A doctor in Tulsa has an inside look at a Medicare pilot project. John Henning Schumann is a primary care physician and teaches at the University of Oklahoma School of Community Medicine. His practice gets $40 per month per high-risk patient. The money goes to a team of nurses who provide follow-up care to patients, calling them to answer questions, arrange transportation or simply provide patient education.
Schumann’s patient Ted is one of the frequent fliers who get this extra help.
A 40-something patient I’ll call Ted has a list of conditions that would have tongue-tied Carl Sagan. Even though I see Ted in my clinic every month, he still winds up visiting the emergency room 20 times per year.
Yes, 20. Before he became my patient, he went even more frequently. So, the current situation, bad as it may be, represents halting progress.
I see Ted every month, deal with his current health concerns and tweak his medications. But it’s still not enough to keep him from making what I consider frequent, unnecessary trips to the hospital.
This is where our new nurses come in … calling high-risk patients and talking them through their anxieties, reinforcing the need for them to take their medicine, troubleshooting transportation and scheduling screening services. Not only do the nurses schedule colonoscopies and mammograms, they follow through to make sure that patients are educated about the tests’ purpose and that they actually get done.
I was so intrigued by what our new nurses do that I’ve started attending their staff meetings.
Every month we receive an overview of our practice and the number of patients deemed high-risk. We are now swimming in data: how many times patients visit the ER, how many times they are hospitalized, how quickly we see them when they leave the hospital and how often they get readmitted for the same condition.
It’s a whole new way of looking at our work. Our perspective has moved from a string of one-on-one encounters that are the traditional lifeblood of medical practice to an aerial view of the whole enterprise. It makes me feel like an Apollo astronaut seeing the earth from above for the very first time. It’s an inspiring view.
