MDNews - Central New York

compromising the services delivered to our popula- tion of highly complex patients." FILLING GAPS IN PATIENT CARE Nephrology Associates of Syracuse PC has insti- tuted or expanded a number of protocols to streamline and facilitate the referral process and enhance access to specialists. In March 2015, the practice launched a pilot transitional care management service aimed at preventing readmission following hospitalization for chronic kidney disease or any illness, such as pneumonia, that may impact kidney function — a paramount factor in both managing healthcare- related expenses and ensuring proactive patient care. As part of the program, follow-up visits with a physician or mid-level provider are scheduled within one to two weeks of patient discharge. The practice also partners with HealtheConnections, the Regional Health Information Organization (RHIO) of Central New York, to receive electronic alerts when current patients are discharged from a local hospital. A nurse then reaches out to patients once they are home to ensure they have the support and resources necessary to successfully manage their condition. The practice's physicians have privileges at Crouse Hospital and St. Joseph's Hospital Health Center and share rotating on-call responsibilities at each facility, ensuring patients have ready access to a nephrologist. The practice's courteous sta• collaborates daily with the hospitals to coordinate care to meet the changing needs of patients. "Working in the hospitals allows us to provide a better continuity of care, which is particularly impor- tant for complex patients," says Philip Ondocin, MD, nephrologist and certified hypertension specialist at Nephrology Associates of Syracuse PC. "We per- form thorough sign-outs on a weekly basis because the hando• of care can be the weakest link in the continuity-of-care chain." Nephrology Associates of Syracuse PC's team of physicians and mid-level providers makes rounds at six local dialysis centers where patients' condi- tions are closely monitored and managed. There is ongoing collaboration among the practice's sta• and the dialysis center sta•, who all focus on meeting the needs of the patients. The practice also o•ers access to nephrolog y care on a monthly basis at satellite locations in Auburn, Fulton, Oneida and its newest location in Camillus. Additionally, the practice has a collaborative relationship with State University of New York (SUNY) Upstate Medical University's kidney transplant team. The two teams of providers work together to identify patients who may be candidates for kidney transplantation and to coordinate pre- and post-transplant care. ADVANCED TECHNOLOGY ENHANCES CONNECTIONS In May 2012, Nephrology Associates of Syracuse PC implemented eClinicalWorks' EHR system. To ensure the practice maximizes the potential patient and provider benefits of EHR, sta• members and physicians have remained apprised of technologi- cal advancements by instituting regular updates, including the ability to share data with physicians at other facilities. In the current era, patients — especially those who are enrolled in health plans with high cost-sharing requirements — expect to play more active roles in their health care. The eClinicalWorks' EHR system contains a patient portal so patients, as well as their spouses and adult children (with permission), can access health records and laboratory test results, send secure, non-urgent messages to the o¬ce, request prescription refills, and request appointments. With the help of the RHIO of Central New York, Nephrolog y Associates of Syracuse PC is a lso tackling the challenge of interoperability, which " Instead of avoiding the changing tide in health care, we have delved into the changes because we believe knowledge is power. We educate ourselves so we can best respond to these challenges in a meaningful way that benefits our patients and partners. Our No. 1 priority is to provide quality care, while also collaborating fully with our physician and facility partners." • ANNE ZACCHEO, MBA, PRACTICE DIRECTOR OF NEPHROLOGY ASSOCIATES OF SYRACUSE PC ADEBOWALE O. OGUNTOLA, MD PHILIP T. ONDOCIN, MD M D N E W S . C O M /// M D N E W S C EN T R A L N E W YO R K ■ 2 016 0 7

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