The key area of focus over the last 6 months for the clinicians at UpStream has been on Care Team Activation.  Care Team Activation is at the core of the UpStream Model of care.  The unique skillsets of our clinical care team each offering their perspective and brining their expertise to the care of our patients.  

At UpStream when we say Care Team Activation we mean: Integrating ‘who the patient is and what the patient needs’ with the team member who can most meet the patients’ current and future needs. Maximizing the talents, experience, and education of each team member and ensuring each care team member is operating at the top of their licensure or certification and while engagement with PCPs and patients.  Equipping our care teams with the clarity, resources, and metrics needed to drive the right care, at the right time, to the whole patient. Today we are bringing, Care Activation to life across many of our teams. Several teams in North and South Carolina are implementing care in this manner.  

The following patient scenario is our Care team model coming to life.

In South Carolina, a currently enrolled CCM patient who was admitted to the hospital in July and discharged home the next day. The reason for admission was hypertensive urgency and syncope. Post discharge, the patient had a syncopal episode at the bus stop on the way to his cardiac appt. When he got there, they did an assessment and direct admitted him to MUSC.  Again, the patient was discharged and the UpStream CRN planned a visit to his home the same day as his discharge to home.   

The home visit was on a Friday afternoon. During the nursing post discharge assessment in the home, the patient notes he had been having symptoms for quite some time but did not tell any family as he did not want to burden them. The patient’s wife was able to join the nursing visit.  The UpStream CRN took time during the home visit to offer education and shared the importance of discussing medical issues with family.  The CRN highlighted the need for getting prompt care and educated the patient and wife on signs and symptoms for early intervention.  The nurse taught the patient and wife what to look out for that would warrant a visit to the MD.  

Part of the CRN’s work is to help identify abnormal assessment findings and elevate those to the care team for action. During his visit, the patient expressed a significant headache with intermittent vision disturbance and pressure. The patient had a history of HTN, A-fib, DM, CHF, and CAD. During the visit, he was hypertensive and hyperglycemic. The CRN attempted to contact the PCP during the visit but had no success.  While in the home, the CRN was able to get ahold of my Clinical Pharmacist, who gave recommendations on an insulin dose which the patient administered.  The CRN stayed in the home and re-checked again in 30 minutes and it was higher, so the Clinical Pharmacist was reconsulted and another insulin dose was administered. During this time, another call was made to the Primary Care team but with no luck reaching the Physician. With the weekend coming, the CRN was concerned about a stroke for this patient and wanted to speak to the physician. The Clinical Pharmacist was again tapped and gave recommendations to add a small dose of BP med to current regimen to hold the patient over until Primary Care visit the following week.   

The CRN wrapped up her visit after almost 3 hours in the home and the patient was safe and in no distress.  The CRN’s work was not done yet after the visit ended.  The CRN left the home to finish the coordination from out in the field. The Primary Care physician did return the call to the CRN, took the assessment findings and was very grateful for the action taken in the field.  The Primary Care physician did make a recommendation for a new HTN medication for the patient.   

The CRN returned a call to the patient to advise that he needed to pick up his new med and re-counseled on signs and symptoms to look out to prevent readmission. The following Monday, the UpStream Health Concierge called the patient and did a thorough check on patient’s status.  The patient reported blood pressure was better controlled since starting the additional med and symptoms were resolving.  

The patient did keep his post discharge visit with the Primary care team and was found to be hypertensive at that time. The patient did have his Therapeutic Work-Up Completed by his Clinical Pharmacist later that week.  The CP did advise medication changes to address hyperglycemia and HTN which the Primary Care physician agreed with.  The Clinical Pharmacist is following up weekly with the patient. 

The CRN and HC continue to work on SDOH issues identified on the nursing assessment related to illiteracy and are working together to solve these problems for him in the future.