Jessa Dunivan Outlines Areas for Improvement Where Care Management Can Help

After the first 2 performance periods of the Oncology Care Model, it became clear hospice care was an area where Northwest Medical Specialties could improve, and care coordinators could help, said Jessa Dunivan, patient services manager, Northwest Medical Specialties.

Transcript

After the results of the first 2 performance periods of the Oncology Care Model came out, what areas did you see opportunities for improvement where care management could help?

Where we learned that we needed to improve was our hospice, end-of-life care. When we recognized after that performance period that we needed to improve in this area, the patient care coordinators took on the population management for the hospice population.

So, when a referral is sent for hospice, the patient care coordinators are notified, and then we track and check in on those patients throughout their journey in the hospice service. And we check up on them, we make sure that their notes are coming back to our charts, so that our doctors, who are still their providers, are aware of what’s still happening with that patient even though they’ve been referred to hospice. And then, subsequently, if a patient passes away, the patient care coordinators have a key role when someone passes away in the tasks that are completed when that happens.

You would think that in a normal scenario, if a patient passes away, then things end, and you move on. That’s not how it looks at our practice. When we get notified that someone has passed away there are very important things that have to happen in order to make sure that that loop is closed, and really, we do that for the patients and their families. When someone’s deceased, we make sure that all their referrals are closed out, and we notify those imaging facilities, because we don’t want those facilities contacting the family to schedule an appointment. We contact the pharmacies, and we discontinue their active prescriptions to make sure if the patient has mail-order prescriptions that are going out, that those aren’t in the mail and going to be received by the family and then the family is going to be charged for those medications that they can’t return.

So, closing down a chart properly really will alleviate undue stress on the family—financially, emotionally, so that they can begin their grieving process or begin the process that they deal with on their own that’s not going to be interfered by logistical things that should have happened in beginning, so that’s a really important task to us.