Family physician Uchenna Emeche, MD, and colleagues from MedStar Franklin Square Family Health Center in Baltimore, Md., were presented the 2019 Award for Practice Improvement from FPM journal and the Society of Teachers of Family Medicine (STFM) at its Conference on Practice and Quality Improvement in Phoenix today. The award recongizes their efforts to improve care and reduce utilization for high-risk patients through intensive care coordination.
The group identified patients who were high risk (at least two hospitalizations in a six-month period) and developed an intensive care coordination program that involved weekly phone calls, home visits by nurses, and a team approach to care for both chronic medical issues as well as social determinants of health. The multidisciplinary team included a social worker and a community health advocate in addition to each patient’s primary care physician. The program has demonstrated decreased hospitalization rates as well as decreased cost for the organization.
"Since 2015, we’ve served 114 patients. We currently have 23 patients enrolled. We’ve seen reductions in both hospital admissions and hospital charge data. Hospital charges for these patients decreased from $1,398,665 to $317,999," Emeche wrote.
FPM has partnered with STFM since 2010 in giving out the Award for Practice Improvement.
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