Archive for the ‘Transitions in Care’ Category

Do You Factor Transitional Care into Medicare Value-Based Reimbursement?

April 8th, 2014 by Patricia Donovan

There is a wealth of assistance available to avoid hospital readmissions penalties.

In the suite of performance-based measurement that currently comprises Medicare reimbursement, a big component of value-based purchasing relates to transitional care, as well to the readmission penalty program, notes Amy Boutwell, MD, MPP, president of Collaborative Healthcare Strategies and a co-founder of the IHI STAAR (State Action on Avoidable Rehospitalizations) Initiative, Dr. Boutwell is also senior physician consultant to the National Coordinating Center for the CMS QIO Care Transitions Theme.

All of these elements factor into your Medicare reimbursement over the next several years. The good news is that along with these penalties and performance-based value purchasing strategies, there is a wealth of technical assistance available to hospitals and community-based teams trying to improve care transitions. There are literally hundreds of millions of dollars in technical assistance that has been funded by CMS and the Administration on Aging to help hospitals and community-based partners such as area Agencies on Aging and others work together to improve care transitions to reduce readmissions.

Many of you are very familiar with the Hospital Engagement Networks. I want to remind you that the Quality Improvement Organizations (QIOs), of which there is one in every state, have been charged through their contracts to help communities. Groupings of hospitals and of post-acute providers in regional geographies help to improve care transitions and care coordination across settings. Take advantage of the wealth of other programs and incentives that are coming out of the federal government in this domain.

We know the readmission penalties are here to stay and there will be time lines between your good efforts at the pilot level today and your ability to see those numbers move in terms of getting your hospital out of the penalty zone. In my experience, we do need to move quickly from pilot projects to a portfolio of work to help make some traction on readmission performance for hospitals. I always go back to the STate Action on Avoidable Rehospitalizations (STAAR) initiative, which I co-founded. Its how-to guide to reducing hospital readmissions is the broadest stroke guidebook that is out there.

Some toolkits have a very fine level of detail, which is very helpful; the STAAR toolkit contains broad concepts. I hope it is helpful to teams. These days, I’m seeing hospitals take good ideas from everywhere and put them together into one strategy based on their own resources and cross analysis.

Excerpted from 33 Metrics for Care Transition Management.

Top Tools, Workflows and Processes for a Patient-Centered Medical Home

February 4th, 2014 by Patricia Donovan

Online tools such as EHRs and registries facilitate care coordination in the patient-centered medical home.


Chart scrubbing, electronic medical records and disease registries form the framework of patient-centered care, according to respondents to the 2012 Patient-Centered Medical Home survey. The following tools, workflows and processes are enhancing patient-centered care delivery by responding organizations, as told in their own words:

  • Added patient advisory council, which has made great suggestions.
  • ‘Electronic medical record (EMR) lite’ with secure e-mail.
  • Extended hours obviating urgent care centers or ER visits.
  • Chart scrubbing: review of the charts of patients coming in for appointments so that the provider is made aware of everything that needs to happen at that visit so it can be taken care of proactively.
  • Microsystems.
  • Registry management.
  • Using lower level (education) workers in the process.
  • Patient profile to include all providers, specific care gaps, etc.
  • Discharge reconciliation registry.
  • Our EMR is the most effective; it supports everything else. Secondly, standardized written protocols/standing orders that allow the healthcare team to provide care that increases office efficiency and quality indicators.
  • It’s not about the tools, it’s about training the people to use the tools effectively and efficiently. ‘LEAN’-ing is not a cure; it’s another aspect of training.

Excerpted from: 33 Metrics for Care Transition Management

3 Nurse Navigator Tools to Enhance Care Management

January 29th, 2014 by Jessica Fornarotto

Where does the nurse navigator spend their day? Certainly on transitions of care. Bon Secours Health System nurse navigators use a trio of tools to identify patients' obstacles to care and connect them to needed resources, explains Robert Fortini, vice president and chief clinical officer of Bon Secours Health System.

One tool that our nurse navigators use that's built into our EMR is the hospital discharge registry from Laburnum Medical Center, one of our largest family practice sites with about nine physicians. This tool is used to identify which patients the navigators need to work with, and it's where the navigators begin and end their day. This registry provides a list of all the patients who have been discharged from one of our hospitals in the last 24 hours, and each patient is listed by the physician. The navigators have to reach out to each of these patients and make telephonic touch within 24 to 48 hours of discharge. Medication reconciliation is extremely important at this time and can be very challenging. When a patient goes into a hospital, often their medications get scrambled, and they come out confused and taking the wrong prescriptions. Nurse navigators spend a lot of time on medication reconciliation at this point.

The Navigators also conduct 'red flag' rehearsals with this tool, so that the patient knows the signs and symptoms of a worsening condition and what to do for it. We also schedule the patient with a follow-up appointment, either with a specialist who managed the individual in the hospital or with their primary care physician. We try to do it as close to the time of discharge as possible, within five to seven days, or more frequently if the risk of readmission is higher.

Second, nurse navigators also use a documentation tool to help manage the care of heart failure patients. This tool allows the navigator to stage the degree of heart failure using a hyperlink called the 'Yale tool.' The Yale tool allows us to establish what stage of heart failure the patient is in: class one, two, three, or four. Then, a set of algorithms is launched based on these stages' failure; we manage the patient according to those algorithms. For example, if a patient falls into a class four category, we might bring them in that same day, or the next day, for an appointment rather than wait five or seven days because they're at more risk. We might also make daily phone calls or network in-home health, as well as make sure that the patient has scales for weight management and an assessment of heart failure status. All of those interventions will be driven by the patient's class of heart failure.

The last tool we use is a workflow for ejection fractions. The patient's ejection fraction will define specific interventions that the navigator will follow.

Excerpted from: Profiting from Population Health Management: Applying Analytics in Accountable Care.

5 Barriers to Optimal Care in the Post-Acute Setting

January 22nd, 2014 by Jessica Fornarotto

Summa Health System's care coordination network of skilled nursing facilities (SNFs) is working to decrease fragmentation, length of stay and unnecessary readmissions while improving outcomes of care. Mike Demagall, administrator of Bath Manor & Windsong Care Center, a participant in this network, identified five barriers to patient care that originated in the acute care setting.

First, we found a lack of quality information received upon transfer from an acute care to a nursing facility and the lag time in identification of post-acute bed availability. The social worker was calling or faxing information to a facility, and the facility took up to 24 hours to respond as to whether a bed was available. That person may have been ready that day; instead it postponed that discharge another day.

We also had barriers to the patient’s acceptance of the need for post-acute care. Social workers and care coordinators at the bedside tell them when it is time for rehabilitation.

The next barrier was family expectations. Does the family feel that they need to go to the nursing home? The hospital staff and the insurers had to spot the appropriate levels of care. One of the concerns we had was, 'Is this going to send a lot of our patients — our referrals — to home healthcare and decrease our referrals by participating in this?' That happened to not be the case at all.

There was still a lack of knowledge and respect toward long-term care (LTC). All the discharge planning individuals, which were the case manager nurses and social workers, were able to tour the facility. Each facility had the opportunity to present their services and what they do. That helped with the overall cohesion of the group, and it moved this project forward.

There was also a lack of quality information received from the nursing facilities on the transfer to an emergency department (ED). That was information that we needed to get back, just as we were asking for information as those residents were coming in.

Excerpted from: 7 Patient-Centered Strategies to Generate Value-Based Reimbursement

5 Pillars of Stanford Coordinated Care Home Visits

December 31st, 2013 by Patricia Donovan

Connecting its high-risk patients to essential community resources is the fifth pillar of Stanford Coordinated Care's post-discharge home visits program.

This community connection for complex patients rounds out the four elements of the CTI that take place during each home visit: medication reconciliation, red flag education, follow-up physician visits, and a personal health record (PHR).

"We think it’s important to get the patient hooked into whatever resources in the community can also help them to have good outcomes and not have to go back into the hospital," explained Samantha Valcourt, clinical nurse specialist with Stanford Coordinated Care, during a recent webinar on Home Visits: Assessing Complex Patients Post-Discharge to Reduce Readmissions.

These local resources might include recruiting the patient's church group to visit or assist with meals preparation, she said.

Stanford visits their just-discharged complex patients in the home environment because it offers a close look at the individual's mobility, safety, nutrition status and support system. Of the five-point program, medication reconciliation is the most important task performed during the home visit, Ms. Valcourt noted.

Medication management problems immediately following the hospital discharge are a key factor driving hospital readmissions among high-risk Medicare beneficiaries, she said.

Just as it modified the CTI to suit its population, Stanford has added three questions to the HARMS-8 readmissions risk assessment tool developed by Care Oregon to identify patients who would benefit from a home visit. The post-discharge visits, which last about an hour on average, are conducted by Ms. Valcourt, an advanced practice nurse. Her preparation for the home visit begins when the patient is still in the hospital, she explains.

"About 20-25 percent of my time is spent on the pre-work and post-work around home visits, such as seeing the patient in the hospital, reviewing hospital notes and the discharge summary, coordinating with the PCP and care coordinator, and making follow-up phone calls."

Among the process and outcome measures Stanford uses to evaluate the effectiveness of the home visits, which are separate from traditional home care, is the Patient Activation Measure®, which identifies a patient's level of engagement in their own care.

Although program results are anecdotal at the one-year point, Stanford hopes the home visits will not only reduce rehospitalizations in the approximately 200 high-risk patients it serves, but also reduce lengths of stay, empower patients to partner in their care, improve patient satisfaction and bridge the hospitalist-primary care provider gap, Ms. Valcourt noted.

Ms. Valcourt provides more details on Stanford Coordinated Care's home visits program in this interview.

Infographic: Informal Care Givers – $234 Billion Job Goes Unpaid

December 19th, 2013 by Jackie Lyons

Nearly nine in 10 Americans who need some form of long-term care (LTC) get assistance from family members or friends who volunteer their time. An estimate of this work adds up to $234 billion, according to a new infographic from PBS.

This infographic also shows how this compares to the GDP and total U.S. LTC costs, and reasons why these costs will continue to grow.

$234 Billion Job Goes Unpaid

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.

You may also be interested in this related resource: Implementing Culture Change in Long-Term Care: Benchmarks and Strategies for Management and Practice.

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

Infographic: Giving Thanks for Caregivers

November 28th, 2013 by Jackie Lyons

As the baby boomer population continues to age, the need for long-term care continues to increase.

Sixty-five million family caregivers in the United States provide care for chronically ill, disabled, or aged family or friends, according to a new infographic from ACSIA, Long Term Care Inc. This infographic presents the duties, effects and financial aspects of care giving, along with statistics and facts regarding caregiver education and health.

Top 15 Enlightening Facts about Caregivers

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.

You may also be interested in this related resource: Guide to Care Transition Management.

One-Minute Health Metrics Video: Home Visits for Medically Complex Patients

October 1st, 2013 by Jackie Lyons

Forget yesterday's house calls; today's home visits for homebound or medically complex patients enhance the patient experience by helping individuals meet everyday needs, avoid rehospitalization or an ER visit, and connect with community resources.

In fact, three-fourths of healthcare organizations visit some percentage of their patients or health plan members in their homes. This One-Minute Metrics video summarizes home visit practices of 155 healthcare organizations from HIN's Healthcare Benchmarks market research.

You may also be interested in this related resource: 2013 Healthcare Benchmarks: Home Visits.

Infographic: A Short Look at Long-term Care for Seniors

September 16th, 2013 by Jackie Lyons

Under the ACA, there are provisions for states to expand Medicaid to help people receive long-term care (LTC) services. Still, as baby boomers age, the need for LTC increases.

Thirty-five percent of U.S. adults 40 years or older say they have set aside money for their long-term needs, according to a new infographic from the Journal of the American Medical Association. This infographic also includes information about the number of seniors who will need LTC, the role of Medicaid as the primary payor for LTC, the shifting of Medicaid spending from institutional-based care toward community-based care and more.

A Short Look at Long-term Care for Seniors

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.

You may also be interested in this related resource: Formula for CMS Five-Star Quality Population Health Management.

Infographic: Long-Term Nursing Facilities – Golden Years?

September 9th, 2013 by Jackie Lyons

About 1.5 million Americans live full-time in nursing facility, amounting to costs of more than $100 billion per year.

Nursing home rooms cost an average of $75,190 for a private room and $66,795 for a semi-private room, according to a new infographic from Nursing School Hub. This infographic also identifies who's footing the bill for long-term care and details nursing facility occupancy and cost by state, average facility statistics, types of care and quality care deficiencies.

Golden Years?

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.

You may also be interested in this related resource: Chronic Care Professional Manual 5.0 .