Case Management Focus on Care Transitions Helps to Halve 30-Day Medicare Rehospitalizations

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.

Melanie Fox will describe how Caldwell UNC Health Care’s managers embedded in primary care practices and work sites are improving the quality of care and reducing healthcare costs during a September 25, 2014 webinar, Embedded Case Management in Primary Care and Work Sites: Referral, Stratification and Protocols, a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 12:00 minutes

BCBSM Specialists Warm to Outcomes from Care Coordination Collaborations

Although initally challenging, the engagement of specialists in Blue Cross Blue Shield of Michigan’s medical home program generated several outstanding primary care-specialist collaborations that improved care coordination and reduced unnecessary utilization and spend related to difficult-to-manage patients, notes Donna Saxton, field team manager for BCBSM’s value partnerships program.

A pioneer since 2005 in the development of outcomes-based measures to evaluate patient care, BCBSM based its standards on the Chronic Care Model. Today, the payor acts as a resource for other medical home recognition and accreditation efforts.

Donna Saxton share details from its PCMH designation requirements and the system of rewards and incentives that has produced results for the plan, the PCMH practices and its members during an April 30, 2014 webinar, Generating Medical Home Savings and Quality Improvements Through Outcome-Based Measures, a 45-minute program sponsored by The Healthcare Intelligence Network, now available for replay.


Length: 4:31 minutes

Navigating Patients Pre-Discharge on Care Transitions

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.

Josh Luke, Ph.D., vice president of post acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative, shared the key features of the program during Award Winning Readmission Prevention Protocols: Navigating Care Transitions with Preferred SNF and Home Health Providers, a 45-minute webinar on January 8th, 2014, at 1:30 pm Eastern.


Length: 12:55 minutes

Assessing Readmission Risk to Prioritize Home Visits for Complex Patients

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.

Samantha Valcourt shared how Stanford’s Coordinated Care uses a home visit assessment to improve care transitions post-discharge during a December 19, 2013 webinar, Home Visits: Assessing Complex Patients Post-Discharge To Reduce Readmissions.


Length: 6:28 minutes

Medicare Pioneer ACO Year One: Lessons from a Top-Performer

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.


Length: 14:03 minutes

Empowering Patients Toward Self-Management To Reduce Readmissions

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.

Ms. Goroski shared lessons learned from the 14 communities that participated in the CMS care transition demonstration project and details on program rollout to over 12 million Medicare beneficiaries in 400 communities during a May 22, 2013 webinar, now available for replay Patient Engagement and Provider Collaborations Across the Healthcare Continuum to Improve Care Transitions.


Length: 5:42 minutes

Bending the Cost Curve with a Commercial Value-Based Payment Contract: A Case Study from Advocate Physician Partners

A value-based contract between Advocate Physician Partners (APP) and Blue Cross Blue Shield of Illinois (BCBSIL) has reduced inpatient admissions and emergency room visits and has bent the cost curve after its first year. In this interview, Dr. Carrie Nelson, APP’s medical director for special projects, describes how APP’s eight-year clinical integration of 4,000 physicians and 10 hospitals has laid the groundwork for this value-based contract.

Dr. Carrie Nelson presented during Bending the Cost Curve with a Commercial Value-Based Payment Contract: A Case Study from Advocate Physician Partners, a 45-minute webinar on July 18, 2012, now available for replay, during which she shared lessons learned from the first year of implementing the value-based contract between APP and BCBSIL. APP’s clinical integration program is described in detail in Case Study in Clinical Integration: The Advocate Physician Partners Experience.


Length: 4:14 minutes

Geisinger Reduces All-Cause 30-Day Readmission Rates Through Remote Monitoring Program

Geisinger Health Plan reduced the relative risk of all-cause 30-day readmissions by 44 percent compared to a matched control group using an interactive voice response (IVR) system developed by AMC Health. The IVR system targeted patients who were at high risk for readmissions following a hospital discharge. Care managers identified those complex patients that were at high risk for post-discharge complications that could lead to a readmission, explained Dr. Maria Lopes, chief medical officer at AMC Health.

The IVR system makes one call per week for four weeks, using branching logic to identify issues with medication adherence, PCP follow-up, and complications, as well as a risk and falls assessment. The program is integrated into the care management workflow to make this impact, she added.


Length: 11:07 minutes

Reducing Readmissions Through Multi-Disciplinary Post-Discharge Support

To achieve the lowest rates of readmissions in its history, HealthCare Partners Medical Group of California first identifies patients at high risk for readmission. HealthCare Partners corporate medical director Dr. Stuart Levine describes HCP’s four key strategies to risk-rank patients and suggests proactive measures to limit the number of individuals who are rehospitalized.

Dr. Levine discussed HCP’s approach to hospital readmissions during, Reducing Readmissions Through Multi-Disciplinary Post-Discharge Support, webinar on May 18, 2011 now available On-Demand via the Web or on DVD or CD from the Healthcare Intelligence Network.




Length: 3:19 minutes

Identifying Functional Decline in Chronic Care Patients To Reduce Preventable Healthcare Utilization

Functional decline in an elderly person can be the first indicator of a chronic condition ready to snowball out of control. Patricia Zinkus, director of case management at Fallon Community Health Plan, and Susan Legacy, FCHP’s senior manager of case management, describe how their collaborative multidisciplinary intervention monitors for these changes, and why the program’s social component is just as critical as home visits and case management outreach.

Ms. Zinkus and Ms. Legacy shared details from FCHP’s risk-sharing model during Identifying Functional Decline in Chronic Care Patients To Reduce Preventable Healthcare Utilization, 45-minute webinar on April 27, 2011.




Length: 3:26 minutes