2021 has been designated as the International Year of the Health and Care Worker
by the World Health Organization
. The designation is in appreciation and gratitude for the unwavering dedication in the fight against the COVID-19 pandemic and to highlight the key role of human resources for health in society’s ability to care for the health of its citizens at the global level.
At Caravan Health, we want to recognize the many layers and multiple levels of people who work tirelessly to benefit their patients and communities. Caravan Health client, Knox Community Hospital, understands that quality health care takes a team and in honor of the Year of the Health and Care Worker, this month we are highlighting their success in value-based care.
Located in Mt. Vernon, Ohio, Knox Community Hospital (Knox)
serves its community with a wide range of services through their Joint Commission-accredited hospital. Knox has been with Caravan Health since 2016 and participates in the Collaborative ACO.
A common occurrence when providers make the transition to value-based care is the sharing of patient success stories. Oftentimes these stories involve a social determinant or health literacy issue that was not previously identified with fee-for-service, traditional care approaches. The patient success stories offer pragmatic proof that team-based care helps to improve patient outcomes. Recently, the staff at Knox shared an example of team-based population health at work.
A 66-year old male with an impressive history of chronic illnesses including lymphocytic leukemia, atrial fibrillation, thrombocytopenia, hyperlipidemia, diverticulitis, bilateral hearing loss, sleep apnea, and obesity. The patient had recently been admitted to the hospital with COVID-related pneumonia and treated with broad spectrum antibiotics and a variety of other medications, convalescent plasma, and supplemental oxygen.
Prior to making a call to the patient, the Knox TCM Navigator reviewed the patient’s discharge instructions and summary. The Navigator spotted a concern. The discharge summary included instructions to stop a cardiac medication due to infection. The Navigator followed up with a number of members of the collective care team and it was confirmed that the medication was to be halted, however, it was soon understood that the patient had continued to take the medication after being discharged.
Further collaboration and communication resulted in the stoppage of the medication due to heightened risk factors and the patient fully understood and complied. The patient was made aware that he was not to resume taking this cardiac medication until he received further instruction from his care team.
The experience not only resulted in the effective intervention of a patient who was continuing to take a medication that contraindicated his current health status, but it also encouraged the patient to express interest in more nurse-led support. The patient was referred to Knox’s Chronic Care Management Program.
“Our team-based approach is a foundation of the thoroughness of our patient care. With our enhanced communication we help patients not only gain access to the highest quality of service, but we also help to prevent them from falling through the cracks. Quality health care truly takes a team.”
Beth Tracy, RN
Knox Community Hospital