Archive for the ‘Care Transitions’ Category

Infographic: Focus on Care Transitions to Reduce Readmissions and Boost Your Bottom Line

May 30th, 2018 by Melanie Matthews

Decreased hospital readmissions leads to improved patient outcomes, which improves brand reputation, ultimately leading to increased patient volume and market share. Reducing readmissions begins with creating a seamless care transition plan for what will happen within the hospital as well as after discharge, according to a new infographic by the Studer Group.

The infographic examines how reducing readmissions impacts a hospital’s bottom line and techniques to improve care transitions.

The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI A care transitions management program operated by Sun Health since 2011 has significantly reduced hospital readmissions for nearly 12,000 Medicare patients, resulting in $14.8 million in savings to the Medicare program. Using home visits as a core strategy, the Sun Health Care Transitions program was a top performer in CMS’s recently concluded Community-Based Care Transitions (CBCT) demonstration project, which was launched in 2012 to explore new solutions for reducing hospital readmissions, improving quality and achieving measurable savings for Medicare.

The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI explores the critical five pillars of the Arizona non-profit’s leading care transitions management initiative, adapted from the Coleman Care Transitions Intervention®.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Integrated Case Management Scripts Keep MSKCC Patient Care Team on Same Page

February 1st, 2018 by Patricia Donovan
Healthcare Scripting

MSKCC scripting improved the consistency of patient communication and staff efficiency.

To help ensure its patients receive consistent messages, Memorial Sloan-Kettering Cancer Center (MSKCC) has developed a series of scripts for use by its integrated case management team. Here, Laura Ostrowsky, RN, CCM, MUP, MSKCC director of case management, describes some scripting scenarios employed by the state-of-the-art specialty hospital.

There are a variety of ways we’ve done scripting. For example, there was a time when a case manager would meet with a doctor and the doctor would say, “I think we need to set up hospice for this patient.” The case manager then would go into the patient’s room and say, “I’m here to help you to set up your discharge plan. I know you’ll be going to hospice.”

And then the patient would say, “What are you talking about?”

One thing all case managers know is that when you go into a patient’s room, especially if someone told you they said something to the patient, you first must confirm what the patient understands about that previous conversation. If it turns out that they didn’t understand what you were told to talk about, then you don’t have that conversation. You go back to the staff member that sent you in there and discuss it. Perhaps you schedule a family meeting to discuss that issue.

We also developed scripts not only for preadmission staff, but for all staff trying to get approvals from insurers for high-cost medications and for procedures. We work with them to identify how to answer questions from the insurance company or insurance case manager so that those tasks can be handled by the doctor’s office or admitting department rather than by case management.

The approach of our length of stay reduction teams, while not exactly scripted, is concerned about consistency of message. The teams came up with the steps and planned the patient education material with the imperative that we never overestimate a length of stay, but rather err on the short side.

The imperative is that everybody speaks to the patient the same way. The case managers make a point to tell the team, “Don’t make promises we can’t keep.” That’s not exactly scripting, but it keeps everybody on the same page. For example, don’t tell a patient they are going to have plenty of help at home. Or that they will get home care and someone will be there every day, because you don’t know if that is going to happen.

Instead, you can say to the patient, “We are going to see if you are eligible for home care. I am going to send the case manager in to see you. They will check your benefits and go over eligibility. We will do our best to get you the services you need.”

Source: Integrated Case Management: Elevating Quality and Clinical Metrics with Multidisciplinary Team-Based Care

integrated case management

Integrated Case Management: Elevating Quality and Clinical Metrics with Multidisciplinary Team-Based Care details the framework and implementation of the service-based multidisciplinary program MSKCC adopted to ensure that the care it provides to more than 25,000 admitted patients each year is both cost-effective and cost-efficient.

Infographic: Medicare Home Health Beneficiaries

January 29th, 2018 by Melanie Matthews

Home healthcare patients are among the poorest, sickest and most vulnerable beneficiaries in the Medicare program, according to a new infographic by the Partnership for Quality Home Healthcare.

The infographic compares a traditional Medicare beneficiary with a Medicare home health beneficiary and factors that demonstrate why Medicare home health beneficiaries are financially vulnerable.

The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI A care transitions management program operated by Sun Health since 2011 has significantly reduced hospital readmissions for nearly 12,000 Medicare patients, resulting in $14.8 million in savings to the Medicare program. Using home visits as a core strategy, the Sun Health Care Transitions program was a top performer in CMS’s recently concluded Community-Based Care Transitions (CBCT) demonstration project, which was launched in 2012 to explore new solutions for reducing hospital readmissions, improving quality and achieving measurable savings for Medicare.

The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI explores the critical five pillars of the Arizona non-profit’s leading care transitions management initiative, adapted from the Coleman Care Transitions Intervention®.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Community Health Partnerships Can Change the Culture of Poverty: 2017 Benchmarks

November 28th, 2017 by Patricia Donovan

Community health partnerships address unmet needs, providing services related to transportation, housing, nutrition and behavioral health.

For residents of some locales, community health partnerships (CHP) —alliances between healthcare providers and local organizations to address unmet needs—can mean the difference between surviving and thriving, according to new CHP metrics from the Healthcare Intelligence Network (HIN).

“We could not survive without community partnerships. Our patients thrive because of them. They are critical to help change the culture of poverty that remains in our community,” noted a respondent to HIN’s 2017 survey on Community Health Partnerships.

Partnerships can also mean the difference between housing and homelessness. According to the survey, more than a quarter of community health partnerships (26 percent) address environmental and social determinants of health (SDOH) like housing and transportation that can have a deleterious effect on population health.

“To date, we have housed 49 families/individuals who were formally homeless or near homelessness,” added another respondent.

“Social health determinants are more important than ever to managing care,” said another. “Community health partnerships make a big impact when it comes to rounding out care.”

Motivated to improve population health, healthcare providers are joining forces with community groups such food banks, schools and faith-based organizations to bridge care gaps and deliver needed services. The majority of community health partnerships are designed to improve access to healthcare, say 70 percent of survey respondents.

Eighty-one organizations shared details on community health partnerships, which range from collaborating with a local food bank to educate food pantries on diabetes to the planting of community gardens to launching an asthma population health management program for students.

Seventy-one percent conduct a community health needs assessment (CHNA) to identify potential areas for local health partnerships. Priority candidates for 36 percent of these partnerships are high-risk populations, defined as those having two or more chronic medical conditions.

Overall, the survey found that 95 percent of respondents have initiated community health partnerships, with half of those remaining preparing to launch partnerships in the coming year.

Other community health partnership metrics identified by the 2017 survey include the following:

  • Local organizations such as food banks top the list of community health partners, say 79 percent.
  • The population health manager typically has primary responsibility for community health partnerships forged by 30 percent of respondents.
  • Foundations are the chief funding source for services offered through community health partnerships, say 23 percent. However, funding remains the chief barrier to community health partnerships, say 41 percent.
  • Forty-five percent have forged community health partnerships to enhance behavioral health services.
  • Two-thirds attributed increases in clinical outcomes and quality of care to community health partnerships.
  • Forty-four percent reported a drop in hospital ER visits after launching community health partnerships.

Download an executive summary of results from the 2017 Community Health Partnerships survey.

Chronic Care Plus for the Chronically Homeless: ‘Recuperative Care on Steroids’

September 28th, 2017 by Patricia Donovan

Chronic Care Plus is designed for ‘Joe,’ a prototypical vulnerable client and frequent hospital user who for some reason has not connected to either his community or healthcare system.

Illumination Foundation’s joint venture pilot, which began as an ER diversion project, now offers community-based stabilization following a hospital stay for medically vulnerable chronically homeless patients. Here, Illumination Foundation CEO Paul Leon describes the origins of Chronic Care Plus (CCP), which has been associated with a $7 million annual medical cost avoidance at all hospitals visited by the 38 CCP clients.

Back in 2008 when we first started, we began to realize that housing was healthcare. With many of the patients we were seeing, although we experienced great success, we ended up discharging them many times back into a shelter or into an assisted living or sober living situation. And although these options were better than being in the hospital or being discharged to the street, we knew we could improve on this.

So, in 2013, we implemented the Chronic Care Plus (CCP) program. Basically, CCP was recuperative care on steroids. It was recuperative care with more tightly wrapped social services and a longer length of stay. At that time, we began a pilot program in conjunction with UniHealth and St. Joseph’s Hospital in which we took the 28 most frequent users and kept them in housing for two years. We also brought these individuals through recuperative care, and wrapped them tightly with social services.

These efforts would eventually lead us to create our ‘Street2Home’ program, which we’re working on now. It implements more bridge housing and permanent supportive housing that is supplied not only by us but by collaboratives in the community. We are able to link to these collaboratives to take our individual, our ‘Joe,’ from a street to eventual permanent housing.

Source: Homelessness and Healthcare: Creating a Safety Net for Super Utilizers with Medical Bridge Housing

home visits

Homelessness and Healthcare: Creating a Safety Net for Super Utilizers with Medical Bridge Housing spotlights a California partnership that provides medical ‘bridge’ housing to homeless patients following hospitalization. This recuperative care initiative reduced avoidable hospital readmissions and ER visits and significantly lowered costs for the collaborating organizations.

SNF Visits to High-Risk Patients Break Down Barriers to Care Transitions

September 21st, 2017 by Patricia Donovan

For patients recently discharged from the hospital, a SNF visit covers the same ground as a home visit: medications, health status, preparing for physician conversations and care planning.

The care transitions intervention developed by the Council on Aging (COA) of Southwestern Ohio for high-risk patients starts off in the hospital with a visit by an embedded coach, and includes a home visit.

Additionally, to reduce the likelihood of a readmission, patients discharged to a skilled nursing facility (SNF) also can expect a COA field coach to stop by within 10 days of SNF admission. Here, Danielle Amrine, transitional care business manager for the COA of Southwestern Ohio, describes the typical SNF visit and her organization’s innovative solution for staffing these visits.

We conduct the home visit within 24 to 72 hours. We go over medication management, the personal health record (PHR), and follow-up with specialists and red flags. At the SNF, we do the same things with those patients, but in regards to the nursing facility: specifically, do you know what medications you’re taking? Do you know how to find out that information, especially for family members and caregivers? Do you know the status of your loved one’s care at this point? Do you know the right person to speak to about any concerns or issues?

We also ask the patients to define their goals for their SNF stay. What are your therapy goals? What discharge planning do you need? We set our SNF visit within 10 calendar days, because normally within three days, they’ve just gotten there. They’re not settled. There haven’t been any care conferences yet. We set the visit at 10 calendar days to make sure that everything is on track, to see if this person is going to stay at the SNF long-term. Our goal is to have them transition out. We provide them with all of the support, resources and program information to help them transition from the nursing facility back to independent living.

For our nursing facility visits, we also utilize the LACE readmissions tool (an index based on Length of stay, Acute admission through the emergency department (ED), Comorbidities and Emergency department visits in the past six months) to see if that person would need a visit post-discharge.

For our CMS contract, we are paid for only one visit. Generally we’re only paid for the visit we complete in the nursing home, but through our intern pilot, our interns do that second visit to the home once the patient is discharged from the nursing home. We don’t pay for our interns, and we don’t get paid for the visit. We thought that was a perfect match to impact these patients who may have a hard time transitioning from the nursing facility to home.

Source: Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients

home visits

In Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients, Danielle Amrine, transitional care business manager at the Council on Aging (COA) of Southwestern Ohio, describes her organization’s home visit intervention, which is designed to encourage and empower patients of any age and their caregivers to assert a more active role during their care transition and avoid breakdowns in post-discharge care.

Infographic: Real-Time Communication Is Key to Improving Post-Acute Care Transitions

September 11th, 2017 by Melanie Matthews

When it comes to transitions between inpatient, post-acute, and home environment settings, nearly three quarters (71%) of the NEJM Catalyst Insights Council respondents to its Care Redesign survey on Strengthening the Post-Acute Care Coordination believe that improved real-time communication is the biggest opportunity to improve post-acute transitions. Survey results are highlighted in a new infographic by NEJM Catalyst.

The infographic also examines other strategies for improving post-acute care transitions.

A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics
Concerned about escalating hospital readmissions from skilled nursing facilities (SNFs) and the accompanying pinch of Medicare readmissions penalties, three Michigan healthcare organizations set competition aside to collaborate and reduce rehospitalizations from SNFs.

To solidify their coordinated approach, Henry Ford Health System (HFHS), the Detroit Medical Center and St. John’s Providence Health System formed the Tri-County SNF Collaborative with support from the Michigan Quality Improvement Organization (MPRO).

A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics examines the evolution of the Tri-County SNF Collaborative, as well as the set of clinical and quality targets and metrics with which it operates.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

MSKCC Integrated Case Management Enhances Efficiency, But Never At Patients’ Expense

August 29th, 2017 by Patricia Donovan

MSKCC’s service-based interdisciplinary team adheres to the four C’s of team-based care.

With a reputation synonymous with state-of-the-art cancer care, Memorial Sloan Kettering Cancer Center (MSKCC) shouldn’t have much to prove.

But like most healthcare providers, with the dawn of value-based care, MSKCC began to face tougher competition from hospitals with managed care contracts and limited networks. To attract and retain payors, MSKCC had to demonstrate that its care was both cost-effective and cost-efficient.

“Under managed care, you had to be able to prove your worth,” explains Laura Ostrowsky, MSKCC’s director of case management. “And worth was more than just best care, it was best care in a quality-effective manner.”

To accomplish this, MSKCC adopted a multidisciplinary, team-based care coordination approach, Ms. Ostrowsky explained during Integrated Case Management: A New Approach to Transition Planning, an August 2017 webinar now available as an on-demand rebroadcast.

Transition planning used to be referred to as discharge planning, she noted.

Integrated case management is at the heart of MSKCC’s service-based strategy, with MSKCC case managers  assigned by service. “That means that if a case manager is based on the tenth floor, which houses breast and GYN services, and one of those patients is in the ICU, they’re still being followed by the breast or GYN case manager.”

The variety of care settings is one of a half dozen reasons integrated case management is necessary, Ms. Ostrowsky added.

Communication among all team members is key, she continued, outlining the four ‘C’s’ of team-based care—so much so that some scripting has been created to keep all team members on message with patients.

However, a commitment to standards in communication and other areas should never override a patient’s need. “The clinical issues should always take priority,” Ms. Ostrowsky emphasized.

A day in the life of an MSKCC inpatient integrated case manager runs the gamut from reviewing and assessing new patients to orchestrating transition planning. “Our patients go out with all kinds of services, from infusion care to home chemotherapy to wound VACs.” Some patients are transferred to post-acute facilities, while others face end-of-life issues that include hospice care, which could be inpatient or home.

Hospice care was one area of focus for MSKCC—in particular, getting providers to speak frankly with patients about hospice and incorporating those services earlier on in the patient’s diagnosis when appropriate, both of which required a cultural shift. “Our patients didn’t come to Memorial to be told that there’s nothing that we can do for them,” she explained. “And our doctors didn’t come to work at Memorial to send people to hospice. They came here to cure cancer.”

In taking a closer look at end-of-life services, Ms. Ostrowsky found that physicians tended to refer to hospice later than she hoped that they would. “I wanted to really look at our length of stay in hospice as a way of identifying the timeliness of referral.” A longer hospice stay allows the patient to form relationships with their hospice caretakers rather than feeling abandoned and “left to die,” concluded Ms. Ostrowsky.

By placing case managers in inpatient areas and encouraging key case management-provider conversations that she shared during the program, MSKCC improved hospice referral timeliness and grew hospice length of stay. In turn, these quality improvements correlated with higher patient (and family) satisfaction.

Integrated case managers have also been key in identifying patients who can benefit from LTACH services and moving them there sooner, she added. “We can decrease length of stay within the hospital and get [patients] that kind of focused care that they need sooner.”

Listen to Laura Ostrowky describe the surprise question that can improve timeliness of hospice referrals.

Improve Medication Adherence, and Payors Pay Attention

June 20th, 2017 by Patricia Donovan
medication adherence

Training in motivational interviewing helps Novant health set medication adherence goals that are meaningful to patients.

Seeking additional dollars from managed care contracts? Work harder at getting patients to adhere to medication therapies, advises Rebecca Bean, director of population health pharmacy for Novant Health. Here, Ms. Bean describes ways her organization is improving medication adherence, including pharmacist referrals, while enhancing Novant Health’s bottom line.

Medication adherence is a huge focus for our organization. There are some quality measures related to adherence, including CMS Star measures. They are triple-weighted, which indicates they mean a lot to payors. Often, medication adherence is a way to get additional dollars through managed care contracts. Our pharmacists work hard at helping patients adhere to medication therapies.

We have found some benefit to using adherence estimators. Adherence estimators give you a better feel for what is causing the patient to have difficulty with taking their medication. The other finding is that oftentimes providers are unaware; they have no idea patients aren’t taking medications. This becomes a safety issue; providers may keep adding blood pressure medications because they are not getting that blood pressure to goal. If for whatever reason the patient suddenly decides to take a medication they weren’t taking before, there could be a serious issue with taking all of those blood pressure medicines at one time.

The other benefit to estimating adherence and identifying root causes is that it frames the discussion with the patient. I don’t want to spend an hour talking to a patient about why it’s important to take this blood pressure medicine when it’s actually a financial issue. If I know it’s a financial issue, then I can make recommendations on cost-saving alternatives. It helps you to be more efficient in your conversation with the patient.

The other challenge of adherence is that patients are reluctant to be honest about this issue. You have to be creative to get the answers you need or get to the truth about adherence. If you flat out ask a patient if they’re taking their medications, most of the time they will say yes.

One other helpful strategy when working with patients to set adherence goals is to have them set goals that mean something to them. It’s not helpful for me to set a goal for a patient. If I ask them to tell me what they’re going to do, then they’re accountable for that. It is very helpful to get your staff trained in motivational interviewing. This trains them to meet the patients where they are and to understand what is important to that patient, which helps you frame the medication therapy discussion.

Source: Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk Populations

pharmacists and medication adherence

Leveraging Pharmacists to Reduce Cost and Improve Medication Adherence in High-Risk Populations examines Novant Health’s deployment of pharmacists as part of its five-pronged strategy to deliver healthcare value through medication management services.

Shared SNF Patients, Common Readmissions Goals Unify Three Competing Health Systems

June 15th, 2017 by Patricia Donovan

A common desire to reduce SNF readmissions resulted in the formation of Michigan's Tri-County SNF Collaborative.

A common desire to reduce SNF readmissions resulted in the formation of Michigan’s Tri-County SNF Collaborative.

Concerned about escalating hospital readmissions from skilled nursing facilities (SNFs) and the accompanying pinch of Medicare readmissions penalties, three Michigan healthcare organizations decided to set competition aside to collaborate and reduce rehospitalizations from SNFs. Here, Susan Craft, director of care coordination, family caregiver program, Office of Clinical Quality & Safety at Henry Ford Health System, describes the origins of Michigan’s Tri-County SNF Collaborative, of which her organization is a founding member.

I want to talk about the formation of the Tri-County SNF Collaborative between Henry Ford Health System, Detroit Medical Center, and St. John Providence Health System. As quality and care transition leaders from each of the health systems, we see each other frequently at various meetings. After some good conversation, we learned that each of us was partnering with our SNFs to improve quality and reduce readmissions.

We all required that they submit data to us that was very similar in nature but not exactly the same, which created a lot of burden for our SNFs to conform to multiple reporting requirements. We knew we were working with the same facilities because geographically, we are all very close to each other. We recognized that this was really a community problem, and not an individual hospital problem. Although we are all competing healthcare systems, those of us with very similar roles in the organization had very little risk from working together. And because we had so much in common, it just made sense that we create this collaborative.

We also worked with our MPRO (Michigan Quality Improvement Organization) and reviewed data that showed that about 30 percent of our patient population was shared between our three health systems. We decided it made sense to move forward. We created a partnership that was based on collaboration and transparency, even within our health systems. We identified common metrics to be used by all of our organizations and agreed upon operational definitions for each of those. We all reached out to our SNF partners to tell them about the collaborative and invite them to join, and then engaged MPRO as our objective third party. We created a charter to solidify that cooperation and collaboration.

Source: A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics

reducing SNF readmissions

A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics examines the evolution of the Tri-County SNF Collaborative, as well as the set of clinical and quality targets and metrics with which it operates.