In health care, patients discharged from rescue care – either the emergency department or inpatient settings – are frequently lost and lack information about their conditions, future studies, and appointments. If you could design the ideal toolkit to assist recently discharged patients navigate their post-discharge care, what would you include?

First, you would want to know specific information about the patient, including things like demographics, insurance, if they belong to a medical home, their all-clinic visit history and upcoming appointments, and the discharge summary for their recent ED or inpatient visit. And you would want this information to be instantly available, sent directly to you, in one place, and conveniently organized so it can be tracked and sorted. Basically, a “one-click,” “one-stop” shop of patient information for post-rescue care navigation.

A Tool to Help Patients Stay the Care Course

The information a physician might need is similar to the information a travel agent needs to assist a customer: identifiers, address, payment source, intended itinerary, prior travel, etc. Now, imagine if the traveler needed their travel agent to

  • be automatically notified when the traveler goes off course; and 
  • contact the traveler with correctional plans.

You’d need quite a sophisticated tool to do that – like a GPS-location-triggered Four Square® application. Post-discharge patients would benefit from such a tool linking them to their patient-centered medical home (PCMH) care manager. The tool would automatically identify when a patient deviates from their expected care course, link to electronic health records, retrieve select information, and email that information their care manager (travel agent). The care manager then would contact the patient and coordinate follow-up care. This week, Olive View-UCLA Medical Center released such a tool. When an adult PCMH patient registers at the ED, an automated email notification is sent to their PCMH care manager alerting them of the rescue care event. Now, our team is working on enhancements to the tool, so the notification will include:

  • the patient’s clinic visit history for the previous six months;
  • upcoming clinic visits for the next six months; and
  • a discharge summary for the recent ED or inpatient visit.

Stay tuned for more details on our new tool and how it’s helping patients and their caregivers. This is the second blog in a series highlighting how the Los Angeles County Department of Health Services is helping patients better navigate their care. Read the first entry.