1. Darius Kostrzewa, MD Martha Farrelly, NCM

2. Access to PCPs Office Open access/same day appointments Expanded office hours Educating patients about your availability 24/7 access to PCP – concierge practice

3. Role of Nurse Care Manager Physician partner Patient advocate Educator/Life coach Resource coordinator Liaison

4. Current System We receive an e-mail every morning with list of patients seen in the ED and those admitted. Wade through Meditech to determine what was done for patient and where they are now. We do not get notification of patient transfer to another hospital or notice of death. Daily list of discharged patients would be helpful Access to any physician/nurse ED notes.

5. ED Follow Up Call patients seen in the ED. Often need to ask them what they were told to determine what their problem was. ED or triage notes would be very helpful Discharge instructions with current meds and any new scripts patients are leaving the hospital with. Discharge instructions need to be specific and legible!!! ? Simple diagnosis-specific instructions reviewing what to do, when to do it, and who to call.

6. Meet my Friend Shirley B 82 year old female Primary caregiver for spouse with advanced Parkinson Disease History of anxiety/depression Multiple medications Complicated family dynamics Frequent emergency room visitor “I was tired, I had a headache, my kids weren’t around, so I called the rescue.”

7. Geriatric Patient Geriatric population is huge challenge. When help is offered, it is either too expensive or not convenient enough. These patients need a lot of reassurance, repeated contact in order to trust us and trust our recommendations. Role is to educate, advocate and coordinate needed resources to keep patient out of ED.

8. Hospitalist/Admission/ED Communicating with PCPs – exchange of information on admission and discharge. Care Transitions Discharge instructions Patient Education

9. VNS Direct communication with NCMs definitely improves continuity of care. We receive list of mutual patients, discharge instructions of new VNS clients Opportunities exist to improve home care services. ? Respiratory program for COPD patients similar to CHF protocol. Could telemedicine work for these patients?

10. Standards of Care in PCPs Office Setting up standards for CPE CSI measures End of life issues – most healthcare dollars spent in last years of life. How do we keep elderly at home? Family meetings/list of patients living alone. NCM geriatric assessments