Gather "Round": An Integrated Care Model for the Emergency Department Multi-Visit Patient.

Autor:	Feld A; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., Carollo M; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., Freeman-Reyes J; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., McCarthy S; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., Lind MA; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., Weinstein R; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., O'Dea C; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., Joy M; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., Morley EJ; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., Aitken P; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., Schwaner R; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., Giarraputo D; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine., Heslin SM; April Feld, DNP, RN, NEA-BC, CCM, CPHQ , is the Director of Ambulatory Care Management for the Clinically Integrated Network at Stony Brook Medicine.; Matt Carollo, B.S., CPHIMS, is a Clinical Transformation Analyst for Stony Brook Medicine Information Technology at Stony Brook Medicine.; Jere Freeman-Reyes, MA, is the Assistant Director Operations and Analytics for Inpatient Care Management at Stony Brook Medicine.; Susan McCarthy, LCSW CCM , is the Director of Inpatient Social Work at Stony Brook Medicine.; Mary Ann Lind, RN BSN CMAC, ACM-RN , is the Director of Inpatient Care Management at Stony Brook Medicine.; Robert Weinstein, MS, is a Data Analyst for Ambulatory Quality at the Clinically Integrated Network at Stony Brook Medicine.; Caitlin O'Dea LCSW, CCM, is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Maria Joy, LMSW, CCM , is a Social Work Care Manager for Outpatient Care Management at the Clinically Integrated Network at Stony Brook Medicine.; Eric J Morley MD, MHA, MS, CPHQ, is the Chief Quality Officer at Stony Brook Medicine.; Paul Aitken, MD, MPH , is the Chief of Population Health and Associate Dean for Clinical Integration at the Clinically Integrated Network at Stony Brook Medicine.; Robert Schwaner MD , is the Medical Director and Chief of Toxicology for the Department of Emergency Medicine at Stony Brook Medicine.; Dominic Giarraputo BS , is a Senior Programmer Analyst in the Department of Information Technology at Stony Brook University Hospital in Stony Brook, New York. His concentration is in clinical decision support and workflow design and management.; Samita M. Heslin, MD, MBA, MPH, MA, MS , is the Associate Medical Director for the Department of Emergency Medicine and Deputy Chief Medical Information Officer at Stony Brook Medicine.
Jazyk:	angličtina
Zdroj:	Professional case management [Prof Case Manag] 2025 Jan-Feb 01; Vol. 30 (1), pp. 12-20. Date of Electronic Publication: 2024 Nov 19.
DOI:	10.1097/NCM.0000000000000756
Abstrakt:	Purpose: Emergency departments (EDs) are a vital component of the United States healthcare system and care for over 130 million patient visits annually. Nonurgent ED visits can contribute to crowding, delays in care, and adverse effects. Many high-utilizing ED patients may present with complex medical, behavioral, and social needs that are not necessarily emergent or urgent in nature. The authors created an Integrated Care Model, called the Multi-Visit Patient (MVP) program, for patients with 5 or more visits to the ED in a rolling 12-month period. The MVP program incorporated an interdisciplinary group of ED leadership and case management (CM) to identify, engage, and intervene with ED MVPs, aiming to improve their ED utilization. Patients received comprehensive screenings for depression, falls, alcohol use disorder, caregiver support, social determinants of health, and more. Based on these screenings, the CM team implemented interventions such as connecting patients with outpatient specialists and linking patients to community-based organizations to optimize stability, wellness, and reduce ED utilization. Primary Practice Setting: The collaboratively developed MVP program was implemented in the ED of a large, suburban, tertiary care academic hospital. Findings/conclusions: The MVP program identified 221 MVP patients over a 20-month period and successfully connected with 89% of them. Of these 221 patients, 78% (172 patients) chose to engage in the MVP program, with 160 completing their engagement with an outcome. Among the patients who completed their engagement and for whom the study could match separate utilization data (151 patients), the study observed a 57% reduction in ED visits. Implications for Case Management Practice: Case managers play a crucial role in the effectiveness of the MVP program by coordinating comprehensive care for high-utilizing ED patients. The MVP program includes transition of care initiatives designed to improve patient outcomes. Through screenings and targeted interventions, case managers identify and address the complex medical, behavioral, and social needs of MVP patients. This collaborative, interdisciplinary approach underscores the importance of timely and coordinated care, benefiting both patients and the health system. The MVP program exemplifies the critical role of case managers in reducing unnecessary ED visits and enhancing overall patient care. Competing Interests: The authors report no conflicts of interest. (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)
Databáze:	MEDLINE
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