Follow-up Calls Keep TMC Patients Connected and On Track

As Tucson Medical Center launches an innovative model of health care delivery designed to help patients stay healthy and out of the hospital, Kathy Arnold might be considered something of a forerunner.

For the past three years, the woman responsible for post-hospitalization support in the Senior Services division has been calling patients after they leave the hospital to make sure they are on track with the instructions they received when they left TMC’s care.

That’s likewise a big theme with the recently authorized accountable care organization, Arizona Connected Care, and its focus on providing a cohesive continuum of care to make sure patients don’t fall through the cracks during the time between visits to their providers.

Arnold last year followed up with 1,086 patients.

She has to be targeted in her contacts, with more than 200 people a week over the age of 65 being discharged from TMC. She doesn’t call folks affiliated with Saguaro or New Pueblo physicians groups, since they do their own follow-up with patients. She doesn’t call those referred to hospice and she doesn’t call people who have already received services from TMC’s chronic disease coordinators.

With an aim toward touching base with patients who are at risk for readmission, she looks for elderly patients who live alone and don’t have a strong support system. Long hospital stays or multiple stays are red flags, too, as are chronic conditions.

Arnold will call and see how they’re doing with their discharge instructions – if they were able to get the appropriate medication, or make their next therapy appointment, or pencil in an appointment to see their primary care doctor. In some cases, she’s able to help patients get in for appointments more rapidly. In others, she is able to provide information on transportation options or refer them to some of the free support groups and educational classes offered through Senior Services.

In one recent case, Arnold said she called a woman who really liked the TMC pharmacist who gave a detailed explanation about her medication. The woman wanted to talk to the pharmacist again for a follow-up question. Arnold was able to connect that patient with pharmacy.

“I think it’s really in line with the after-care you’re hearing about,” Arnold said, noting her role parallels the goal of the new accountable care organization to ensure stronger coordination among providers to help patients stay on the road to recovery.

 “It’s a relationship you build on while the patient is in the hospital,” Arnold continued. “That discharge period is very critical. It can be confusing for patients, so it’s really key to have the follow-up. In fact, the more we have, the better.”

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Tucson Medical Center | 5301 E. Grant Road | Tucson, Arizona 85712 | (520) 327-5461
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