A New Team to Help Those Most in Need

Last week I attended a meeting where I was excited to learn about the early successes of our new Complex Care practice. This team was created to help patients with repeated hospital admissions and visits to the emergency department. They work to identify and address the root causes of these patients’ high hospital utilization by creating patient-specific plans, which can involve longer, more frequent appointments, coordination with providers across multiple specialties, and access to social services.

The team is led by general internists Mark Lamos, MD, and Vaibhav A. Parekh, MD, both of whom have years of experience in managing patients with chronic disease. Nick Davenport, MSW, the social worker on the team, plays a critical role in helping patients resolve the social challenges that prevent them from getting the care that they need. Our Complex Care patients often have more than one chronic illness, which can lead to them being prescribed multiple medications. Our Lead Ambulatory Care Pharmacist, Susan Arnold, PharmD, is a valuable resource for our patients who may have trouble managing their new and existing prescriptions.

Complex Care patients are initially identified through CRISP (Chesapeake Regional Information Sharing for our Patients — the regional information organization) claims and Epic data or through direct referrals from physicians. The team first focused on patients outside of our employed primary care base but has expanded to include some GBMC Health Partners patients. If an identified patient wants to join Complex Care, the team does a thorough evaluation of his or her medical history and schedules an appointment to learn more about the patient’s current condition. They then develop a comprehensive care plan, which involves coordination across specialties and often includes a home visit. The team has quickly learned that each patient’s experience and challenges are unique, and they work incredibly hard to make sure that every patient’s needs are met.

The initial patient utilization results from before and after joining Complex Care can be seen below:

What an outstanding start! I am so proud of the team for delivering evidence-based care while also navigating the social determinants that make it difficult for patients to maximize their health and stay out of the hospital. Congratulations to Mark, Vaibhav, Nick, Susan, and their staff members for achieving such amazing outcomes for their patients!