The Heart of Care: Navigating Post-Discharge Care Gaps During a Pandemic

May 1, 2020

"Sharon" was back home after a hospitalization for COVID-19-like symptoms. She had tested negative for COVID-19, but her respiratory symptoms persisted. More than 48 hours after discharge, she was still waiting for a nebulizer to be delivered and for her prescription to be filled at the pharmacy.

Sharon was feeling understandably anxious when she received a routine post-discharge call from Alison Stern, a care management coordinator with Evolent. This follow-up conversation revealed the gap in care, which could potentially lead to an emergency department visit or readmission if not treated.

Alison notified Linda Cassidy, a disease case manager who promptly reached out to Sharon, then made a flurry of calls to Sharon's primary care practice and durable medical equipment (DME) suppliers. She uncovered the source of the problem: The medication had not been prescribed, and the nebulizer prescription went to the wrong DME company. After additional calls, Linda was able to coordinate with the doctor's care team to get the nebulizer and medicine to Sharon.

The following day, when Linda called Sharon, she was already feeling healthier and stronger.

"It meant a lot to this member that someone cared about her," Linda recalled. "I think it gave her reassurance that even after discharge, there's a team in her corner, still working for her and pulling for her."

Alison and Linda's proactive outreach not only helped Sharon get her prescriptions filled, but they engaged with her again days later when her temperature rose. Linda encouraged Sharon to first reconnect with her doctor's office by phone in order to follow safe social distancing measures.

For Linda, this case reinforced the value of post-discharge follow-up work—particularly during a national health emergency. There may often be "something after discharge that doesn't fall into place," she said. "This was a good reminder of why the work we're doing is so important."

​About The Heart of Care
Every day, members of Evolent's care management teams use their clinical expertise and problem-solving skills to help individuals overcome serious health challenges. The Heart of Care series tells stories from the field that highlight their dedication to patients. For more information, see the blog post by Evolent CEO Frank Williams.
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