While many things are hard to predict, we’re seeing that many of the challenges of COVID-19 will continue to be with us for some time to come. Yet I’m encouraged by the terrific work our teams are doing to ensure our patients and the community have access to high-quality care to manage their health and well-being, especially during COVID-19.
The Care Coordination team in particular has been willing to go where the need was greatest and make a significant difference in the first few months of the pandemic. Tasked with checking on COVID-19-positive patients recovering at home, our care coordinators identified at-risk patients and escalated symptoms that needed immediate intervention to their providers when necessary. An analysis of two cohorts of 75 patients each yielded dramatic results in outcomes: The 30-day readmission rate for COVID-19 patients with care coordination was 4.8% compared to 8% for the other cohort of COVID-19 patients. Patient feedback was also very positive, with patients overwhelmingly grateful for the outreach.
The Vanderbilt Medical Group realized similarly positive results with direct outreach to group of 1,500 Medicare patients due for annual wellness visits (AWVs) during shelter-at-home orders. To ensure these patients 65 and older stayed safe at home but still received care for existing conditions, the team encouraged them to take advantage of telehealth. Drs. Dan Cottrell, Jill Jones and Mohana Karlekar led the effort to provide education for all primary care clinicians on the new workflow, and nursing staff and patient service specialists checked in with patients several times to remind them of their appointments, answer questions and prepare them for their AWV telehealth visit. Patients reported liking the telehealth service, so the team will continue to offer it as an option while also scheduling more in-person visits. A dashboard is in development that will track telehealth AWVs and advance care planning at a practice and provider level.
—David Posch,