By identifying the socioeconomic drivers for this 54-year old man’s readmission and the best interventions based on his individualized needs, the care team stopped the progression of the man’s deep vein thrombosis to a pulmonary embolism.
A 54 year old man was discharged from the hospital diagnosed with Deep Vein Thrombosis (DVT) and placed on an anticoagulant. At admission, the man was flagged as a high risk for readmission due to multiple diverse factors but, especially relevant were two socioeconomic factors – poor transportation and low household income. One of the top recommended interventions for this patient was a follow-up visit to his PCP following discharge. However, three days later, the patient arrived late to his follow-up appointment. While discussing the plan of care with the patient, the physician learned that the patient had arrived by taxi and did not fill his Eliquis prescription because he couldn’t afford his medication. The physician confirmed progression of the DVT and the risk of progression to a pulmonary embolism. Noting the socioeconomic risk factors, the physician enrolled the patient in a Drug Assistance Program. The anticoagulant prescription was started, and this patient avoided a potentially severe readmission.
If the Jvion insights were taken into account and the individualized recommended interventions were actioned upon by case management before the initial discharge, this patient would have had the resources available to fill his prescription and transportation could have been arranged for his follow up appointment. The physician on this case mentioned that this was a “near miss” and he was fortunate that he did make his follow-up appointment via taxi, where other patients would not have been as fortunate.