Archive for the ‘Care Transitions’ Category

Infographic: Overcoming Barriers To Improve Care Transitions

May 1st, 2017 by Melanie Matthews

Leveraging the right technology can improve post-acute patient outcomes, according to a new infographic by Ensocare.

The infographic looks at: the impact of streamlining multiple, disparate workflows; and how to strengthen post acute networks, simplify ongoing post-acute follow-up communications and improve patient engagement during care transitions.

The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROIA 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.

Infographic: Stopping the Revolving Door of Short-Term Readmissions

April 10th, 2017 by Melanie Matthews

Transitioning eligible patients to hospice can help hospitals avoid Medicare’s 30-day readmission penalty, according to a new infographic by VITAS.

The infographic examines how hospice can reduce readmission rates and increase patient satisfaction.

Reducing SNF Readmissions: Quality Reporting Metrics Drive ImprovementsA tri-county, skilled nursing facility (SNF) collaborative in Michigan is holding the line on hospital readmission rates for the three competitive health systems participating in the program.

Henry Ford Health System, Detroit Medical Center and St. John’s Providence, along with the state’s Quality Improvement Organization (QIO), MPRO, developed standardized quality reporting metrics for 130 SNFs in its market. The SNFs, in turn, enter the quality metrics into a data portal created by MPRO.

During Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvements, a 45-minute webinar on May 11th at 1:30 p.m. Eastern, Susan Craft, director, care coordination, family caregiver program, Office of Clinical Quality & Safety at Henry Ford Health System, will share the key details behind this collaborative, the impact the program has had on her organization’s readmission rates along with the inside details on new readmission reduction target areas born from the program’s data analysis.

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.

Touting ‘Magic’ of Home Visits, Sun Health Dispels 5 Care Transition Management Myths

April 4th, 2017 by Patricia Donovan


With an average of 299 warm, sunny days a year, Phoenix is a mecca for senior transplants. However, as Phoenix-based Sun Health knows well, when an aging population relocates far from their adult children, there’s a danger that if some of them experience cognitive decline or other health issues, no one will notice.

That’s one reason home visits are the cornerstone of Sun Health’s Care Transitions Management program. Visiting recently discharged patients at home not only tracks the individual’s progress with the hospitalization-related condition, but also pinpoints any social determinants of health (SDOH) that inhibit optimum health.

“There are a number of social determinants of health that, if not addressed, could adversely impact the medical issue,” explains Jennifer Drago, FACHE, executive vice president of population health for the Arizona non-profit organization. Ms. Drago outlined the program during A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, a March 2017 webinar now available for replay.

Identifying social determinants of health (SDOH) such as medication affordability, transportation, health literacy and social isolation are so important to Sun Health that SDOHs form the critical fifth pillar of its Care Transitions Program. Modeled on the Coleman Care Transitions Intervention®, SDOH identification and support balance Coleman’s four pillars of education, medication reconciliation, physician follow-up visits, and personalized plan of care.

The belief that organizations can effectively execute transitions of care programs pre-discharge or by phone only is one of five care transition myths Ms. Drago dispelled during the webinar. “You will have an impact [with phone calls], but it won’t be as great as a program incorporating dedicated staff and that home visit. I can’t tell you the magic that happens in a home visit.”

That “magic” contributed to Sun Health’s stellar performance in CMS’s recently concluded Community-Based Care Transitions Program demonstration. Sun Health was the national demo’s top performer, achieving a 56 percent reduction in Medicare 30-day readmissions—from 17.8 percent to 7.81 percent—as compared to the 14.5 percent readmission rate of other demonstration participants.

Sun Health’s multi-stepped intervention begins with a visit to the patient’s hospital bedside. “Patients are a captive audience while in the hospital,” explained Ms. Drago. That scripted bedside encounter, which boosted patients’ receptivity to the program, addresses not only the reason for the hospitalization (hip replacement, for example) but also co-occuring chronic conditions, she continued.

“The thing that will have the greatest chance of going out of whack or out of sync in their recovery period is their chronic disease, because they’re probably not eating the same, they’re more sedentary, and their medications likely have been disrupted.”

Ms. Drago went on to present some of the intervention’s tools, including care plans, daily patient check-ins, and the science behind her organization’s care transitions scripts.

After sharing six key lessons learned from care transitions management, Ms. Drago noted that while her organization participated as a mission-based endeavor, others could model Sun Health’s intervention and benefit from those readmissions savings. She also shared a video on the Sun Health Care Transitions Program:

Listen to an interview with Jennifer Drago on the science behind care transition management.

HINfographic: Home Visits Curb Readmissions and ER Utilization

March 15th, 2017 by Melanie Matthews

Seventy percent of healthcare organizations providing care to patients in their homes attributed a reduction in either hospital readmissions or in ER utilization to those home visits, according to the December 2016 Home Visits survey by the Healthcare Intelligence Network.

A new infographic by HIN examines the populations targeted by home visits, the primary purpose during a home visit and a promising home visit protocol.

2017 Healthcare Benchmarks: Home Visits Visiting targeted patients at home, especially high utilizers and those with chronic comorbid conditions, can illuminate health-related, socioeconomic or safety determinants that might go undetected during an office visit. Increasingly, home visits have helped to reduce unplanned hospitalizations or emergency department visits by these patients.

2017 Healthcare Benchmarks: Home Visits examines the latest trends in home visits for medical purposes, from populations visited to top health tasks performed in the home to results and ROI from home interventions.

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.

Infographic: Transitional Care Management

March 13th, 2017 by Melanie Matthews

Transitional Care ManagementMedicare’s billing codes for Transitional Care Management (TCM) highlight the importance of timely post-discharge contact with patients by provider offices, and timely face-to-face follow up and evaluation by TCM providers. Incorporating automated patient communications can facilitate efficient and effective handoffs, and support a consistent track of care to help providers earn TCM reimbursements and avoid hospital readmission penalties, according to a new infographic by West Healthcare.

The infographic looks at the financial impact of reducing readmission penalties and examines how automated patient communications can improve care transitions.

A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home VisitsSun Health, an Arizona non-profit organization, launched its Sun Health Care Transitions program in November 2011. Modeled after the Coleman Care Transitions Intervention® and adapted to meet the needs of its community, the program has been credited with keeping readmission rates well below the national average.

Sun Health’s program was part of the Center for Medicare and Medicaid Services’ National Demonstration Program, Community-Based Care Transitions Program, which ended in January. Not only did Sun Health lead the CMS demonstration project with the lowest readmission rates, Sun Health also widened the gap between their expected 30-day readmission rate (56 percent lower than expected) and their expected 90-day readmission rate (60 percent less than expected).

During A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, a March 23, 2017 webinar at 1:30 p.m. Eastern, Jennifer Drago, FACHE, executive vice president, population health, Sun Health, will share the key features of the care transitions program, along with the critical, unique elements that lead to its success.

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.

3 Priority Populations for Home Visits and 10 More House Calls Benchmarks

February 14th, 2017 by Patricia Donovan

More than half of home visits include screening for social determinants of health.

More than half of home visits include screening for social determinants of health.

Which patients should healthcare providers visit at home? A new survey on home visits identified three key populations that should receive home-based care management: the frail elderly and homebound (69 percent); the medically complex (69 percent); and individuals recently discharged from the hospital (68 percent).

In stratifying patients for these home visits, 62 percent rely on care manager referrals.

These were just two findings from the 2017 Home Visits survey conducted by the Healthcare Intelligence Network. Nearly three quarters of the survey’s 107 respondents visit targeted patients at home, an intervention that can illuminate health-related, socioeconomic or safety determinants that might go undetected during an office visit.

Who’s conducting these home visits? In more than half of responding programs, a registered nurse handles the visit, although on rare occasions, patients may open their door to a primary care physician (4 percent), pharmacist (4 percent) or community paramedic (3 percent).

Once inside the home, the visit is first and foremost about patient and caregiver education, say 81 percent of respondents, with an emphasis on medication reconciliation (80 percent). Fifty-nine percent also screen at-home patients for social and economic determinants of health, factors that can have a huge impact on an individual’s health status.

Patient engagement, including obtaining consent for home visits, tied with funding and reimbursement issues tied as the top challenges associated with in-home patient visits.

How to know if home visits are working? The most telling success indicator is a reduction in 30-day hospital readmission rates, say 83 percent of survey respondents, followed by a drop in hospital and ER utilization (64 percent). Seventy percent of survey respondents reported either a drop in readmissions or in ER visits.

Here are a few more metrics derived from HIN’s 2017 Home Visits survey:

  • Eighty-five percent of respondents believe that the use of in-home technology enhances home visit outcomes.
  • Fifteen percent report home visits ROI of between 2:1 and 3:1.
  • Eighty percent have seen clients’ self-management skills improve as a result of home visits.

Download an executive summary of results from HIN’s 2017 Home Visits Survey.

7 Healthcare Movements to Monitor in 2017

January 2nd, 2017 by Patricia Donovan

Add a different caption here.

Growing population base should be a 2017 priority for healthcare organizations, advises Steven Valentine.

In offering a set of guiding principles for 2017 success, Steven Valentine, vice president, Advisory Consulting Services, Premier Inc., outlines seven key areas healthcare executives should monitor in the coming year.

First, we have seen some commercial plans move to risk adjustment payments. This could be helpful or detrimental. We definitely have seen more time spent as health systems have moved to more risk payments, more two-sided models.

Next, a definition of financial responsibility (DoFR) will be critical: knowing all the various benefits that are offered and perhaps listing them on the left side of a spreadsheet. As you move across the sheet, what remains with a health plan, if anything? What would go with the physician organization? What would go to an inpatient facility acute hospital? To ambulatory providers and post-acute providers? We would advise you to begin to move in 2017 to standardize those DoFRs.

Then, if at all possible, exclude specialty drugs, where we’ve seen tremendous price increases. If you can exclude any new kinds of therapies, and I mention one there that’s been popular and growing in 2016, IVIG, and we expect a pretty good jump in 2017. Some doctors have labeled this the ‘feel good infusion.’

Then, determine whether you can do anything on an exclusive basis that would help you capture more population. At the end of the day, strategically, in 2017, you need to grow your population base.

Next is effective use of comanagement agreements and a renewed focus on your risk adjustment factor (RAF) scores: there will be slight adjustments as they go down and you’re going to have to do a better and better job of documenting and trying to push those up.

Then we see patient engagement; we do want to see the patients engaged. The more you use various patient portals, the more helpful it will be.

Finally, we also look at the repatriation of patients, because if you have them under your care, you would be responsible for getting those patients and paying for them.

Source: Healthcare Trends & Forecasts in 2017: Performance Expectations for the Healthcare Industry

http://hin.3dcartstores.com/Home-Visits-for-Clinically-Complex-Patients-Targeting-Transitional-Care-for-Maximum-Outcomes-and-ROI_p_5180.html

Healthcare Trends & Forecasts in 2017: Performance Expectations for the Healthcare Industry, HIN’s thirteenth annual business forecast, is designed to support healthcare C-suite planning during this historic transition as leaders prepare for both a new year and new presidential leadership.

Guest Post: Care Transitions Are Susceptible To Breakdowns; Technology-Enabled Patient Outreach Offers Clarity and Improved Outcomes

November 15th, 2016 by Chuck Hayes, vice president of product management for TeleVox Solutions, West Corporation

Technology-Enabled Patient Touchpoints Post-Discharge

A surprisingly simple way to improve care transitions is to reach out to patients within a few days of hopsital discharge automatically with the help of technology.

Transitional care’s inherently complex nature makes it susceptible to breakdowns. During care transitions there are many moving parts to coordinate, patients are vulnerable, and healthcare failures are more likely to occur. For these reasons, transitional care is a growing area of concern for hospital administrators and other healthcare leaders.

Errors that happen at pivotal points in care, like during a hospital discharge or transfer from one facility to another, can have serious consequences. Fortunately, strengthening communication and engaging patients can effectively solve many of the problems that transpire during care transitions.

When patients’ needs go unmet after being discharged from the hospital, the risk of those individuals being readmitted is high. Around 20 percent of Medicare patients discharged from the hospital return within a month. CMS has taken several steps to try to improve transition care and minimize breakdowns that lead to hospital readmissions. Under the government’s Hospital Readmissions Reduction Plan (HRRP), hospitals can be assigned penalties for unintentional and avoidable readmissions related to conditions like heart attacks, heart failure, pneumonia, COPD, and elective hip or knee replacement surgeries.

Between October 2016 and September 2017, Medicare will withhold more than $500 million in payments from hospitals that incurred penalties based on readmission rates. These penalties affect about half of the hospitals in the United States.

Not only are payment penalties problematic, but because readmissions rates are published on Medicare’s Hospital Compare website, public opinion is also worrisome for hospitals with a high number of readmissions.

A surprisingly simple way to prevent patients from returning to the hospital is to reach out to them within a few days of discharge. Outreach can be done automatically with the help of technology. For example, with little effort, hospitals can send automated messages prompting patients to complete a touchtone survey. A survey that asks patients whether they are experiencing pain–and whether or not they have been taking prescribed medications–provides good insight about the likelihood of them returning to the hospital. It also allows hospitals to respond to issues sooner rather than later.

Medical teams know that patients are particularly vulnerable during the 30 days following a hospital discharge. Leveraging technology-enabled engagement communications multiple times, in multiple ways throughout that month-long window is a good strategy for improving post-discharge transitions. Whether that involves reminding a patient about a follow-up appointment, asking them to submit a reading from a home monitoring device, verifying that they are tolerating their medication, or communicating about something else, it is important to have plans in place to initiate an intervention if necessary.

For example, if a patient indicates that they are experiencing side effects or symptoms that warrant examination by a doctor, a hospital team member should escalate the situation and help coordinate an appointment for the patient. Recognizing problems is one component of improving care transitions, responding to them is another.

Imagine a patient has recently been released from the hospital after having a heart attack. The patient was given three new prescriptions for medications to take. He may have questions about when and how to take the medications or whether they can be taken in combination with a previous prescription. Hospital staff can use technology-enabled communications to coordinate with the patient’s primary care doctor and pharmacy to ensure the patient has all the information they need to safely and correctly follow medication instructions. The hospital can also survey the patient to find out if he is having difficulty with medication or other discharge instructions, and learn what services or interventions might be beneficial. Following that, a care manager can provide phone support to answer questions.

Fewer than half of patients say they’re confident that they understand the instructions of how to care for themselves after discharge. Without some sort of additional support, what will happen to those patients? In the past, hospitals may have felt that patient experiences outside the walls of their facility were not their concern. But that has changed.

Care transitions are exactly that–transitions. They are changes, but not end points. Hospitals should foster a culture that recognizes and supports the idea that care does not end at discharge. It continues, just in a different way. When patients physically leave a hospital, the manner in which care is delivered needs to progress. Rather than delivering care in person, healthcare organizations can support patients via outreach communications. The degree to which that happens impacts how well (or poorly) transitions go for patients.

Improving care transitions is not as daunting as it might seem, particularly for medical teams that use technology-enabled communications to support and engage patients. To ensure patients have the knowledge and resources they need, and that they are acting in ways that will keep them out of the hospital, medical teams must focus on optimizing communications beyond the clinical setting.

About the Author: Chuck Hayes is an advocate for utilizing technology-enabled communications to engage and activate patients beyond the clinical setting. He leads product and solution strategy for West Corporation’s TeleVox Solutions, focusing on working with healthcare organizations of all sizes to better understand how they can leverage technology to solve organizational challenges and goals, improve patient experience, increase engagement and reduce the cost of care. Hayes currently serves as Vice President of Product Management for TeleVox Solutions at West Corporation (www.west.com), where the healthcare mission is to help organizations harness communications to expand the boundaries of where, when, and how healthcare is delivered.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remain with them. The company accepts no liability for any errors, omissions or representations.

Infographic: Optimizing Post-Acute Care

October 17th, 2016 by Melanie Matthews

Seventy-five percent of hospital readmissions are preventable—more than $17 billion annually is wasted due to readmissions within 30 days, according to a new infographic by CareCentrix.

The infographic lists four keys to success in improving post-acute care and reducing readmissions.

Medicare’s proposed payment rates and quality programs for skilled nursing facilities (SNFs) for 2017 and beyond solidify post-acute care’s (PAC) partnership in the transformation of healthcare delivery. Subsequent to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), forward-thinking PAC organizations realized the need to rethink patient care—not just in their own facilities but as patients move from hospital to SNF, home health or rehabilitation facility.

Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands examines a collaboration between the first URAC-accredited clinically integrated network in the country and one of its partnering PAC providers to map out and enhance a patient’s journey through the network continuum—drilling down to improve the quality of the transition from acute to post-acute care.

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.

‘Connect the Dots’ Transitional Care Boosts ROI by Including Typically Overlooked Populations

October 11th, 2016 by Patricia Donovan

Typically overlooked patient populations do benefit greatly from nurse-directed transitional care management.

Some typically overlooked patient populations do benefit greatly from nurse-directed transitional care management.

Determining early on that transitional care works better for some patients than others, the award-winning Community Care of North Carolina (CCNC) transitional care (TC) program is careful to allocate resource-intensive TC interventions to those patients that would benefit most. Here, Carlos Jackson, Ph.D., CCNC director of program evaluation, explains the benefits of including often-overlooked patients in TC initiatives.

Transitional care must be targeted towards patients with multiple, chronic or catastrophic conditions to optimize your return on investment. These patients are the ones that benefit the most. It’s the ‘multiple complex’ part that is the key; this includes conditions that are typically overlooked in transitional care, such as behavioral health or cancers.

We may pass over and not focus on these patients in typical transitional care programs, but actually, they do benefit greatly from our nurse-directed transitional care management.

For example, with a cancer population, transitional care keeps them out of the hospital longer. The transitional care is not necessarily preventing or curing the cancer, but it’s helping to connect those dots in a way that keeps them from returning to the hospital. Again, we are also talking about complex patients. This is not just anybody with cancer; this is somebody with cancer and multiple other physical ailments as well.

The same is true for people who come in with a psychiatric condition. Again, we’re talking about a very sick population. For every 100 discharges, without transitional care almost 100 of these patients will go back to the hospital within the next 12 months. That’s almost a 100 percent return to the hospital. But with transitional care, only about 80 percent return to the hospital within the coming year.

This translates to an expected savings of nearly $100,000 just in averted hospitalizations per 100 patients managed. We were able to demonstrate that the aversions happened not only with the non-psychiatric hospitalizations, but also on the psychiatric hospitalizations.

Even though nurse care managers often tend to be siloed, by doing this coordinated ‘connecting the dots’ transitional care, they were able to prevent psychiatric hospitalization. That certainly has implications for capitated behavioral health systems. We don’t want to forget about these individuals.

Source: Home Visits for Clinically Complex Patients: Targeting Transitional Care for Maximum Outcomes and ROI

http://hin.3dcartstores.com/Home-Visits-for-Clinically-Complex-Patients-Targeting-Transitional-Care-for-Maximum-Outcomes-and-ROI_p_5180.html

Home Visits for Clinically Complex Patients: Targeting Transitional Care for Maximum Outcomes and ROI describes the award-winning Community Care of North Carolina (CCNC) transitional care program, how it discerns and manages a priority population for transitional care, and why home visits have risen to the forefront of activities by CCNC transitional care managers.