Danielle Snyderman, MD Brooke Salzman, MD Geoffrey Mills, MD, PhD Lauren Hersh, MD Susan Parks, MD Department of Family and Community Medicine, Jefferson University, Philadelphia, Pa danielle.snyderman@jefferson.edu
The authors reported no potential conflict of interest relevant to this article.
Establish an “action plan.” For patients with chronic, periodically symptomatic diseases such as asthma and heart failure, action planning can be useful. Action plans should include information that reinforces patients’ daily self-care behaviors and instructions for what to do if symptoms get worse. Action planning also might include simple if-then plans (“if x happens, then I will do y”), which can help with problem solving for common scenarios. Action plans have been shown to reduce admissions for children with asthma 46 and adults with heart failure when coupled with home monitoring or telephone support from a registered nurse. 16,47
Generate an individualized care plan for each patient, taking into account your patient’s health literacy, goals of care, and level of social support. This care plan may include educational and behavioral interventions, action planning, and follow-up plans. Most successful approaches to reducing readmissions have included both system-level and patient-level interventions that use an interdisciplinary team of providers. 48
Make the most of follow-up visits . The traditional 15-minute FP visit can make it challenging to provide the level of care necessary for recently discharged patients. Multiple models of team-based care have been proposed to improve this situation, including using the “teamlet” model, which may include a clinician and one or 2 health coaches. 49 During each visit, the health coaches—often medical assistants trained in chronic disease self-management skills—see patients before and after the physician. They also contact patients be- tween visits to facilitate action planning and to promote self-management.
Palliative care programs: A resource for FPs
Action plans should include information that reinforces patients' daily self-care behaviors and instructions for what to do if symptoms get worse. The growth of palliative care programs in US hospitals has helped increase the emphasis on establishing goals of care. Inpatient-based palliative care consultation programs work with patients and families to establish goals. However, after discharge, many of these goals and plans begin to unravel due to gaps in the current health care model, including lack of follow-up and support. 50 Outpatient palliative care programs have begun to address these gaps in care. 50 Comprehensive palliative care programs are quickly becoming an important resource for FPs to help address transitional care issues.
CASE › When you ask Mr. and Mrs. T about his goals for treatment, they say are getting tired of the “back and forth” to the hospital. After discussing his lengthy history of worsening CHF and diabetes, you raise the idea of palliative care, including hospice, with the couple. They acknowledge that they have had family members get hospice care, and they are open to it—just not yet. In a "teamlet" model, health coaches meet with patients before and after the physician, and contact patients between visits. The 3 of you craft an “if-then” plan of care to use at home. You schedule a 2-week follow-up visit and remind Mr. T and his wife of your office’s 24-hour on-call service.
CORRESPONDENCE Danielle Snyderman, MD, Department of Family and Community Medicine, Jefferson University, 1015 Walnut Street, Suite 401, Philadelphia, Pa 19107; danielle.snyderman@jefferson.edu
