Archive for the ‘Home Visits’ Category

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:

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.

Reframing the Care Transition Conversation to Increase Home Visit Acceptance

May 9th, 2017 by Patricia Donovan

Sun Health Care Transitions

Patient scripting using the “feel, felt, found” approach increased patients’ acceptance of home visits.

In conducting hospital bedside visits to introduce its Care Transitions Program, Sun Health learned that the way its LPNs or social workers described the program to patients influenced their acceptance. Here, Jennifer Drago, executive vice president of population health for Sun Health, provides more detail on scripting developed with the help of a behavioral psychologist that refined the care transition approach, overcame patient objections and increased program acceptance rates.

How did we develop scripting that helped increase patient retention rates? Two things come to mind. First, we changed how we described the home visit. When we were in the hospital or on the phone, we refined our discussion to talk about a brief home visit by a registered nurse. We explained some of the things the nurse would do during the visit and what the patients would gain from them. We reframed the description to highlight what was in it for the patient. And we always describe it as a brief home visit.

Secondly, we worked hard on overcoming objections. We conducted a short survey, and tracked our results over time to determine our top objections. We then framed scripting around each one of those top objections using the “feel, felt, found” approach recommended by our behavioral psychologist.

For example, we taught our nurses to say: “I understand you feel that way. Others in our program have felt that way in the past, but what they’ve found is after they’ve gone through the Care Transitions program …”

The nurses were able to overcome that objection using that framework. We created scripting for the top three or four objections we normally received, and found that to be very helpful.

Source: The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI

advanced care coordination

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

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.

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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.

‘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.

Home Visits Validate Predictive Analytics and 10 More 2016 Risk Stratification Trends

August 30th, 2016 by Patricia Donovan

Assuring data integrity is the top challenge to health risk stratification, according to a July 2016 healthcare benchmarks survey.


Two key trends emerging from a July 2016 survey on Stratifying High-Risk Patients highlight the need to occasionally eschew sophisticated tools in favor of basic, face-to-face care coordination.

As one survey respondent noted, “A key element [of stratifying high-risk patients] is building a trusting face-to-face relationship with each patient, knowing what they want to work on, coaching them and activating them.”

The first learning gleaned from the survey’s 112 respondents is that, despite the prevalence of high-end risk predictors, algorithms and monitoring tools, clinicians must occasionally step into the patient’s world—that is, literally enter their home—in order to capture the individual’s total health picture.

Fifty-six percent of respondents make home visits to risk-stratified patients; a half dozen identified the home visit as its most successful intervention for risk-stratified populations.

That inside look at the patient environment illuminates data points an electronic health records (EHRs) might never bring to light, including socioeconomic factors like limited mobility that could prevent a patient from keeping a follow-up appointment.

“I never know until the moment I enter the home and actually see what the environment is like whether we correctly predicted the need for high intervention (and get a return on it),” commented one respondent.

The second trend in risk stratification is the emerging laser focus on ‘rising risk’ patients, an activity reported by 72 percent of respondents. This scrutiny of rising risk populations helps to prevention their migration to high-risk status, where complex and costly health episodes prevail.

Other data points identified by the 2016 Stratifying High-Risk Patients survey include the following:

  • Almost four-fifths of 2016 respondents have programs to stratify high-risk patients, and the infrastructures of more than half of these initiatives utilize clinical analytics, predictive algorithms, EHRs and other IT tools to manage care for high-risk patients.
  • The reigning health risk calculator continues to be the LACE tool (Length of stay, Acute admission, Charleston Comorbidity score, ED visits), used by 45 percent in 2016, versus 33 percent two years ago.
  • For more than a quarter of 2016 respondents, assuring data integrity remains a key challenge to risk prediction.
  • A case manager typically has primary responsibility for risk stratification, say 52 percent of respondents.
  • Diabetes is the most prevalent clinical condition among high-risk patients, say 47 percent.
  • At least 70 percent report reductions in hospitalizations and ER visits related to risk stratification efforts.
  • Improvement in the highly desirable metric of patient engagement is reported by 74 percent of respondents.

Click here to download an executive summary of survey results: Stratifying High-Risk Patients in 2016: As Risk Prediction Prevails, Industry Eyes Social Determinants, Rising Risk.

CCNC Home Visits in Transitional Care: Payoffs of Targeting Priority Patients

April 7th, 2016 by Patricia Donovan

Timely and appropriately targeted home visits for priority Medicaid beneficiaries significantly reduced hospital admissions and readmissions.

The philosophy behind Community Care of North Carolina’s award-winning care transition management program is simple: transitional care works better for some than others.

Before investing in home visits, pharmacist involvement and early outpatient follow-up, healthcare organizations should discern the patients most likely to benefit from these resource-intensive interventions as well as those who won’t, advised Carlos Jackson, PhD., CCNC director of program evaluation.

“Transitional care often becomes a one-size-fits-all intervention, where providers feel they have to do the same thing for everybody coming out of the hospital,” Jackson noted during Measuring and Evaluating the Impact of Home Visits for Clinically Complex Patients, a March 2016 webinar now available for replay.

In outlining the CCNC approach, Jackson recommends transitional care be targeted towards patients with multiple, chronic or catastrophic conditions to optimize an organization’s return on investment.

His organization’s dexterity in determining and managing a priority population for transitional care (TC) helped to earn CCNC the inaugural Hearst Health Prize for Population Health earlier this year. With a presence in all one hundred North Carolina counties, CCNC manages 1.5 million Medicaid beneficiaries, among other populations.

Statistically, CCNC determined that only a quarter of its Medicaid discharges were likely to meaningfully benefit from transitional care, and that even within that priority population, only a smaller segment would benefit meaningfully from resource-heavy interventions.

Of all face-to-face encounters with CCNC priority patients, include hospital bedside and office visits, appropriately targeted home visits reduced this population’s likelihood of being readmitted to the hospital most significantly, noted Jackson.

“Of course, you can’t do a home visit with everybody. If you want a positive return on investment to cover the cost of the home visit, you need to focus on the highest risk patients.”

Modeled on the Coleman Transitions Intervention Model®, the eight-year-old CCNC program has elements common to many transitional care initiatives—data analytics, embedded care management, telephonic and face-to-face follow-up. But CCNC has reexamined some traditional transitional care tenets, such as the notion that this type of care is necessary for all.

“Actually, most patients don’t benefit,” Jackson noted. “Lower risk patients don’t benefit. The evidence for benefit is much weaker if you are not one of these high risk, multiple chronic patients.”

His organization has also widened its transitional care lens beyond a focus on reducing readmissions. “It’s sometimes myopic to focus on just serving the 30-day readmissions,” Jackson continued. “If you can deliver good transitional care, you can keep them out of the hospital for a very long time and affect their outcomes way into the future.”

The CCNC transitional care approach for North Carolina Medicaid beneficiaries with multiple chronic conditions resulted in more than 2,200 fewer readmissions and 8,000 fewer inpatient admissions in 2014 as compared to 2008, Jackson concluded.

Infographic: Hospitals Overconfident, Unprepared To Reduce Readmissions

July 15th, 2015 by Melanie Matthews

While hospitals report they are confident in their ability to reduce readmissions, according to a new survey conducted by Q-Centrix, the percentage of hospitals penalized for readmissions has increased each year since CMS began imposing them.

The percentage of hospitals penalized for readmissions reached a high of 78 percent for FY 2015. Given the historical trend and the three additional diagnoses recently added, the percentage of hospitals penalized will likely be much higher than the 55 percent who reported that they expected to be penalized, according to an infographic produced by Q-Centrix on the survey results.

2014 Healthcare Benchmarks: Reducing Hospital Readmissions While great strides have been made in the reduction of 30-day all-cause hospital readmissions, CMS still penalized more than 2,200 hospitals in 2013 for exceeding 30-day readmission rates for heart failure, pneumonia and myocardial infarction. This year, CMS penalties extend to acute COPD and elective hip and knee replacements.

2014 Healthcare Benchmarks: Reducing Hospital Readmissions documents the latest key initiatives and partnerships to reduce readmissions by patients with these costly conditions and others by more than 100 healthcare organizations.

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3 Embedded Care Coordination Models Manage Diverse High-Risk, High-Cost Populations

June 30th, 2015 by Patricia Donovan

YNHHS embedded care coordination

YNHHS uses an embedded care coordination approach to manage its high-risk, high-cost medical home patients, geriatric homebound and health system employees.

When it comes to coordinating care for its highest-risk, highest-cost individuals—whether patients in a medical home, the geriatric homebound or its own employees—Yale New Haven Health System (YNHHS) believes an onsite, embedded face-to-face approach will best position it for success in a value-based healthcare industry.

The Connecticut-based health system shared its vision for managing patients across its continuum via three embedded care coordination models during a June 2015 webinar, Embedded Care Coordination for At-Risk Populations: A Case Study from Yale New Haven Health System, now available for replay.

In the first model, livingwellCARES, RN care coordinators at YNHHS’s four health system campuses work with its high-risk, high-cost health system employees and their adult dependents with chronic disease.

“We help these employees access the care they need and identify their goals of care. We get under the surface a little bit to determine barriers to their being as healthy as they can be and manage them over time,” explained Amanda Skinner, executive director, clinical integration and population health, adding that YNHHS offers employees incentives such as waived insurance co-pays for participation.

Launched three years ago, livingwellCARES was YNHHS’s “on-the-job training for learning to manage care across the continuum,” she continued. Starting with employees with diabetes, livingwellCARES expanded to care coordination of most chronic diseases. Having significantly impacted clinical metrics like A1Cs as well as hospital utilization and ED visits in the approximately 500 employees it manages, livingwellCARES is now transitioning to a more risk-based approach.

The second embedded care coordination model, a patient-centered medical home (PCMH), also launched three years ago. Focused on complex care management, the PCMH is heavily driven by data derived from its electronic health records and patient registries, Ms. Skinner continued.

Because five of eight PCMH care coordinators are embedded and cover multiple physician practices, YNHHS is exploring the use of televisits by care coordinators to manage patients in the practices served. Also important is schooling PCMH staff in the relatively new practice of “warm handovers” during critical transitions of care.

Nine challenges of the PCMH embedded model shared by Ms. Skinner include engaging patients and obtaining reimbursement for various pay for performance programs.

In the third model, outpatient geriatric care coordination, embedded high touch care coordinators manage frail elderly deemed homebound by Medicare standards—when it’s a severe and taxing effort to leave the home—and those in assisted living facilities, explained Dr. Vivian Argento, executive director of geriatric and palliative services at Bridgeport Hospital.

“There is a challenge not just with frailty but also with access—having these patients go into the physician offices—so that the care tends to get shifted into the hospital because it’s easier for those patients to get there,” Dr. Argento explained.

Physicians and nurse practitioners provide care in the patient’s home to break that utilization cycle, while embedded care coordinators constantly collaborate with the care team to risk-stratify and prioritize patients, resolve medication concerns, make referrals, manage care transitions, triage telephone calls—all tasks required to coordinate care for what Dr. Argento termed “a very sick Medicare population in in the last two to three years of life.”

Well received by the geriatric patients, the program also has positively impacted healthcare utilization metrics: its annual hospital admission rate of 5.4-5.8 percent is significantly below Medicare’s overall 28-30 percent hospitalization rate, and the program boasts a readmissions rate of 14 percent, versus Medicare’s 20 percent national average, Dr. Argento added.

Post-Discharge Home Visits, SNF Visits Halve Readmissions for High-Risk Population

April 27th, 2015 by Patricia Donovan

In an Ohio care transitions management initiative, post-discharge home or SNF visits to Medicare beneficiaries at high risk for readmission have helped to curb rehospitalizations by nearly 50 percent.

As one of CMS’ Community-based Care Transitions Program (CCTP) demonstration projects, field coaches for the Council on Aging (COA) of Southwestern Ohio conduct home visits for high-risk Medicare fee-for-service patients in nine partner hospitals, explained Danielle Amrine, the COA’s transitional care business manager during an April 2015 webinar, Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients, now available for replay.

The COA of Southwestern Ohio completed 10,202 home visits from June 2012 through 2014, Ms. Amrine said. “The national readmission rate is around 21.3 percent. Those patients involved in our CCTP program experienced a readmission rate of 10.48 percent.”

Home visits occur within 24 to 72 hours of a patient’s discharge from the hospital; SNF visits within 10 days, to allow the patient to settle in at the SNF. For SNF visits, made to the top 10 nursing facilities where patients most often discharged, field coaches utilize the LACE readmissions tool to assess the need for a home visit post-discharge.

The intervention is designed to empower patients of any age and their caregivers to assert a more active role during their care transition.

Reinforced by a trio of follow-up phone calls, a typical home visit lasts about one hour. While geared to the patient’s needs, the visit always covers the crucial medication reconciliation, which allows the coach not only to assess the patient’s role in managing their medication regimen but also to identify any medication discrepancies. Medication misunderstandings are particularly common during transitions in care.

In a recent month, COA coaches identified 77 medication discrepancy issues, which, once resolved, resulted in only four of these patients from being readmitted back to the hospital.

The Southwestern Ohio program, the second in the nation to be funded by CMS to conduct home visits, is modeled on the four pillars of Eric Coleman’s Care Transitions Intervention®. However, the COA has added a fifth pillar, community services, to connect patients to the COA’s broad range of in-house and community-based services during the critical transition between providers or care sites.

The program relies heavily on personal health records (PHRs) to facilitate cross-site communication and ensure continuity of care data across practitioners and settings.

Success from the COA care transitions initiative also extends to emergency department utilization by this population: the national average baseline is around 11.6 percent, and CCTP participants show an admission rate of 9.39 percent, Ms. Amrine added.

About 15 percent of scheduled home visits do not occur; the program has created a number of strategies to address this falloff.

Future enhancements by the COA of Southwestern Ohio program include a behavioral health intervention and a pilot in which University of Cincinnati College of Pharmacy interns will reconcile medications via Skype® or other telemedicine application.