Archive for the ‘Transitions in Care’ Category

Home Visits for the High-Risk: Targets, Timelines and Training

July 29th, 2014 by Patricia Donovan

Many patient-centered medical home (PCMH) initiatives have added home visits to care transition management to reduce avoidable hospital readmissions and ER utilization. Jessica Simo, program manager with Durham Community Health Network for the Duke Division of Community Health, describes likely candidates for home visits, the structure of a typical home visit and recommended staff training.

HIN: Which diagnosis or patient profile benefits most from a home visit?

(Jessica Simo) As a general rule for the patient population we serve, the people who get the most home visits are middle-aged individuals with at least two chronic health conditions. These are not generally healthy individuals who had one adverse event that brought them to our attention. These are people living day in and day out with chronic health problems they struggle with managing. Those people benefit the most from the amount of time it takes to do a home visit.

HIN: What is the average length and typical format of a home visit?

(Jessica Simo) The average home visit lasts 45-60 minutes. It would be longer for the initial home visit when an assessment is being done—where the Care Partner (a partnering stakeholder from across the Duke University health system and the Durham community) collects information for the first time about medications the patient takes, their sources of support, ADL deficits, etc. Those visits tend to be a bit longer, certainly an hour at a minimum, but once that rapport has been established, the weekly visits are often less than an hour. They become briefer as a patient transitions from phase one to phase two of the Care Partners Pathway because there is less to talk about at that point. This is a good thing; it means they are improving.

The home visits are structured around assessments and protocols, but as the home visits progress and the care partner becomes more familiar with the patient, there is less reliance on assessments and more on follow-up from the previous week.

HIN: How do you prepare and train staff to conduct home visits?

(Jessica Simo) The best way to prepare somebody to do home visits is to have them shadow a more experienced staff person. There are too many independent variables at play when you go into somebody’s home and you just don’t have control over that environment. Nor should you. It’s impossible to anticipate every possible scenario. Therefore, we do a lot of shadowing for at least a month before someone does a home visit on their own.

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

Snapshot of CMS Bundled Payment Care Initiative

July 1st, 2014 by Patricia Donovan

From both transparency and best processes standpoints across the entire nation, post-acute care presents an incredible opportunity to streamline not only the staging but also the quality of care provided to Medicare beneficiaries, notes Kelsey Mellard, vice president of partnership marketing and policy for naviHealth, a convener for Models 2 and 3 of the CMS Bundled Payment Care Initiative (BPCI).

Bundled payments touch four opportunities to engage providers in various settings. Model 1 is for retrospective acute care episodes, which focus only on the acute hospital stay. Model 2, which is where naviHealth is most engaged to date, is retrospective acute care hospitals plus the post-acute care. Our goal is building alignment—not only financial alignment but also quality alignment across both the hospital and the post-acute care settings, regardless of whether it’s a home health agency, a skilled nursing facility (SNF), an inpatient rehabilitation facility (IRF) or a long-term care hospital (LTCH). With model 3, we just have the episode focused on the retrospective post-acute care only. Finally, model 4 is for acute care hospital stays only.

Within these four models to date, we’ve seen over 300 organizations sign up and be active in phase 2, which means that they are in the risk-bearing phase. They are financially bearing risks for an episode based on the target sites that CMS has generated. Primarily, the 300 are split between Model 2 and Model 3. The first model, retrospective acute, is most active in the New Jersey market, model 4 has a few hospitals that are scattered throughout the country.

NaviHealth went live focusing on model 2 for a couple of reasons in January 2014, with 11 hospitals in five states. We will expand again in October and will further expand starting January 1, 2015, given the time frame that CMS has allowed us to continue our expansion and our partnerships as an awardee convener.

CMS is keenly focused on the variation of post-acute care, based on the most recent Institute of Medicine (IOM) report stating that if regional variation in post-acute care did not exist, we would see Medicare spend variations fall by 73 percent.

From a transparency standpoint and from a best processes standpoint across the entire nation, post-acute care has an incredible opportunity to streamline not only the staging, but also the quality of care provided to Medicare beneficiaries.

Excerpted from: Inside CMS' Bundled Payments Pilot: Profitable Post-Acute Care Partnerships

Nurse Practitioners Slowly Gain More Access to Patients; Could Relieve Anticipated Physician Shortage

June 5th, 2014 by Cheryl Miller

Patients are slowly gaining access to care provided by advanced practice registered nurses (APRNs) as a number of states have taken steps to loosen restrictions on highly educated nurse practitioners (NPs).

Minnesota became the 19th state, plus the District of Columbia, tooffer patients full and direct access to NP service. According to the American Association of Nurse Practitioners (AANP), it is an important step that improves access to care and more effectively uses NPs to meet the state's growing healthcare needs. Officials state the following in a press release:

This comes at a time when the changing demographics of health care, especially primary care, necessitates that states make full use of the nurse practitioner workforce. The nursing community is committed to addressing these challenges in future sessions to ensure that patients have a choice of health provider and receive full access to the health services they need.

Maryland was one of the first states to loosen existing restrictions, according to a story from the Robert Wood Johnson Foundation (RWJF). In 2010 the state replaced its requirement for lengthy collaborative agreements between NPs and physicians with less cumbersome “attestation statements” that identify a physician who is willing to collaborate when clinically necessary but do not require physician signatures.

The law eliminated situations where patients were left without care if their physician died, retired, or left the state. NPs can now open practices and serve larger patient populations. This has helped with the primary care shortage in Maryland.

And the shortage is not limited to Maryland. As the Healthcare Intelligence Network reported in a previous news story in 2013, the RAND Corporation predicted that as more Americans seek health services once newly insured under the Affordable Care Act (ACA), physician shortages could worsen, and reach as high as 45,000 by 2025.

And the recent Veterans Affairs problem that is making headlines around the world has been attributed to a shortage of primary care physicians (PCPs), as documented here in the New York Times.

Expanding the role of nurse practitioners and physician assistants could help eliminate the anticipated shortage of PCPs over the next decade, the RAND report suggested.

Other states that have taken steps to ease NP restrictions in recent years include the following:

  • In Utah, state Medicaid officials agreed to recognize and reimburse NPs for primary care services for beneficiaries.
  • Oregon’s governor signed a law that allows NPs and clinical nurse specialists to dispense prescription drugs.
  • In Iowa, the state Supreme Court ruled that NPs can supervise fluoroscopy, a high-tech X-ray, without physician supervision.
  • In 2011, North Dakota scrapped a requirement that NPs work in collaboration with physicians.

But these changes are not without their controversy. Some feel that it goes too far, that the supervision of a physician should be maintained. According to this editorial in the Times-Herald Record, "though well intentioned, such proposals underestimate the clinical importance of physicians' expertise and overestimate the cost-effectiveness of nurse practitioners."

Other areas of healthcare pose the same challenge. In Minnesota, a state law allows dental therapists to work under the supervision of dentists and perform many of the tasks they do, something that has been opposed nationally and in most other states.

But the field of NPs is also changing. First created in 1965 to meet the growing demand for basic pediatric care, by 2015 all new NPs will need to be trained at the doctorate level as a Doctor of Nursing Practice, and 104 new DNP programs are in development, according to a new infographic from Maryville University Master of Science in Nursing Online.

6 Criteria for Evaluating Vendor Partners for Remote Patient Monitoring

April 22nd, 2014 by Patricia Donovan

Just as there are guidelines for identifying individuals most likely to benefit from remote monitoring, healthcare organizations must also choose remote monitoring vendor partners with care, advises Gail Miller, vice president of telephonic clinical operations in Humana's care management organization, Humana Cares/SeniorBridge, who shared lessons gleaned from vendor selection for Humana's nine separate pilots of remote patient monitoring.

I want to share how Humana chose the partners that we work with in these programs, because there are so many potential vendors to work with in the remote monitoring space. We had been evaluating companies off and on for about a year. We ended up doing a request for information (RFI) process with the top 25 we had identified internally. They weren't necessarily the biggest vendors or the companies with the strongest balance sheet, but rather those that met the different capability criteria we were looking for and possessed the flexibility and creativity to work with us.

Some think that it’s a good idea to warn people when you’re going to be working with a large entity like Humana, so that the companies we choose are prepared to deal with our procurement and legal processes, and understand it will take some resources on their side. Since the change to the HIPAA rule in 2013 there iss more downstream liability, so we require additional business liability insurance, and our business information agreements are quite stiff. All of those things must be worked through before we can work with a vendor.

We were also looking for companies that could be easily scalable. You could have a great piece of equipment, but if it’s going to take ten months or a year to procure another thousand, that’s not going to work for us because we have to be thinking on a national basis. We also were looking for vendors willing to work with members with various home situations. We did not want to exclude anybody from our pilot.

For example, some of the equipment we looked at would only run if there were broadband in the home. We needed someone to put some type of device that they could plug in, that would help boost them or create a 4G or 3G network wherever they were. We needed to adapt to the different home situations that our individuals lived in.

Then, the equipment had to be senior friendly. We learned a lesson from a great study with Intel about three years ago. The results had some positives and some negatives, but one thing we learned was that the size of the equipment was important. At that time, the piece of equipment we were using weighed about 37 pounds. Because of the frail nature of some of our members, we had to hire an intermediary to do setup and delivery and then package it up and send it back afterward. It created a lot of extra cost and a little more confusion trying to arrange those deliveries and pickups.

One thing that we are dedicated to doing this time is making sure that whatever equipment we had in the home that we could manage it easily, and that hopefully the senior themselves or their caregiver would be able to set it up.

Excerpted from: Remote Patient Monitoring for Enhanced Care Coordination: Technology to Manage an Aging Population

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

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