Hospitals in pursuit of excellence

Team-based Care Improves Transitions

Baseball managers tinker with team lineups to improve results on the field, and hospitals can do the same with health care teams. At WVU Hospitals, in Morgantown, W.V., physicians and medical residents teamed up to see their patients at the hospital’s outpatient clinic, within 7 to 14 days after discharge. A psychologist, pharmacist, and nurse case manager soon joined the team. Medical residents talk with patients before discharge, explaining the follow-up process and ensuring patients have a prescheduled appointment. The nurse case manager tracks all appointments, contacting patients until they are seen. On clinic days, the team huddles in the early afternoon and sees patients afterward. With this team-based follow-up care, 80% to 85% of patients are seen within 14 days of discharge. One additional benefit: discharge summaries have improved now that residents use their own summaries for the follow-up. Karen Fitzpatrick, M.D., quality director, WVU Family Medicine, says buy-in from physicians was quick “as we talked about the high value to patients.” Team-based care after discharge provides “one-stop shopping” for patients, and their feedback has been positive, Fitzpatrick adds.

For more information, contact Fitzpatrick at fitzpatrickk@wvuhealthcare.com.

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