The Impact of Post-Discharge Outreach on Patients

Video Transcript

Jenny Simmonds, MSN, BSN, Clinical Communications Center Director, Intermountain Healthcare:

We see patients through the entire joint journey, so we see them through acute care and then transitions—which is what I do—and then into the longitudinal, which is a connection with our ambulatory care managers. Some of the really great work that we were able to do and the visibility that we have of where patients are in that continuum of care.

One of our patients discharged from the hospital, long time COPDer, got home and their oxygen tank had run out and home care hadn’t shown up with their oxygen yet. The outreach came to the patient and they were just going to try to go to bed and see if they could wait until the morning to get their oxygen. We were able to reach out to the home care company, get EMS over there to give them some oxygen until home care could get out there and then be able to supply them with oxygen. We’re doing this almost daily with oxygen or supplies.

We also have just a lot of little tiny things that we have like patients calling and saying, “Hey, my kid has a cough”. And these are patients that maybe could be treated at home. We have the ability to go into the system and make an appointment for them and say, “Your loved one’s fine. I’m looking over their discharge orders. Let me make an appointment for you tomorrow to see your PCP.” We’re able to make those connections and help patients avoid Emergency Departments and Instacare visits unnecessarily.

Those are some of the main things that we do with our work. And some really scary things we’ve helped with too. Suicidal patients, getting them to the right care. We do that on a daily basis as well.