Chief Primary Care Medical Officer Patient-Specific Scenarios
| Starfield Primary Care Function | Patient | CPCMO (and CPCMO-Led Team) Response to Specific Patient Scenario |
|---|---|---|
| Accessible PCP contact Care coordination Ensure comprehensiveness Maintain continuity | Woman aged 92 years with hip fracture unable to be discharged to skilled nursing facility because PCP recently retired | Leverage relationships with community PCPs and computerized PCP networking resources to identify and refer to a new PCP Provide PCP functions including admission to SNF until patient established with new PCP and first appointment can take place Ensure patient has comprehensive pain management plan and that Advanced Directive planning has been done with hospitalists, patient, and family before discharge Coordinate communication with prior PCP; ensure relevant information from prior PCP is transferred to new PCP and to SNF and that follow-up with orthopedics occurs in timely fashion |
| Accessible PCP contact Care coordination Ensure comprehensiveness Maintain continuity | Man aged 54 with meta-static cancer unable to be discharged home with hospice because has no PCP | Leverage relationships with community PCPs and computerized PCP networking resources to identify and refer to a new PCP Provide PCP functions including admission to hospice until first appointment with new PCP can take place Support hospice function as needed so that patient can be discharged home. If there is not time to identify new PCP, facilitate communication and care with hospice as PCP would normally do Stay connected to patient through the end-of-life process until and unless new PCP can be identified |
| Accessible PCP contact Care coordination Ensure comprehensiveness Maintain continuity | Child with traumatic brain injury whose PCP is not included in care during hospitalization with resultant avoidable readmission | Work with hospitalist team so that PCP can be included in family meetings Ensure that plan for specialist referrals after discharge is realistic for the family and that PCP team has the resources to support complex discharge plan Assist social workers with accurately and adequately addressing social determinants of health for the family so that social as well as medical needs are being addressed at discharge Facilitate effective discharge plan to adequately supported PCP |
| Accessible PCP contact Care coordination Ensure comprehensiveness Maintain continuity | Homeless geriatric woman with complex social and health needs whose PCP is not contacted | Work with hospitalist team so that PCP is identified and contacted Engage complex care team in hospital who will follow up with intensive case management after discharge Provide assistance to hospitalists and PCP in order to facilitate systems of care for complex patients Create hospital systems for complex patients so that inpatient and outpatient care can be connected alongside frequent readmissions to acute care settings |
CPCMO = chief primary care medical officer; PCP = primary care physician; SNF = skilled nursing facility.