In December of 2015 Jane* arrived at the Wheaton Franciscan- St. Joseph Emergency Department (ED) in Milwaukee, complaining about abdominal pain. While Jane had next-step recommendations from a previous health system's care team, she chose not proceed with the plan. After she was discharged from her first visit at St. Joseph, Jane continued to seek care there and at other EDs in the area, sometimes multiple times a day, until she was admitted, always complaining of abdominal pain.
This is just the type of case that the St. Joseph's Transitions of Care team takes on. As a part of an initiative that the hospital began in 2014, a team made up of registered nurses, social workers, and health care coordinators manages patients in the Emergency Department to provide education on the appropriate use of the ED and to assist patients with establishing a medical home. They also assist the in-patient case managers at St. Joseph with their high risk patients as well as those readmitted within 30 days.
Jane turned down the Transitions Team's assistance, and at this point, Cheryl Taylor, Director of Care Management, Renal Operations for Wheaton Franciscan Healthcare's North Market, became involved. She consulted WISHIN Pulse and found records of Jane visiting multiple EDs along Wisconsin's eastern border.
"It became clear that this patient was drug-seeking," says Taylor, "it appeared as though she was going from health system to health system."
With the collaboration of St. Joseph's inpatient care managers, Risk Management, Ethics, and the Office of General Counsel, a care plan was developed to help Jane continue with treatment in the most appropriate setting, which, in this case, was not the hospital.
St. Joseph Transitions of Care Team
Many patients arrive at St. Joseph's ED with primary-care needs
rather than emergency situations due to the lack of access to such care in low-income neighborhoods like the ones surrounding the hospital. In this situation, patients are seen by an on-staff physician and also work with the Transitions of Care team to connect with a primary-care physician outside of the Emergency Department to set up regular appointments and reduce avoidable ED visits. If team members can access the patient's health history through WISHIN, which is likely spread over several systems, they can better pinpoint the patient's primary-care needs, whether it's managing diabetes, asthma, or another condition.
"We've seen a decrease in unnecessary ED use that I think can be attributed to our Transitions of Care team but also in part to WISHIN." says Taylor. She added, "We know that WISHIN is important for data tracking and care coordination. True care coordination means having all of the knowledge on a patient, not just what's in our system."
"The investment we are making in WISHIN has value to the patient and the provider because we are able to access the whole record," Taylor states. "I am 100% on board with using WISHIN."
"It adds a layer of transparency. When I ask a patient why they were just at another ED and they try to deny it, I have the facts," explains Taylor.
Taylor looks forward to a time when more extensive patient notes, such as care plans, and behavioral health data will be accessible through WISHIN and thus will be able to automatically follow patients wherever they seek care.
"To have additional notes on how the team dealt with the patient would improve care coordination, stop duplication and it would help to hold the patient accountable."
*Not the patient's actual name.