Archive for the ‘Home Visits’ Category

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.

3 Goals of Hospital Home Visits: Reconciliation, Red Flags and Re-Education

April 14th, 2015 by Cheryl Miller

Hospital-initiated home visits conducted during post-discharge follow-up significantly curb avoidable admissions, readmissions and ER visits, according to findings from the Healthcare Intelligence Network’s 2013 Home Visits e-survey.

The hospital sector is almost twice as likely to conduct home visits than other sectors, and to focus on three key aspects of the discharge care plan: medication reconciliation, red flag recognition and patient/caregiver education.

Hospitals are much more likely to conduct home visits to conduct post-discharge follow-up than overall respondents, our survey found. Almost two-thirds of hospitals, which comprised 27 percent of the survey 155 respondents, visit patients at home following discharge, versus 43 percent overall. Hospital-initiated home visits are also half as likely to include a home assessment as visits by the overall surveyed population (16 percent of hospitals versus 37 percent of respondents overall).

A case manager most often conducts the home visit on behalf of the hospital; this sector is only one-fourth as likely to send a nurse practitioner on this visit (5 percent of hospitals versus 16 percent overall). The visits focus on key aspects of the discharge care plan: medication reconciliation, red flag recognition and patient/caregiver education.

That said, hospital case managers are more likely than their industry counterparts to offer palliative care during the visit (35 percent versus 29 percent overall), but only about half as likely to discuss nutritional status (29 percent versus 52 percent overall) or assess activities of daily living or ADL (24 percent versus 40 percent overall).

Chart reviews and EHRs comprise responding hospitals’ primary method of identifying patients in need of home visits. This sector is twice as likely to conduct home visits for 10 percent or less of its patient population (65 percent versus 37 percent overall).

Despite the frequency with which it conducts home visits, hospitals are twice as likely to report no return on investment from home visit programs (17 percent versus 9 percent overall), and are twice as challenged by home visit funding/reimbursement (61 percent versus 36 percent overall) and technology limitations (11 percent versus 6 percent overall).

Source: 2013 Healthcare Benchmarks: Home Visits

Home Visits

2013 Healthcare Benchmarks: Home Visits examines the latest trends in home visits for medical purposes, from the populations visited to top health tasks performed in the home to results and ROI from home interventions. This 40-page report analyzes the responses of 155 healthcare organizations to HIN’s inaugural industry survey on home visits.

Home Health on Care Transitions Management: Focus on Post-Acute to Home Handoff

April 7th, 2015 by Patricia Donovan

With the hospital-to-home care transition deemed the most critical by half of healthcare organizations, home health sits on the front lines of care transitions management.

An overwhelming majority of home health organizations, which comprised approximately 10 percent of respondents to HIN’s 2015 survey on Care Transitions Management, have a care transition management program in place: 80 percent versus 67 percent overall, and of those that don’t, 100 percent intend to implement one in the next 12 months, versus 56 percent overall.

Contrary to overall respondents, this sector considers the hospital to post-acute care transition key (50 percent versus 24 percent overall) as well as the post-acute care to home handoff (50 percent versus 9 percent overall).

Heart failure is the top health condition targeted by home health organizations (87 percent of respondents, versus 81 percent overall). This sector also targets acute myocardial infarction, or AMI (62 percent versus 51 percent overall), and the frail elderly, a top concern for 75 percent of this sector versus 44 percent overall.

Half of home health organizations surveyed self-developed care transitions programs (50 percent versus 34 percent overall). Similarly to most respondents, programs include medication reconciliation (87 percent versus 75 percent overall) and transition/handoff training (87 percent versus 39 percent overall). This sector also relied on telephonic follow-up (87 percent 79 percent overall) in their care transition programs.

Transition coaches were primarily responsible for coordinating care transitions, according to 37 percent of home health respondents, versus 25 percent overall.

Some ways home health organizations improved transitions of care included creation of community partnerships with acute care facilities, development of post-acute networks, and collaborations with all clinical and hospice providers.

Successful strategies for this sector included separating data input from hands-on patient discharge paperwork so clinicians doing the transition could focus more on the patient, and not typing. Also, maintaining open communication with all staff and following up on communication with the patient and/or caregiver to ensure they transitioned appropriately into the new setting helped them to identify any concerns in the hopes of avoiding an unnecessary hospitalization.

Provider engagement remains the biggest challenge to this sector’s transition management efforts, say 37 percent of home health organizations, versus 13 percent overall.

Source: 2015 Healthcare Benchmarks: Care Transitions Management

http://hin.3dcartstores.com/Chronic-Care-Management-Reimbursement-Compliance-Physician-Requirements-for-Value-Based-Revenue_p_5027.html

2015 Healthcare Benchmarks: Care Transitions Management HIN’s fourth annual analysis of these cross-continuum initiatives examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and delivery of value-based care.

Communication During Care Transitions: Technology, Templates Clarify Handoff Message

March 19th, 2015 by Patricia Donovan

With communication between care sites a top barrier to efficient transitions for one quarter of respondents, HIN’s fourth comprehensive Care Transitions Management survey pinpointed information tools getting the message across during patient discharge and handoff.

Technology offers a leg up by way of telehealth and remote monitoring, respondents said; 75 percent of respondents transmit patient discharge or transition information via electronic medical records (EMR).

2015 Care Transition Survey Highlights

  • Discharge summary templates are used by 45 percent of respondents.
  • Beyond the EHR, information about discharged or transitioning patients is most often transmitted via phone or fax, say 38 percent of respondents.
  • Twenty-seven percent of respondents record patient discharge instructions for patients’ future access.
  • After communication, inconsistent follow-up is the most frequently reported barrier to care transition management, say 21 percent of respondents.
  • The hospital-to-home transition is the most critical transition to manage, say 50 percent of respondents.
  • Home visits for recently discharged patients are offered by 49 percent of respondents.
  • Heart failure is the top targeted health condition of care transition efforts for 81 percent of respondents.
  • A history of recent hospitalizations is the most glaring indicator of a need for care transitions management, say 81 percent of respondents.
  • Beyond the self-developed approach, the most-modeled program is CMS’ Community-Based Care Transitions Program, say 13 percent of respondents.
  • Eighty percent of respondents engage patients post-discharge via telephonic follow-up.
  • A majority of respondents—72 percent—assign responsibility for care transition management to a healthcare case manager.
  • Download an executive summary of the February 2015 Care Transitions Management survey.

14 Protocols to Enhance Healthcare Home Visits

January 20th, 2015 by Cheryl Miller

Use of telemonitoring equipment, electronic medical records (EMRs), a staff dedicated to monitoring home visits and engaged caregivers are just some of the protocols used to enhance home visits, according to 155 respondents to the Healthcare Intelligence Network’s most recent industry survey on home visits.

Following are 10 more protocols used to improve the home visit process:

  • Inclusion of home visiting physician in hospital rounds; and the collaboration of home visit physician with primary care physician (PCP) and complex case managers.
  • Using our medication management machines with skilled nursing follow-up to increase medication compliance.
  • Proactive phone calls to determine if a patient’s condition is worsening and in need of home visits.
  • Daily workflow management algorithms with prioritization and mobile access to electronic case management records.
  • Using teach-back to assure comprehension.
  • Easy to use/wear multimodal, advanced diagnostics telemonitoring allowing patients total mobility and continuous real-time monitoring.
  • Medication reconciliation is crucial in eliminating confusion for the patient, and our electronic medical record (EMR) accurately reflects what the patient is taking, including over-the-counter (OTC) and supplements.
  • Hospital coach gathers information and prepares the patient for discharge, coordinates with home visit staff, home visit team (coach and mobile physician) and completes home visit.
  • Portable EMR to document and review medical information on the spot.
  • EHR-generated lists, community-based team, community Web-based tracking tool, telehome monitoring devices, preferred provider network with skilled nursing facility/long-term acute care (SNF/LTAC), home health and infusion therapy.

Source: 2013 Healthcare Benchmarks: Home Visits

http://hin.3dcartstores.com/2013-Healthcare-Benchmarks-Home-Visits_p_4713.html

2013 Healthcare Benchmarks: Home Visits examines the latest trends in home visits for medical purposes, from the populations visited to top health tasks performed in the home to results and ROI from home interventions.

Sentara Home Visits for High-Risk ‘VIPs’ Drive Hybrid Case Management Outcomes

November 13th, 2014 by Cheryl Miller

When the Sentara Medical Group evolved to a hybrid embedded case management model in 2012, case managers spent time in the practice, but also managed care through other touch points, including home visits, explains Mary M. Morin, RN, NEA-BC, RN-BC, vice president, nurse executive with Sentara Medical Group. How to identify high-risk patients for case management, and home visits in particular? Here, Ms. Morin addresses that question posed by The Healthcare Intelligence Network during a recent webinar.

Question: How does Sentara identify high-risk patients for case management in general and for home visits in particular? Do all patients in the case management program receive home visits?

Response: (Mary M. Morin) This program started as a pilot in 2012. It was targeted at patients that we called very important patients — high-cost, high-utilizers, the top of the pyramid. There are about 2,300 patients within 11 of our primary care sites. We kept it small, with five RN care managers. That population included all payors, most importantly our health plan patients. Because of our health plan, we were able to really study whether RN care management had an impact on the total cost of care — not unlike other organizations, if you can find a cost savings and justify the expense of having RN care managers, it makes the case much more solid moving forward with formalizing the program.

We sorted those patients by high-risk, high-cost or high-cost, high-utilizers because of chronic diseases. We looked at patient with congestive heart failure (CHF), chronic obstructive pulmonary disorder (COPD), asthma, renal failure and diabetes. We excluded patients that had any traumatic event like a car accident or something that led to high-cost, or they had cancer or they were a transplant patient.

The purpose was to engage that population. It is voluntary. We studied that population for three years. It allowed us to measure our outcomes over time because we weren’t sure if there was seasonality to the patients with chronic disease: did they just not use services because of seasonal issues or because it’s a cycle issue within the chronic disease phase? After three years of data, we determined there is definitely a difference in the outcomes of this patient population and their utilization.

Home visits was one of the big differences in the model. The main reason to do home visits is not to do patient care, but to do an assessment of the patient’s environment. A lot of times, patients don’t share with us their actual living situation. They tell you that they’re walking, and then you find out they walk within a five-foot radius. The real emphasis for home visits was to get in and meet the patient in their environment.

We found that RN care managers in the home facilitated advance care planning. That is best done in the patient’s home with a family member present, not in the doctor’s office or waiting until the patient is admitted to the hospital. We found that patients appreciated the visits. The RN care managers who went in really cleaned up the medications. Patients will hold on to medications.

value-based reimbursement
Mary M. Morin, RN, NEA-BC, RN-BC, is a nurse executive with Sentara Medical Group, where she is responsible and accountable for non-physician clinical practice within the Sentara Medical Group (160 clinics/practices) to ensure integration and alignment with Sentara Healthcare, regulatory compliance, standardization of nursing practice/care, and patient safety.

Source: Hybrid Embedded Case Management: New Model for Cross-Continuum Care Coordination

7 Lessons from a Health Network’s Home Visit Program

September 23rd, 2014 by Melanie Matthews

Home visits to patients with complex care needs can provide huge returns by identifying patient compliance barriers that are only apparent when seeing a patient in their home. Dr. Larry Greenblatt, M.D., director for the chronic care program at Durham Community Health Network for Duke University Medical Center, shares organizational lessons from using home visits as part of a care transition program to reduce avoidable hospital readmissions and emergency room utilization.

With our patient population, none of these patients in the program have simple or single diagnosis. We learned that Care Partners providing intensive and frequent service with a strong face-to-face component backed by an interdisciplinary support team can help high-utilizing patients receive their care in more effective and efficient outpatient settings.

Second, when using previous programs that focused on telephone education and advice, we discovered that the face-to-face interactions have a direct impact on these patients and their ability to change their care model.

Third, we discovered that, if effective on a larger scale, our care model could be used nationally as a significant means of reducing healthcare costs.

Fourth, this intervention reduced unplanned admission days by 77 (71 percent) in three months. This reduction greatly benefits the medical patients and gives us increased capacity for new admissions. It also improves the life and the care of those patients who are involved in the program.

Fifth, most of our pilot patients had unmet mental health and substance abuse problems and had difficulty obtaining needed services. That was another benefit of having the multidisciplinary team sitting around the table as we did care conferences on our patients on a weekly basis. We actively addressed the mental health needs to help get a patient’s medical issues taken care of and result in higher benefits from our care being linked to all of the care.

Sixth, this multidisciplinary approach, direct face-to-face contact and ongoing telephone contact is the secret in making this program work.

And finally, patients often did not have a primary care provider at the beginning of the pilot and they benefited from being linked with one. Finding them a medical home was important and made the patients feel more comfortable with continuing to keep outpatient appointments.

home visits
Dr. Larry Greenblatt, MD, is the medical director for the chronic care program at Durham Community Health Network. Dr. Greenblatt is also an associate professor of medicine at Duke University Medical Center, where he has been on the faculty since 1994. Dr Greenblatt focuses on postgraduate medical education and primary care.

Source: Home Visit Handbook: Structure, Assessments and Protocols for Medically Complex Patients

Community Health Network Retools Readmissions Ruler for High-Risk Heart Failure Patients

September 9th, 2014 by Patricia Donovan

From the many evidence-based health risk stratification tools available, Community Health Network has adapted a popular hospital readmissions indicator for use with medically complex patients at high risk of readmissions. Deborah Lyons, MSN, RN,NE-BC, network disease management executive director for Community Health Network, describes the adaptation process.

HIN: Where do home visits for heart failure patients enter the picture?

Deborah Lyons: We do a high-risk home assessment while we have patients in the hospital. Fully 100 percent of our patients that are admitted to inpatient status are automatically screened and ranked in terms of readmission risk. That’s where we use the LACE/ACE tool. We embedded that tool in our software so it can predictively tell us which patients to focus on.

HIN: How did you decide on the LACE tool? Is the ACE tool different than the LACE tool?

Deborah Lyons: The LACE itself is evidence-based. We work with the advisory board. And they had just done an analysis of all the predictive models out there in terms of readmission risk when we started this work. There were only two tools that were moderately predictive for risk. LACE was one of them. LACE looks at length of stay (L), acute admission (A), (meaning they came in through the emergency room), their Charleston Comorbidity score (C) and the number of ED visits (E) they’ve had in the past six months.

All this information was easily available to us at the time that we did this because we were on a different computer system. But the concern was that the L factor (length of stay), might lead us to place the patient at high risk when they were leaving the hospital. Maybe they started at low risk and then on the fourth day of stay, because they had been there four days, now they moved to high risk but they’re being discharged. You really can’t do anything at day of discharge. We first set a threshold for LACE, which we tested and validated and then ran a correlation and asked ourselves, “If this threshold is a LACE high risk, what would a correlating threshold be if we dropped the length of stay?” That’s how we moved to an ACE score.

Source: Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics

Stratifying High-Risk Patients


Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics
Reviews a range of risk stratification practices to determine candidates for health coaching, case management, home visits, remote monitoring and other initiatives designed to engage individuals with chronic illness, improve health outcomes and reduce healthcare spend.

Home Visits 101: Empower the Patient, and Don’t Forget the Gloves

September 2nd, 2014 by Patricia Donovan

It’s hard to plan a home visit for a recently discharged patient if you don’t know they’ve been in the hospital. Obtaining data on hospitalized patients is one of the challenges of administering a home visits program, notes Samantha Valcourt, MS, RN, CNS, a clinical nurse specialist for Stanford Coordinated Care (SCC), a part of Stanford Hospital and Clinics.

Some of the challenges I’ve experienced with our home visits program is first of all, knowing when our patients are actually in the hospital. It’s easy to know when they’re at SCC; I get an electronic communications or an EMR. However, if patients go outside our system, I may not know. Sometimes that discharge summary is not available when I’m ready to go see the patient the day after. Holidays and weekends always increase that 48- to 72-hour window and I really do try to get in there the following day if possible.

For patients that don’t see primary care doctors within our clinic, it can sometimes be a challenge getting hold of their primary care doctor outside of SCC, and then explaining my role and why I need them.

On the back of our patient ID card, we emphasize to our patients to please contact us if they’re even considering going to the emergency department so that perhaps we can avoid a hospital admission or a readmission. If they are being seen in the hospital, we want them to call us as soon as they’re there, as soon as they’re able to, or to have their family member call so we can make sure that we’re involved in that transition.

Another lesson learned is definitely to empower the patient. Again, as a nurse I try to do as much for the patient as I can. But I have to keep in mind that when I’m in the home, my goal is to make sure will be able to identify the red flags and symptoms that indicate things are not going well, and that they’ll be able to contact the doctor’s office with their needs. I make sure that both handoffs are very clear; I never want to leave a patient wondering, ‘Oh I had this nurse and she came into my home and then she called me every few days and then all of a sudden she was gone.’

I need to make sure that I have good communication with that next transition.

And then last, I always carry a set of gloves, because you never know what you’ll walk into. I was not a home health nurse before I did these types of home visits, so I was ill prepared on one of my first visits to a patient with a dialysis catheter that was oozing blood. My nursing instinct caused me to run in there and try to clean things up.

Now I carry a good stock of gloves and supplies, because you just never know.

value-based reimbursement
Samantha Valcourt, MS, RN, CNS, a clinical nurse specialist for Stanford Coordinated Care (SCC), a part of Stanford Hospital and Clinics.

Source: Home Visits for High-Risk Patients: Tools, Timing and Outcomes