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Doctor's Orders

Doctor's Orders

Nurse discharge instructions that sounded simple in the hospital can sometimes seem confusing when you get back home. One way to help clarify any questions that arise and monitor conditions after leaving the hospital is to visit the Care Coordination Center (CCC), which is part of the Torrance Memorial Health System.

“The CCC opened in the fall of 2012 and initially functioned as a postdischarge comprehensive care center, where high-risk patients with complex medical issues are seen within a few days of their discharge home from the hospital,” says Tauseef Haider, MD, an internist and director of the Care Coordination Center. The goals are to ensure that patients understand and are following their discharge instructions—like taking their medications as prescribed—and continuing to improve. Assessing patients and reviewing their instructions soon after discharge allows for appropriate and timely interventions to be made. “This helps to reduce the chances of patients needing to visit the emergency room or be readmitted to the hospital,” says Dr. Haider.

While the center continues to care for post-discharge patients, services have now expanded to also include the long-term care of patients with complex medical problems and providing outpatient palliative care to patients with serious illnesses. While patients considered low-risk upon discharge may only visit the center once or twice, others that are considered high-risk and have complex medical conditions visit more frequently and over a longer period of time.

“One of our top priorities is to coordinate patient care in a comprehensive and compassionate manner to promote healing and wellness,” says Dr. Haider. “Our goals are to educate patients, maximize patient satisfaction and comfort and optimize cost-effectiveness by reducing emergency department visits and hospital admissions.” The center’s staff works collaboratively with outside physicians, inpatient case managers, home health and ambulatory case managers to dramatically improve patient outcomes. In fact, the Care Coordination Center recently received a grant from the UniHealth Foundation in the amount of $602,398 to enhance its services.

Dr. Haider says that every patient sees the entire team—including a physician/nurse practitioner, an advanced practice pharmacist (for a detailed and comprehensive review of their meds) and a licensed dietitian (for understanding the importance of diet in management of their conditions). A post-discharge visit lasts 45 to 60 minutes and includes the following:

  • A brief physical exam pertinent to the patient’s medical conditions;
  • A clinical evaluation of the patient’s progress;
  • A detailed review of discharge instructions;
  • Reconciling discharge medications and optimizing drug regimens;
  • Following up on any pending lab work, imaging studies, cultures and pathology reports from the patient’s last hospitalization;
  • Ordering any follow-up labs;
  • Coordinating and facilitating follow-up discharge visits with various consultants;
  • Coordinating home healthcare, physical/occupational therapies and wound care;
  • Assisting with arranging durable medical equipment (DME) at home;
  • Identifying barriers to post-discharge care and making referrals to Ambulatory Case Management (ACM) in order to overcome these barriers;
  • Patient education and counseling regarding diagnosis, medications, progression of disease, lifestyle modifications and disease management/treatment plans;
  • Clarifying and defining the goals of care;
  • End of life discussions with palliative care patients—including filling out POLST (Physician Orders for Life-Sustaining Treatment) forms.

Dr. Haider says patient visits are never rushed at the Care Coordination Center. “Each member of our team has been carefully chosen and is passionate about this program. We believe that our service will prove to be a signature level of care for South Bay residents.”