This team, launched in October 2023, has revolutionized the progression of care from our emergency room and quickly become a best practice for not only its impact on capacity management but also the positive impact on patient outcomes and collaboration across the acute care setting as well as spanning into the larger system. This team delivers what SPHP never knew possible: a well-rounded progression of care from the emergency department. Prior to this team launch, patients would present to the emergency department and potentially be seen by a member of the care coordination department if a need happened to be identified. There was not a proactive approach to meeting patients' needs that existed to ensure the right patients were being admitted into care and the right patients were being discharged home with a comprehensive plan that involved their ER providers, primary care and/or specialty providers, as well as larger system resources. In addition, the interdisciplinary team has developed key relationships with community agencies to help ensure our most vulnerable patients have their needs met.

This team operationalized a structures process where every ER patient is discussed by an interdisciplinary team every 2 hours to ensure that each patient's needs are not only identified but met in the right setting. This team identified that there was a large opportunity to educate the ER providers as well as hospitalists about the available community services patients were eligible for, how to access them from the ER, the benefits of collaborating with not only the patient's community providers who know the patients best but also the nurse and social work case managers within medical associates to ensure proper follow up. When we ask patients where they want to be, the answer is simple: our patients want to be at home. This program allows a record number of patients who would, prior to this team launch, have been admitted to the acute care hospital where they are at risk for hospital-acquired infections, falls, pressure injuries, and debilitation to go home from the ER with all the care they need set up either in the comfort of their home or be placed in a community setting right from the ER. This team demonstrates stewardship of resources, daily, in their work.

Each month, this team sends approximately 80 patients home or to a community resource like assisted living right from the ER setting that would have been admitted to the hospital prior to launch. Since launch, more than 500 patients have been impacted by this team, their efforts and their commitment to ensuring patients remain at the right level of care, the least restrictive environment, have the services they need to heal and manage their chronic diseases and flow seamlessly through our care continuum. In addition, the relief this team provides the acute care nurses and providers by reducing the number of patients needing inpatient care is immeasurable. The integration and positive outcomes for our patients, their families and our colleagues this team has inspired, demonstrates our mission and core values in action.