Background: Following discharge from hospital, Community Care Teams (CCT) continue the care of patients with chronic medical problems. Handover is by means of discharge summary with no further communication between Inpatient Teams (IPT) and CCT. When problems arise, CCT refer patients to the Emergency Department (ED) and re-admissions back to IPT are not infrequent.
Purpose: To minimize readmission, internists from IPT and family medicine physicians from CCT piloted a co-management model to manage high-needs patient following hospital discharge; using secure instant messaging application TigerText.
Description: High-needs patients are identified by IPT and referred to CCT prior to discharge. Patients leave hospital having met their CCT; with a detailed discharge summary and an internist identified as a Point Of Contact (POC). Community Care Team will review patients at home as a follow-up or if patients develop problems at home. If support from hospital is needed, CCT will contact POC via Tigertext and discuss management. Similar to Whataspp, TigerText allows instant communication between individuals or groups; and files, images and sounds to be shared; and is HIPAA compliant.Since start of pilot in April 2018, we avoided readmission of at least 5 patients. Though the number of patients is small, the savings from admission avoidance are cumulative and can be substantial. This includes man-hours for admission, discharging and billing processes; waiting times at ED and bed occupancy, and medical and transport costs.
An example was a 84 year old frequent flyer with 20 hospital admissions in the previous 12 months for recurrent cellulitis. He was enrolled into to the program following an admission in April 2018 and was discharged with advice on self-management of cellulitis, standby antibiotics and CCT support. With each new episode of cellulitis, he would initiate antibiotics from standby pack and contact CCT. The team comprising of family medicine physician and home-care nurse would visit him at home, provide assessment and care, track progression; and messaged IPT for advice if required. Photographs documenting evolution of cellulitis would be shared on TigerText with all CCT and IPT members.
In the 7 months following enrollment, CCT had performed 10 home visits, discussed management with IPT 4 times and reduced hospital admissions to only 3 times. Patient reported greater satisfaction with care; and members of both CCT and IPT feel more pride and sense of accomplishment with their work; trusted one another and were ready to collaborate on more projects.
Conclusions: Presently hospital and community care are 2 distinct entities, with handover of patient from 1 team to another upon discharge. A co-management model between IPT and CCT may have advantages of reducing readmissions and improving patient and staff experience. Instant messaging applications allowing group sharing of information securely on mobile devices facilitate this; although medico-legal, reimbursement and funding issues must yet be addressed.