. “It may be that the medication needs to be increased, but without monitoring it might have been a month before the patient could see a doctor,” Griffin said.
Patients who consent to the program can use a computer or telephone to stay in touch with their health coach. For some patients, followup may include keeping an online or hard copy log of what they’re eating and of their blood sugar. “We collaborate with the physicians and they play a big role in patients’ care plan,” Griffin said. “The physicians like it, are embracing it, and are giving us positive feedback.”
David LaRosa, M.D., is a champion for the program. “I don’t always have as much time with my patients as I would like to talk about how they’re managing day to day,” he said. “I’m excited that Memorial is bringing this new program to our community.”
He feels patients have an extension of his clinic in their homes because of RevUp. “They can ask questions about their nutrition, receive help with their medications and manage their health on their terms,” he added.
“I am encouraging all of my Medicare patients to take advantage of this new and innovative program.”
The program is also being well received by patients and Memorial expects it to grow. “We’re looking at care coordination for all patients,” Griffin said.
“It’s a step in the right direction for us and for Medicare patients. I would like to see Medicaid and maybe Blue Cross and other payers get involved.”
The case management department receives a daily report from the system indicating any negative responses to the post discharge questions and directly calls the patient to answer questions or connect them with additional resources.
Sharp Healthcare conducted a recent case study that indicated patients using this program had excellent clinical outcomes, including: 70 percent of patients experienced weight loss and were able to change their body composition profile; 80 percent improved their cardiorespiratory fitness; more than 75 percent remained engaged with the program.