Primary care-based interventions cut admissions, ED visits.
By sending teams of clinicians to work with at-risk patients at primary care practices, Lehigh Valley Health Network has reduced hospital admissions by 49% and emergency department visits by 25%. Teams that include a nurse care manager, a social worker, a behavioral health practitioner, and a pharmacist are assigned to primary care practices and work with the top 5% of high-utilizing, high-cost patients. The care managers call at-risk patients within two days of a hospital admission, conduct a thorough assessment, and refer patients who need assistance to the appropriate team member. The care managers develop a close relationship with patients, who often give them information they wouldn't be comfortable telling their physician.
D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D019982:Organizational Case Studies; D010346:Patient Care Management; D010414:Pennsylvania; D011320:Primary Health Care; D011785:Quality Assurance, Health Care