How a new transitions model helped one patient

After discharge it has often been up to the patient to adhere to medication regimens and alert their physician to any complications or confusion, but patients don ’t always have the tools or circumstances to make this an easy task. Learn how a new transitions model helped one patient take charge of his health and better understand and adhere to his care plan. TheSafeMed model was developed at the University of Tennessee in partnership with Methodist Le Bonheur Healthcare in Memphis. It was designed with the strengths of primary care in mind and relies on a collaborative team effort from physicians, pharmacists, nurses and community health workers to form a support network for high-risk and high-needs patients as they transition from the hospital to the outpatient setting.Helping one patient take charge of his health Mr. S had multiple chronic conditions —coronary artery disease, congestive heart failure, chronic kidney disease, hypertension, and a history of depression and cocaine use. He was initially admitted to the hospital because his automatic implantable cardioverter-defibrillator kept firing, causing severe emotional and physical discomfort. Social risk factor screening indicated that he had low to moderate social support at home. Mr. S was on Medicaid and received government disability assistance. His complex medical history and lack of social support made Mr. S an obvious candidate for the intensive care transitions services provided by the SafeMed program an...
Source: AMA Wire - Category: Journals (General) Authors: Source Type: news