Comments:

Bob Dent
Wednesday, April 19, 2017

Hello Stefani,

Thank you for your comment! We have a team of case managers, social workers, hospitalists, and others who meet daily to review at risk patients. There are many metrics we use to provide the right care to the patients. The nurses, as part of the care team, are included. Together, they all should have a clear understanding of the patient's goals. We have seen improvements in some of our metrics after we began our Transition Care Team. We are always looking to improve, however.

Stefani Daniels
Monday, April 17, 2017

Midland is to be applauded to promoting a ulture of safety. I wonder however, if it extends to your case management program and the care coordination activities by your care managers.Are they organized to follow at risk patients longitudinally to advocate for patients and reduce excessive or wasteful medical interventions? Are they promoting timely delivery of care to reduce patient's exposure to iatrogenic risk? Are they making sure every care team member understands each patient's goals and working together for a timely transition? IF the answer is yes, then congratulations...it appears you are maximizing the skill-set of a successful care manager in today's value based marketplace.

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