To control costs, Gundersen Lutheran Health System targets a relatively small group of patients—that 1 to 2 percent of patients at risk for hospitalizations, emergency department visits, and other complications.

Beth Smith, R.N., executive director of patient and family-centered care at the La Crosse, Wis.-based health system describes the group as “complex patients.” Speaking at a health care design conference in Chicago last week, Smith noted that medical complexity is not the only determining factor. A patient might have multiple chronic conditions, but is keeping them in control and has adequate familial support to help stay on track.

Other patients might have simpler conditions, but live alone or lack resources to follow the sometimes challenging medical care plans called for. Smith told the architects, interior designers and health administrators at the Center for Health Design’s meeting how EHR technology supports both the treatment—and identification—of these complex patients.

Gundersen’s EHR, from Epic, has a built-in “tiering score” module, used to determine which patients qualify for extra care coordination services, provided by a group of 22 nurses and social workers. These care coordinators are assigned to monitor the care of the complex patients most at-risk for adverse events. The EHR scoring system includes two components, one for medical complexity, the second for a psycho-social component. Clinicians who want to refer a patient to the care coordination program use the scoring tool to a) see if a given patient qualifies and b) if so, notify the coordination team via Epic. “You can do it in three clicks or less,” Smith said, emphasizing the need for streamlined applications that appreciate the time constraints on physicians and nurses.

At any given moment, some 1,700 patients are being managed by a care coordinator, who stays in close touch with the patient, usually attends office visits, and follows through with specialists. Care coordinators use a special tab in the Epic EHR, which pulls various data elements and milestones from other areas of the chart, offering a consolidated view of the “patient story,” Smith noted. If a patient in the care coordination program shows up in the ED, the nurse or social worker is notified immediately in a messaging alert.

Smith said the effort has helped stabilize patients with hypertension and diabetes, noting that just under half of these complex patients had shown sustained improvements in their clinical markers for a two-year period while participating in the program.

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