How teamwork helps our patients recover comfortably at home

Meet the teams who work to smooth the process for care

A Florida patient wasn’t aware of the meetings, phone calls and coordination between team members it took to make sure he rested at home comfortably with the oxygen he needed. And he never will be.

The process that resulted in the patient’s comfort is because of the team of professionals who made it happen. They are the physicians, hospitalists, care managers, medical directors and other clinic- and hospital-based team members who come together each week for Patient Care Coordination (PCC) meetings discuss patients who are hospitalized, or at risk of hospitalization.

The team rates patients’ risk of hospitalization risk on a scale of 1 to 5, with 5 being the highest risk. In these 1-hour, weekly meetings they also identify patients who may need hospice care or discussions on end-of-life care. These meetings are held in the Orlando and Tampa regions.

PCC meetings, which began in January 2025, help patient care not only by greater collaboration on treatment strategy, but also by connecting people who might have otherwise met in person, said Jay Ranawat, MD, associate medical director for hospitalists in the Orlando region. “That’s been a side effect – and a positive effect,” he said.

The case of the patient who needed oxygen is a textbook example. The patient, who had been discussed at previous PCC meetings, came to the Optum Park Avenue clinic in Apopka, Florida, for a late afternoon acute-care visit. His chronic obstructive pulmonary disease (COPD) symptoms had suddenly become worse.

The patient received steroids and nebulization, but his blood-oxygen remained at 80-85% on room air during minimal exertion – a healthy blood-oxygen level is at least 95%.

To allow the patient to recover at home, he would need an oxygen tank. The clinic had loaned him a tank, but the oxygen was running out, so the clinic needed to get him more almost immediately. That’s where the PCC paid off.

How the team got the patient what he needed

The patient’s provider asked to have the referral coordinator follow up on the request for oxygen – but the medical supply company said it couldn’t deliver the oxygen for a number of days. That is when Claudia Velez, the clinic administrator, reached out to others on the PCC for help. One suggested she talk to Rene Hamm, an acute care transitional nurse, who is part of Dr. Ranawat’s hospitalist team.

Rene had connections inside the medical supply company from previous experience. She found the right person, who put in an order so the patient received his oxygen that night and avoided hospitalization.

“I want to congratulate both Claudia for reaching out and Rene for going above and beyond,” Dr. Ranawat said. “This is how office-hospitalist collaboration should happen.”

Why the Patient Care Coordination team made a difference

Having the PCC in place helped make the office and hospitalist teams aware of the needs of this patient – and aware of each other. That helped a problem get solved without the patient ever realizing how close he was to hospitalization, rather than going home to recover.

“The PCC allows all the different parties to know what’s been tried, and get different opportunities to participate in care,” Rene said. “It gives everybody a clarification about what is happening with patients and get to know everybody who is working with them. You get more comfortable with everyone. You become a face, not just a name on an email.”

“We know we’re not alone and working in our own bubble,” Claudia said. “We think we’ve done everything, but when we connect with people in other roles, we get more ideas, together, about what we can do to give the best care to our patients.”