Hospital Referral Process for MedStar s CHF Program New In home Diuresis Protocol Enrollment Process 6/15/2012
Staff to Be Involved Hospital CHF Coordinator/Liaison We would ask that your facility designate a CHF Coordinator/Liaison. This person would be the main point of contact for the MedStar CHP Coordinator. Together they would be responsible for managing the client s case file and tracking specific data sets to be reported on a monthly basis. Cardiac Caseworker This individual will be the first to identify a possible client for the program by ensuring that the client has met the minimum qualification criteria of having a history of 1 readmission for CHF exacerbation within the previous 12 months that was within a 30 day window of the original admission. The client must have an active Primary Care Physician or Cardiologist. MedStar CHP Coordinator This individual is responsible for the case management and data tracking of each referral. They will work closely with your facility s assigned CHF Coordinator/Liaison to accurately track and report the data collected on a monthly basis. 1 Page
APP/CHP Team Member This team will be responsible for completing the initial in-hospital visit and the scheduling of future home visits once the client is discharged from your facility. They will be responsible for educating the client on how to better manage their current condition and how to identify signs and symptoms of exacerbation of their disease process. With this education and frequent evaluation process, we hope to prevent the need for a readmission visit within the next 30 days of discharge from your facility. Referral/Enrollment process Caseworker identifies a CHF patient that has had at least 1 readmission for treatment of CHF related complaints/symptoms within the previous 30 days of the original admission at any time in the previous 12 months. Caseworker then verifies that this patient has an active PCP or Cardiologist that the MedStar APP can contact. We would like for the caseworker to review the patient s history and identify that the enrollment criteria of having stage 2 or 3 CHF symptomology is present before referring this patient to MedStar. Caseworker will then discuss the program with the patient. If the patient agrees to enroll, the caseworker will have the patient sign the appropriate authorization forms for your facility and when possible for MedStar as well. 2 Page
Once the patient has agreed to enroll, your facility s caseworker can contact the MedStar CHP coordinator to set up an initial in-hospital visit between the on duty APP and the patient. Caseworker should then fax over copies of the signed authorization forms and H&P with face sheet to the MedStar CHP coordinator. MedStar s CHP Coordinator will contact the on duty APP and schedule an inhospital initial visit. This visit will need to be completed within 12-24 hours of the original referral and whenever possible, prior to discharge from your facility. The MedStar CHP coordinator will enter this patient into SharePoint and scan in all hospital information provided thus far. We would ask that a caseworker notify the MedStar CHP coordinator when the patient has been discharged from your facility and fax over copies of any discharge instructions that were given to the client so that we may ensure they are followed as intended. Once notified, the MedStar CHP coordinator will have an on duty APP contact that client within 24 hours of discharge and set up or confirm an initial in-home evaluation. 3 Page
Additional Request We would like to continue to meet as a committee on a monthly basis and discuss any opportunities for improvement and any specific cases that may require further investigation or data tracking. The Data that we would like to collect on every CHF referral from you facility is: # of ER visits and Hospital Admissions for the previous 12 months prior to current admission/referral, what the presenting complaint and/or diagnosis was for each visit. We would also like to be notified of any visits while this patient is enrolled in the MedStar program and what the presenting complaint and diagnosis was and how they arrived at the hospital (EMS or POV). 4 Page