“A patient with some social determinant issues just moved to the area and after having a hard time accessing necessary services, he wound up hospitalized,” says Katelyn Richburg, LPN Case Manager at the Center for Disability Services. “I happened to look at the emergency department report in Hixny while the patient was still in the emergency room and was able to reach out to our hospital navigator, who connected the patient to services in the hospital and after discharge.”
For Richburg, that’s just one example of the edge Hixny gives her in coordinating care for her patients, many of whom have multiple health conditions that require constant attention.
“Just having access to hospital documents is a huge help. We still have some issues with providers formatting information in ways we can use, but without Hixny, we wouldn’t have any of the information,” she explains. “It’s a data portal, so what we get out is only as good as the information that’s put in. We’re at least able to use it to get the kernel of information we need to be able to follow up and collaborate with peers.”
Lifestyle Plans and Follow-Up
Richburg has been using Hixny reports for the last 10 months to support her role in conducting hospital and emergency department (ED) follow-ups within 24 hours of discharge. She coordinates as many as seven transitions of care each week, many of them early on Monday mornings or after 4 p.m. on Fridays—times when it’s difficult to reach peers at the transition facilities—so the reports are critical to making informed decisions about continued care.
In addition, she receives referrals from primary care providers for patients who have high rates of ED visits and hospitalization. Sometimes the requests are based upon social needs that require attention. In both cases, Hixny’s inpatient and ED reports offer her red flags that patients may need more support than what they are receiving.
Whether for patients with diabetes or other chronic care needs, part of this support for Richburg is creating a lifestyle plan with the patient. This may include setting attainable goals like reducing weekly take-out meals from three to two. Conversations like this are based in part on information available through Hixny, such as the number of times the patient has been in the hospital, their risk factors and their routine labs.
To follow their progress and manage continued care for many of these patients, Richburg makes contact in person or by phone at least once a month for at least 20 minutes. To prepare for these calls, she gathers the labs from other facilities for each patient using Hixny and will even use the health information exchange to make sure that any of the patient’s other providers also have access to that information.
Beyond the Clinical Setting
“I followed up with another patient from the ED report who was admitted to the hospital and then transported,” Richburg says. “His needs outweighed the services he was receiving, and I was able to connect him to the housing authority. Now that his housing is stabilized, he has regular access to healthier foods, is eating better and has made it to all of his appointments with me. He’s only been back to the ED once—and that was for a valid medical reason.”
The most important thing, Richburg says, is that more people need to use Hixny to increase the quality and quantity of data available to all: “It’s only going to support better for care for everyone.”
