Care Management

You've Got a Friend

Steven Peskin MD

With apologies to James Taylor, I was recently introduced to a UNC-Chapel Hill professor of psychology, Dr. Edwin Fisher, from my alma mater and the university where the famous singer/ songwriter's father was dean of the School of Medicine. The work that Dr. Fisher is doing under the aegis of the American Academy of Family Physicians Foundation is on target for the Triple Aim.

Peers for Progress, designs, implements, and evaluates peer coach or peer educator programs worldwide. There are ample examples of successful and established programs led or facilitated by peer coaches, motivators, educators, or others, including Alcoholics Anonymous, Mended Hearts, and Weight Watchers. Peers for Progress is building a global network of peer-support organizations that are making a difference in the health of and lives of people affected by a range of health problems and their associated impact on the individual and on communities.

Peer support / peer coaching is truly a winning proposition with benefits to the coached, to the coaches, to better health and health care, and the price is right!

Peers for Progress:

http://www.aafpfoundation.org/online/foundation/home/programs/education/peersforprogress.html#.UQGC26xu48Q.email

Steven R. Peskin, MD, MBA, FACP, is associate clinical professor of medicine at the University of Medicine and Dentistry of New Jersey — Robert Wood Johnson Medical School.

It's Just That Simple

Steven Peskin MD

After grand rounds this morning at the University Medical Center at Princeton, the director of the recently created transitional care program, Kathleen H. Seneca, MSN, was speaking with one of our nephrologists about the purpose of the program. It fills the transitional gap for people discharged from the hospital that do not qualify (in terms of reimbursement guidelines) for home care, but would benefit from additional education, care planning, and hands-on instruction.

The director noted that, for example, these patients might learn something as simple as recording daily weight. They might learn what to do in the event of weight gain in a person with congestive heart failure or advanced kidney disease.

Another example is the time-tested “brown bag” visit, whereby the clinician, in this case an advanced practice nurse, reviews medications — when to take them, how to take them — potentially finding duplications, medications that were to be discontinued after discharge, or ones that were to be re-initiated after discharge.

It's about time! To paraphrase the nephrologist, “I can’t tell you how many times a patient is admitted three, four, five or six times a year for the same issue” that was not properly addressed in the transition from hospital to home.

The readers of Managed Care are likely saying, “Tell me something that I don’t already know.” My point: Take action! It really is just that simple.

Steven Peskin, MD, MBA, FACP
Executive Vice President and Chief Medical Officer
of MediMedia, USA, which publishes Managed Care