Care management program that fill in the gap for patient's being discharged into the community, to reduce hospital readmission.
My name is Lovett owner of Biohealth Case Management(BHCM). We have contracted with 1 hospitalist group and 1 Primary Care group here in central Florida. Both practices cover 2 major hospitals AdventHealth South and East.
The goal of BHCM is to fill in the gaps of discharge planning so that patient aren't readmitted back into the hospitals. The cost will cover care giver services, equipment, transportation, and 24hr case managers who would work remotely. The duties of the case mangers is to provide all services needed above until insurance, home health, PCP, etc....are able to see the patient.
Having many years experience I have found that there is many case mangers, agencies, hospitals, etc... claiming to reduce readmission but none still address many of the issues we face today. One of them being, patient's are still discharged without equipment's, insurance, family support, or proper medication reconciliation.
Case example 1: Primary care doctor and Cardiologist prescribing the same medication with different dosage and either one of them are talking with each other. Patient goes in to fill the med, pharmacy catches it but fills it anyway and explains to the patient to call their doctor. Patient is bed bound can't move without a 3person assist. Numerous calls made but no response.
Case example 2: This patient has good family support. However, patient has over 13 physicians, and 32 meds. Patient's family have been asked by 3 different physicians to bring patient to have labs done weekly. When asked by the patient why couldn't the labs results be shared between physicians? They said the response she got was almost close to nothing..... Patient's daughter says she had to quite her job to take care of her mother.
Case example 3: Patient has no family support other than a next door neighbor. Patient was discharged without hospital bed, walker, commode, and wasn't able to walk . Equipment was left for Home Health agency. However, PCP has yet to see the patient and won't sign off for home health. When I saw the patient he was half dressed and neighbor went to work. Called DCFS but nothing much could be done other then have him on a waiting list for Medicaid........ More to this story but patient was left almost unattended for more then 3days without proper equipment or family support.
Investing in BHCM would not only help us as a organization, but would help the 100s of patients and families that are desperately needing support and don't know where to turn in this huge complex healthcare system.
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