Although Ochsner Health System’s Care Coordination Center (C3) applies consistent methodologies across nine hospitals, one protocol—C3’s attention to two new transition care management (TCM) codes—is scalable for most care coordination efforts, regardless of panel size, suggests Mark Green, system AVP, transition management, at Ochsner Health System.
In this podcast, Green offers more care coordination lessons adaptable to any size player in the healthcare market, and describes the “tipping point” in terms of patient population and assumed financial risk that triggered the creation of C3.
Caldwell UNC Health Care case managers embedded in primary care practices take patient follow-up seriously, calling 90 percent of individuals who visit the ED and almost all discharged from a hospital stay, explains Melanie Fox, director of the Caldwell Physician Network Embedded Case Management program at Caldwell UNC Health Care. In particular, connecting with the recently discharged has helped her organization to reduce 30-day rehospitalizations from 19.16 percent in 2012 to 9.69 percent in 2013. If that crucial transition of care is well managed, all other goals for the patient should fall in line, she notes.
In this audio interview, Ms. Fox describes the 12-point checklist for the recently discharged and offers advice on engaging providers and staff before the case manager even settles in at physician practice.
With hospital readmission rates under close scrutiny by CMS, Torrance Memorial Health System launched a readmission program in early 2013 that has been recognized as a program of excellence for its innovation and impact on the community. Navigators work with patients prior to discharge from the hospital to educate them on the hospital’s Care Transitions program, which includes a network of Skilled Nursing Facilities, or SNF’s and one home health agency. And once the patient is discharged, ambulatory case managers keep watch on the patients after the 30-day penalty phase is over.
Modifying a popular hospital admissions risk assessment tool for its own use helps Stanford Coordinated Care to prioritize home visits for its roster of high-risk patients, all of whom have complex chronic conditions, explains Samantha Valcourt, MS, RN, CNS, Stanford’s clinical nurse specialist. Stanford’s HARMS-11, based on Iowa Healthcare Collaborative’s HARMS-8 hospital risk screening tool, looks at individuals’ utilization, social support and medication issues, among other factors, to measure a patient’s risk of readmission.
The resulting home visits, a critical component of Stanford’s care transitions management program, help to uncover health challenges the complex chronic patient may still face, including four common medication adherence barriers Ms. Valcourt describes in this interview.
Lauded for its care coordination service, Monarch had to overcome a few challenges when retrofitting the Naylor Transition of Care (TOC) model for the ACO among them insufficient patient access, patient skepticism and resource limitations. By focusing on readmissions reductions and four disease management conditions ESRD, COPD, CHF and diabetes and creating a care coordination team that included the newly created care navigator, case managers, and pharmacist, the organization has improved patient compliance, reduced negative drug interactions and hospital days and improved patients access to community services.
During Medicare Pioneer ACO Year One: Lessons from a Top-Performer, a September 18th webinar at 1:30 pm Eastern, Colin LeClair, executive director of ACO for Monarch HealthCare, shared first year lessons from its Medicare Pioneer ACO experience, how it evolved in year two and the impact on its organization’s participation in other accountable care organizations.
When tracked within its electronic medical record, key interventions like transitional care coaching and an expanded Patient Health Questionnaire not only improve the care provided to John C. Lincoln ACO’s population but provide a clearer picture of the accountable care organization’s performance, note Karen Furbush, business consultant, and Heather Jelonek, chief operating officer of the John C. Lincoln Network ACO.
Additionally, the ACO’s Physician Advisory Network, made up of its leading physicians, tracks patterns and trends within the ACO and helps the care team to adhere to best practices in evidence-based medicine. Monthly webinars with the physician advisory network and its EMR specialists provide opportunities for evaluation and training in these best practices. Karen Furbush and Heather Jelonek shared how the John C. Lincoln Network ACO has modified its reporting process, from workflow changes to customizations within its EMR to improve performance results during a July 17, 2013 webinar, Performance Quality Measurement and Reporting for Accountable Care, a 45-minute program sponsored by The Healthcare Intelligence Network.
To rise to the challenge of non-compliant patients, providers should ask how they can work together to empower patients toward self-management rather than why patients are non-adherent in the first place, suggests Alicia Goroski, MPH, senior project director for care transitions for the Colorado Foundation for Medical Care (CFMC). CFMC coordinates the work of state-based Quality Improvement Organizations (QIOs), who have been working with hospitals and community providers to improve care transitions and reduce readmissions.
In this interview, Ms. Goroski describes some of the interventions focused on patients, providers or both groups that have not only lowered key Medicare readmission rates but also reduced participants’ overall admission stats.
The initial goal of Cullman Regional Medical Center’s “Good to Go” program was to reduce readmissions. But CRMC didn’t anticipate the effect that recording discharge instructions and sharing them with patients via phone and computer would have on the patient experience. Cheryl Bailey, CRMC’s vice president of patient care services, talks about the unexpected benefit of the award-winning initiative, the minimal investment required to get “Good to Go” off the ground, and planned expansion for the initiative that is bridging the patient communication gap.
Ms. Bailey, along with Joshua Brewster, director of care management at Regions Hospital, a HealthPartners hospital, shared the key features of their care transition management programs during an April 24, 2013 webinar, Care Transition Management: Strategies for Effective Patient Handoffs, a one-hour program, now available for replay, sponsored by The Healthcare Intelligence Network.
Geisinger Health Plan’s successful Transitions of Care program is the health plan’s response to rising rehospitalization rates among Medicare patients, a major concern of both CMS and private payors. Geisinger Health Plan’s Doreen Salek defines the transition teams’ key area of focus when providing a “clean and clear handoff” of a patient from one care site to another, with the goal of avoiding readmission to the hospital. The health plan’s director of business operations of health services also defines the plan’s ideal home health partner, its blueprint for a universal plan of care to improve care coordination and expectations for patients and their families and caregivers.