During February's Care Manager Forum attendees were introduced to more area resources that patients can access if they need support with basic needs like heating assistance or being able to afford their prescriptions. The United Way shared a new discount prescription card they are offering with a partnership from Family Wise. It can reduce the cost of medications by up to 35 percent and it can be used at all the major pharmacies in our area. If you are interested in learning about the discount card you can call 211.

Care managers were also interested in hearing from a local cardiologist. Alan Jansujwicz, MD, from Northeast Cardiology Associates (NECA) gave a presentation regarding treating patients with heart failure. His discussion focused on medication management of the disease, education for patients, and preventing exacerbations. He shared his knowledge in a practical approach with the care managers. "He provided us with not only a background on how the disease may affect patients, but also how to maximize the benefits of current medication regimes, the importance of educating patients and their families, and how this may apply to their everyday practice. He shared success stories from his own experience and how engaging patients in active management of their disease can improve quality of life," explains Jessica Audet, RN, care manager at St. Joseph Internal Medicine.

Care managers know there is room for improvement when it comes to providing seamless care especially during transitions from one provider to another. That's why a task force is meeting regularly to work on areas of better care coordination. Medication reconciliation is a key area they are working on improving. Care managers recently started handing out plastic sleeves for patients to put their most current medication list in. The sleeves are similar to what you would put your car insurance and registration in. "People really seem to like them - they are going like hot cakes and patients are using them at each encounter," smiles Jessica. Care managers will track the effectiveness of the medication sleeves.

Improving the transition of care for patients when they are discharged from a long-term care facility or a skilled nursing facility is also a top priority. Another task force is working directly with folks from Rosscare and Stillwater Healthcare to identify better ways to notify a primary care practice when a patient is being discharged. "We know that a patient is less likely to be readmitted to the hospital if they are seen within a three days of going home. We just don't have a very good system yet to know who those patients are quickly," shares Kathy. The goal is for the facilities to provide a weekly census of patients being discharged so that care managers can contact the patient as soon as possible.