1. Best Practice: Decreasing avoidable ED visits and 30 day readmits
Michael Casey, MD
Amy Marr, LPN Nurse Manager/Care Coordinator

2. Decreasing 30 day readmits
We use the hospitalist program in our practice so in order to be aware that our patients are in the hospital was the first issue.
Care coordinator in our office receives an updated hospital inpatient list each day.
Hospitalist nurse coordinator has a daily phone call with our care coordinator.
Campaigns aimed at patient engagement/education.
Asking them or family member to call us if they are admitted to any hospital
Upon discharge the patient is called with in hours. The care coordinator ensures that the
Patient understands the discharge instructions
The discharge medications have been filled at the pharmacy
Appropriate Home Health arrangements
Hospital follow-up within 7 days is optimal.
Home Health companies are asked to notify us when admitting one of our patients.

3. Current poster campaign within our office.

4. The front page of our website.
Reinforcing we would like to hear from them.

5. Hospital Follow Up Visit
Prior to the visit the staff ensures that the hospital Discharge summary and pertinent test information is available.
Patients are asked to bring all of their medications in their bottles.

7. Decreasing avoidable ED visits
Same day “sick” appointments.
Our goal is to start the day with at least 10 openings for patients with a same day need.
Once no more appointments are available our phone room takes a message and routes it to our care coordinator. She assists with scheduling.

8. Decreasing avoidable ED visits
Patient Education- we let them know we want to see them. If they go to an Urgent Care during office hours, we remind them that we are here.
Home Health nurse is asked to do prn visits. Assess the patient, lab, vitals etc.
Calls us with an update.

9. Decreasing avoidable ED visits
After hours until 9 pm and from 9am to 9pm on weekends and holidays our on call nurse is available.
The patient leaves a voice mail.
The on call nurse calls the patient within an hour.
The nurse is in touch with the on call MD as needed.
The on call nurse has access to their charts as well as the ability to schedule next day appointments.

10. Patient Education on our website for Urgent Illness and After Hours.