Under the leadership of Dr. Deepali Sen, the multidisciplinary team, Team PHV: Waleed Ali, MD, Brendan Lally, MSW, LCSW, Andrew Robinson MSW, LCSW, Ashley Poore, Patrice Odom, Jessica Seal, Kelly Nessel MBA, has helped hospitalized patients transition to outpatient care in rheumatology clinic.
With the addition of Brendan Lally MSW to the group, the team has been able to provide discharged patients with social work screening and assistance with barriers to care. Transitional interventions also included placing a medical assistant call within a week to establish early follow up. These interventions have shown significant impact, recent analysis show patients who received phone call within 1 week had a four-fold higher chance of follow up within 1 month. Patients who received social work screening showed higher rates of follow up even at 6 months post intervention.
Team PHV helps patients with continuity of care. Long term impact on clinic follow up seen with social work intervention post hospitalization. The rheumatology division has focused on transition care interventions after hospital discharge since 2021.
These interventions have shown significant impact, recent analysis show patients who received phone call within 1 week had a four-fold higher chance of follow up within 1 month. Patients who received social work screening showed higher rates of follow up even at 6 months post intervention.
Patient testimonials reveal the impact that the program has on their lives.
“By being able to get to my doctor appointments I have been able to focus on my overall health both physically and mentally. My experience by having transportation assistance took away the worrying about getting to see my doctors and allows me to focus on my overall health”
“The transportation and case management I have received have helped me so much. The transportation has helped me to make it to my doctor appointments in a timely manner. The case management has helped me to stay healthy and to stay home, and to stay out of the hospital. I am thankful for these services and truly appreciate them.”