Strategies supporting reduced hospitalization rates in a successful OCM practice.

Abstract

139 Background: Team-based implementation of care is a foundational tenant to reducing avoidable ER visits and hospitalizations. This care strategy supports the OCM mission of improving quality and reducing cost through practice transformation. Methods: Comprehensive care team: Physician, Advanced Practice Provider, Nurse Navigator, Financial Navigator, Phone Triage Nurse; Consistent Message: “Call Us Early – Call Us First” campaign. Verbal and written instructions at all staff member touch points, emphasizing patient responsibility to call before going to the hospital; Supporting infrastructure: 2-hour teaching visit with the entire care team prior to all new treatments; Triage Phone Unit, COME HOME (Barbara McAneny, M.D.) triage pathways – 38 symptom and 27 symptom f/u pathways modified; Blocked time-slots at all offices for same-day APP triage appts; Proactive ER and hosp f/u calls. Results: 2017 phone triage data: 9,841 total symptoms calls. 2,476 same day visits. 338 ER saves. 67 ER f/u calls (Nov/Dec 17’ only). OCM pt survey scores improved and internal Netpromoter scores remained stable. Conclusions: A comprehensive team-based patient navigation strategy, supported by consistent “Call Us First” messaging, symptom pathways and same-day patient access, resulted in decreased hospitalization without commensurate increases in ER visits or 24hr observation stays. Pt satisfaction was not impacted negatively. [Table: see text]