With the transition to value-based payment models in healthcare, Primary Care Physicians (PCPs) are seeing a greater need for more efficient care management for high-risk patients and an urgency to manage smarter transitions quickly. According to study performed by Beckers, 66% of readmissions happen within the first 15 days after a hospital discharge. This urgency puts a whole new focus on care transitions from hospital to post-acute care providers and their role amongst the broad care team to keep patients at home longer.

Dr. Chris Trotz and his team at South Jersey Family Medicine put together a program to prevent readmissions, improve patient safety, and enhance patient satisfaction. The initiative focused on increasing communication with a team that historically had no close bond or relationship with the patient — a challenge for a hyper-fragmented and isolated post-acute care segment. They worked with PreparedHealth to integrate enTouch™ into the workflow across the broad care team. Total health management enabled the team to proactively manage the patient case with real-time connectivity. The program resulted in no readmissions within 30 days for any patients enrolled in the program, along with a 20% reduction of the beneficiary cost of care.

We sat down with Dr. Trotz to get a more in-depth look at how he is creating an expanded care team virtually. The conversation was enlightening and he agreed to let us share his secrets to success that will no doubt help many other Primary Care Physicians, as well as Geriatricians, Nurse Practitioners, Care Managers, and other types of providers who need to better utilize their relationships with post-acute providers.

Step 1: Pick the Right Team
Know how you really want to work with your partners and coach them. Create a care team driven by quality of care and a willingness to rally around the patient. Find other providers who are eager to communicate about the patient in real time and engage with each other. Increase engagement between the primary care office, long-term care facilities, skilled nursing facilities, home care agencies, and hospital case managers coordinating discharges from the hospital.

Step 2: Put the PCP at the center
The person who knows the patient best needs to be included at the center of the dialogue. The PCP has the historical knowledge to help the team make quicker, more efficient decisions on interventions and avoid excessive or repeated testing and care.

Step 3: Create Situational Awareness
As a PCP, coach the new team members on the psycho-social aspects of the individual that may contribute to the urge to transition quickly back to the hospital when unnecessary. Being accessible, especially during the initial care transition period is critical to stabilizing a patient in a new, unfamiliar care setting. Often times the needs are not clinical, but behavioral and social in nature. Go beyond a referral or care transition and continue to communicate especially in that critical first 15-day window where most readmissions take place.

Step 4: Engage the Family
Often times the PCP treats the disease or condition. We need to treat the person, which also includes their environment and family members. Most anxiety for a patient stems from their family. Learn to create a respected, empowered relationship where they become an extension of the care team. Engage, inform and educate them on how to be effective and become an extension of your care team. Doing so can prevent unnecessary utilization, and accelerate recovery in their desired care setting, often their home.

Step 5: Set Communication Expectations
Be clear on the types of communication updates you want and what frequency. Technology is great, but with 1000s of patients to care for, a detailed text chat on all of them is not realistic. Set your escalation parameters and key areas that require heightened and active engagement. For example, sudden changes in behavior, non-compliance with medication or therapy, rapid deterioration of condition, lack of community or home-based support are all critical items that PCPs need relayed to them in order to provide timely intervention.