Archive for the ‘Hospital Readmissions’ Category

Reducing SNF Readmissions: Clinical Targets, Quality Scorecards Elevate Performance

May 23rd, 2017 by Patricia Donovan

reducing SNF readmissions

Michigan's Tri-County Collaborative holds the line on hospital readmissions from 130 participating SNFs.

Three geographically close Michigan health systems shared more than a concern over escalating readmissions from skilled nursing facilities (SNFs).

As Henry Ford Health System (HFHS), the Detroit Medical Center and St. John's Providence Health System ultimately discovered from Michigan Quality Improvement Organization (MPRO) data in 2013, they also shared about 30 percent of their patient population.

This revelation, combined with the pinch of new hospital readmission penalties from the Centers for Medicare and Medicaid Services (CMS), prompted the three to set aside competition and siloed strategies and forge a coordinated approach to reducing readmissions from SNFs.

Today, the resulting Tri-County SNF Collaborative operates with a set of clinical and quality targets and metrics created in tandem with more than 130 member SNFs. Tri-County's dozen participation requirements for SNFs range from regular reporting through a dedicated SNF portal to achievement of specified performance metrics.

"We developed collaborative relationships," explained Susan Craft, director of care coordination for the family caregiver program in HFHS's Office of Clinical Quality & Safety. "We wanted to have very open, honest conversations to review issues that were identified and find ways to resolve those."

Ms. Craft shared the roots, framework and results of the SNF collaborative, which launched in the first quarter of 2015, during Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvements, a May 2017 webcast now available for replay.

Once admitted to the collaborative, member SNFs must report on 14 metrics in four key areas: acuity, care transitions, quality and readmissions. In return, SNFs receive a 13-point unblinded quarterly scorecard with metrics on readmissions and patient acceptance response times, among many others.

A multidisciplinary team within Tri-County Collaborative reviews all SNF metrics bi-annually to determine each facility's continued participation.

As for the collaborative's impact since its launch, Henry Ford Health System achieved a nearly 20 percent drop in Medicare SNF readmissions as well as a 28 percent reduction in SNF lengths of stay. The initiative also identified opportunities for improvement, resulting in enhanced outpatient scheduling and nurse-to-nurse handoffs and interventions focused on SNF-specific issues like sepsis, Ms. Craft explained.

Despite these advancements, the collaborative still faces the inherent challenges of competition and transparency, as well as SNFs' hesitancy to adopt value-based practices. "Our SNFs are still entirely dependent on fee for service [payment models]," said Craft. "They haven't been impacted by penalties and value-based purchasing, although that is coming for them next year."

Although not yet referring to participating SNFs as "preferred providers," the collaboratives hopes to one day equip patients with complete data pictures to guide them in SNF selection. Also on Tri-County Collaborative's radar are home care agencies, concluded Ms. Craft.

"We know there needs to be a lot of coordination across all post-acute care settings."

Listen to Susan Craft describe how Michigan's SNF Collaborative set aside competition to improve quality and readmission rates.

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®.

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®.

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Infographic: Top 5 Strategies for Managing Post-Acute Care

April 14th, 2017 by Melanie Matthews

As post-acute care costs increase, now accounting for $1 out of every $4 spent by Medicare Advantage plans, health plans are focusing on post-acute care management, according to a new infographic by CareCentrix.

The infographic examines the top five strategies healthcare organizations are using to manage post-acute care.

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.

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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.

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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.

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In Care Coordination of Medically Vulnerable Homeless Patients, Housing is a Form of Healthcare

January 17th, 2017 by Patricia Donovan

Chronic Care Plus recuperative care reduced ER visits by homeless patients by 84 percent, and avoided nearly $3 million in medical costs.

Most patients discharged from the hospital ultimately return to a secure home environment. Not so for homeless or unstably housed patients; disconnected from healthcare and their community, their lack of stable housing compounds their medical difficulties following a hospital stay.

Enter Chronic Care Plus (CCP), a safety net recuperative care program in California whose mission is to bridge this gap between hospital discharge and permanent supportive housing for homeless patients, or "Joes," as Illumination Foundation Founder and CEO Paul Leon characterized his client profile during a recent presentation.

"I'm sure you can identify the 'Joes' in your neighborhood," Leon told participants during Intensive Care Coordination for Healthcare Super Utilizers: Community Collaborations Stabilize Medically Vulnerable Homeless Patients, a December 2016 webinar now available for replay. "They've come into the ER but are never quite connected with either a federally qualified health clinic (FQHC), your own hospital clinic or any available resources in your community."

The CCP program not only provides housing for recently discharged homeless or unstably housed individuals in model or dormitory-like settings but also reconnects them to the healthcare continuum. The program then wraps clients in a plethora of services, including housing placement, financial literacy, job placement, transportation and behavioral health support.

Back in 2008, Leon's organization was one of only about seven in the nation to provide recuperative care (also known as medical respite care). Recuperative care is care to homeless persons recovering from an acute illness or injury, no longer in need of acute care but unable to sustain recovery if living on the street or other unsuitable place, Leon explained. Today there are about 80 such programs in the United States.

Since then, his foundation created standards and best practices, and in 2013 launched CCP—"recuperative care on steroids, with tightly wrapped social services and a longer length of stay," Leon explained.

Originating as an ED diversion pilot aimed at 20 of the highest users of a local hospital ER, CCP has transformed discharge planning for the homeless and has served more than 2,500 patients since its inception.

During the presentation, Leon shared a host of program analytics, including recuperative care criteria client demographics and CCP statistics on medical, behavioral health, housing and other services provided. He also shared CCP's future plans, and some of the program's barriers and challenges, including medical management education and closing gaps in social services.

In terms of program outcomes, CCP has amassed significant savings as it closes gaps in care and reduces healthcare utilization, including 322 fewer ER visits by this population (a 84.3 percent decrease) and $2.8 million in medical cost avoidance at three participating hospitals.

"For Orange County hospitals as a total, we estimate that there was $5.2 million of savings," added John Kim, grants director of the Illumination Foundation. "If we compare the year prior on an annualized cost basis, that comes to over $7 million of savings to Orange County hospitals."

Click here for an interview with Paul Leon on Chronic Care Plus's challenges and lessons learned as it connects its medically vulnerable homeless to social services.

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.