Implementation of a Protocol to Manage Patients at Risk for Hospitalization Due to an Ambulatory Care Sensitive Condition.

Abstract

Ambulatory care sensitive conditions (ACSCs), such as type 2 diabetes mellitus, chronic obstructive pulmonary disease, hypertension, congestive heart failure, urinary tract infections, asthma, dehydration, bacterial pneumonia, angina without an in-hospital procedure, and perforated appendix put patients at risk for hospitalization. Currently at the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin, no standardized process or protocol exists that can identify and optimize primary care for patients with ACSCs who have been hospitalized but are predicted to be at low risk for rehospitalization. This project aimed to evaluate the implementation of offering further referrals and care for these patients. A pharmacy resident conducted a baseline chart review using a standardized template in the US Department of Veterans Affairs (VA) Computerized Patient Record System to identify additional referrals or interventions a patient may benefit from based on any identified ACSC. Potential referral options included a clinical pharmacy specialist or nurse care manager disease management, whole health/wellness, educational classes, home monitoring equipment, specialty clinics, nutrition, cardiac or pulmonary rehabilitation, social work, and mental health. Comparing the 3 months prior to and the 3 months after offering referrals, there was a cumulative quantitative decrease in the number of emergency department visits (5 to 1) and hospitalizations (11 to 5). Identifying patients at risk for hospitalization from an ACSC via a review and referral process by using the VA patient aligned care team structure was feasible and led to increased patient access to primary care and additional services.