Question special

Hi Dr Jain,

First off, thank you for spending your spare time with us and congratulations on your new position.

You mentioned in an earlier post, "health care reform 2.0 will be about changing our delivery system and building and scaling models of care that truly address the needs of chronically ill, sick patients". Based on your experience, how can we physicians, who naturally work on a one-on-one basis, help to improve the systematic care (both inpatient and outpatient) for these chronic, medically complex patients? As we know, avoiding re-admissions is a key topic these days.

At our hospital, we have one person who individually calls patients post-discharge to make sure they had a follow-up appointment. I have also received letters from RNs at insurance companies who call patients and try to coordinate care. How effective are these strategies and any tips for physicians-in-training?