SafeMed Results

A Patient’s Experience

How’s it working in Memphis, TN? A patient’s SafeMed experience*

The effectiveness and impact of SafeMed is evident in the story of Mr. S, one of the first enrollees in the University of Tennessee/Methodist Le Bonheur Healthcare program. He was identified as a potential candidate for SafeMed by the lead nurse practitioner (NP) during her review of the SafeMed eligibility report. This report is generated by the hospital’s electronic health record (EHR) system each morning. She reviewed his chart and to make sure he met basic program eligibility criteria and then went to meet Mr. S. in his hospital room. There she got to know Mr. S., told him about the SafeMed program and confirmed his eligibility.

Mr. S. was a 58-year-old Caucasian man with 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. His housing situation was unstable and he experienced difficulty with transportation to and from medical appointments. Mr. S had Medicaid and received government disability.

Mr. S needed intensive SafeMed care transitions services, met program eligibility criteria, and was interested in participating. So, over the next three days of his hospitalization he was visited by the lead NP, the lead pharmacist, and the pharmacy technician and licensed practical nurse (LPN) community health workers. The team worked to develop rapport with him and assess his needs.

The lead pharmacist learned that because of his limited income, cost was a major barrier to his 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. They assessed his understanding of the purpose of each of his medicines and how it should be taken

The team also learned that Mr. S had had numerous negative healthcare experiences with both specialists and primary care physicians. He saw two different cardiologists and reported getting conflicting information. He didn’t feel he could talk to a care provider about what made it difficult for him to follow medical advice without being judged, nor did he feel that they understood his situation. The lead 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 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 lead 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 his being re-hospitalized briefly for a concussion and a broken leg. The SafeMed team was immediately alerted of his readmission by the daily eligibility report and team members visited him once again in the hospital. Mr. S’s injuries led to situational housing instability, so the team continued to work with him and the hospital social worker to make sure he had a place to stay following this discharge.

During his first home visit a few days after this second hospitalization, the community health workers reviewed his Patient Friendly Medication List and his CHF Symptom Tracker. However, when the community health workers employed teach-back techniques they found that he had only fair comprehension of self-management care guidelines. They discussed his care plan in greater detail and then asked about 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 community health workers 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 his care. Most importantly, the team decided that the LPN-community health worker should attend his outpatient cardiology follow-up visit to assist him in communicating his concerns to the doctor.

Mr. S. welcomed this help. The LPN-community health worker picked Mr. S. up and brought him to his cardiology visit. 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 patient’s activity level to help him avoid future unnecessary shocks.

As part of Mr. S’s ongoing care plan, SafeMed staff facilitated communication between Mr. S, and his insurance company case manager. This resulted in him getting the assistance he needed with medications and homemaker services. SafeMed staff also undertook great efforts to stabilize his housing situation and he is now living in a boarding home in a safer, more familiar neighborhood. Following his second home visit, he was successfully referred to a community mental health center for depression and substance abuse counseling. With the help of concentrated counseling, ongoing education and a supportive care team, Mr. S. is now meeting his self-identified health goals: walking in his neighborhood and doing daily exercise for cardiac rehabilitation.

The SafeMed team met almost all of its core metrics for Mr. S.:

• His first home visit occurred within 72 hours of discharge
• His first telephone follow-up occurred within 14 days of discharge
• His first primary care visit occurred within 30 days of discharge
• He experienced only one readmission in the 6 months following his initial hospital discharge and this was related to trauma
• S. actively participated in the SafeMed program for four and a half months
• He continues to participate in monthly SafeMed peer group support sessions

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 were encouraged by their breakthrough with Mr. S. They note that initially Mr. S. was not very receptive to help, like many of the medically and socially complex patients who participate in the program, but once he understood that the SafeMed team members really cared and were there to help him he was able to take the actions he needed to take control of his health and avoid further hospitalization.

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