ACO Care Management Team huddles are held every morning for the team to collaborate on patients identified in their panel. Every team member is involved in the care. A patient with a mobility disability with multiple hospitalizations, felt unsafe living at home due to complicated family issues. The ACO team worked with the in-house case manager, made a home visit with the ACO social worker and thereafter did much collaboration with the personal care attendant, family member, friend and home care agency. The nurse worked with the PCP who shed additional information on the patient's mental status. They worked with ED staff and hospitalist to ensure a psych evaluation to identify mental status issues. Complex care rounds were held and a plan devised to ward off readmission. The ACO Care Manager continues to monitor the patient at home.
The ACO Care Management Team:
Kathy Seville, MSN, RN-BC
Melissa King, Quality Care Specialist
Liz Toabe, Pharmacist
Sheila Shelley, BSN, RN
Kathleen Beyerman, RN, NE-BC, EdD, Director
John Davis, LICSWCCM,Social Worker
June Mayo, MSN, AE-C, RN
Susan Powers, RN, MS
Judy Dyer, MA, MSN, RN