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Abstract
Background In 2016, in PCMC, only 75% high risk patients were receiving post hospital follow up care. Given that 24% of our high-risk patients are readmitted, it is fair to assume that no follow up results in higher utilization. For those that did receive follow up, it was variable depending on the physician. Primary care offices did not have a robust process for social needs evaluation. Hence, patients used more ED services for social needs. Programs that address both medical and non medical needs of patients show higher success but are often limited.
Objectives Reduce utilization by addressing medical and non-medical needs of high-risk patients.
Methods TCC appointment consists of: 40-minute medical assessment by a physician, pharmacist lead medication reconciliation, social worker assessment for social and behavioral needs, care navigator to secure resources, and care coordinator to manage the care plan for upto 90 days.
Results A single centered retrospective study was used to evaluate pre and post utilization of high risk patients that were treated in TCC and a similar control group that received care with a PCP. The demographics of both groups were evaluated to ensure similar representation. The results showed a significant decrease in utilization for the TCC patients compared to the control group yielding in approximately $2,145,099 in cost avoidance. In addition, 1:1 pharmacist time showed a projected cost savings of $385,000.
Conclusions Connecting patients and families with appropriate resources and supporting them will increase the quality of care and patient adherence to the care plans which in turn decreases utilization.