Archive for the ‘Transitions in Care’ Category

Engage a Pharmacist and 12 More Prescriptions for Medication Management

October 20th, 2016 by Patricia Donovan

Half of medication management programs engage retail or community pharmacists in 2016.

When should a pharmacist be brought in for a medication management consultation?

When the patient requests a consult, experiences general medication adherence issues, or suffers complications from medications, say respondents to the 2016 Medication Management survey by the Healthcare Intelligence Network.

The 101 respondents to the August 2016 survey also indicated that as a general medication management guideline, and with or without a pharmacist's involvement, polypharmacy patients, individuals taking high-risk medications, those registering frequent ER or inpatient stays and those transitioning between care sites should receive priority.

Drilling down to clinical red flags for medication management, a diagnosis of diabetes is a key indicator, say 84 percent, followed by congestive heart failure or hypertension, say 81 percent of respondents.

Despite the inclusion of pharmacists in 90 percent of medication management programs, 42 percent of respondents say pharmacists are not currently reimbursed for medication management-related tasks.

Other medication management metrics documented by the survey include the following:

  • The three most common components of medication management programs are education and health coaching (71 percent), a medication needs assessment (69 percent) and pharmacist counseling (68 percent).
  • A pharmacist-driven clinical assessment is the most reliable standard for measuring medication management, say 63 percent of respondents.
  • E-prescribing and aids such as medication event monitoring system (MEMS) caps, pillboxes and calendars are the most common medication management tools, according to 49 percent of participants.
  • Patient-reported medication data is the information most commonly assessed for medication management, say 78 percent, closely followed by medication refill patterns (75 percent) and claims data (53 percent).
  • Half of responding medication management programs engage a retail or community pharmacist.
  • Fifty-eight percent of respondents not currently engaged in medication management plan to launch a program in the coming year.
  • Forty-four percent of respondents share electronic health records for medication management purposes.
  • Beyond a pharmacist-driven assessment, the Medication Possession Ratio (MPR) is the key measure of medication management for 31 percent of respondents.

Click here to download an executive summary of survey results: Medication Management in 2016: Polypharmacy, Diabetes Patients Priorities for Pharmacist-Led Interventions.

‘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

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.

UPMC: INTERACT Tools Boost Provider Communication in RAVEN Project to Reduce Long-Term Care Hospitalizations

September 6th, 2016 by Patricia Donovan
UPMC reduces long-term care hospitalizations

Even custodial or housekeeping staff can use the INTERACT Stop and Watch tool to record subtle changes in a patient.

The RAVEN (Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents) project by the University of Pittsburgh Medical Center (UPMC), aimed at improving quality of care for people residing in long-term care (LTC) facilities by reducing avoidable hospitalizations, is set to enter phase two in October 2016. Here, April Kane, UPMC's RAVEN project co-director, describes a pair of key resources that have enhanced communication between providers, particularly those at the eighteen nursing homes collaborating with UPMC on the RAVEN project.

Currently INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement project and has been funded through Medicare. It is designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities (SNFs). The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. These tools are free online.

INTERACT is used in multiple settings, but in our long-term care setting, we've been primarily encouraging the use of two INTERACT tools. There are a wealth of others. First is the Stop and Watch tool. This is a very easy early detection tool that would be used by members of your nursing home staff, such as nurses aides, custodial or housekeeping staff, and other workers who have a lot of one-on-one engagement with residents.

Using this tool, they may notice subtle changes, such as a patient who isn't as well engaged, who has been eating or drinking a little less, or is not as communicative as they had been before. It's a very easy one-page tool. Sometimes it's a card where they can circle if they're seeing something different, for example, "The resident seems a little different," or "They ate less."

The goal would be to take that tool to either the LPN or the RN in charge of the unit they're working on and say, "You know, I was with Mrs. Smith today. This is what I've been seeing that's a little different with her." That nurse should take that tool, validate its usage and then from there, go in and assess the patient.

If appropriate, they should utilize a second INTERACT tool, SBAR (Situation, Background, Assessment, Recommendation), to provide a more thorough assessment of what is going on and determine if this is a true changing condition. The SBAR allows the nurse to provide feedback to physicians in the very structured format physicians are used to reviewing. This allows them to place all the vitals and information in one place.

When they do make that call to the physician, they're well prepared to update them with what is going on with a particular resident. The physician then feels comfortable in deciding whether to provide further treatment on site or if appropriate, to transfer out to the hospital, depending on that resident's need.

Click here for an interview with April Kane on the value of UPMC's onsite enhanced care coordinators in the RAVEN project.

Care Transitions Playbook Sets Transfer Rules for Post-Acute Network Members

July 28th, 2016 by Patricia Donovan

St. Vincent's Health Partners best practices care transitions playbook documents more than 140 patient transfer protocols.

St. Vincent's Health Partners best practices care transitions playbook documents more than 140 patient transfer protocols.

A primary tool for Saint Vincent’s Health Partners Post-Acute Network is a playbook documenting more than 140 transitions for patients traveling from one care setting to another, including the elements of each transition and ways network members should hold each other accountable during the move. Here, Colleen Swedberg, MSN, RN, CNL, director of care coordination and integration for St. Vincent’s Health Partners, explains the playbook's data collection process and information storage and describes a typical care transition entry.

The playbook is made up of several sections, including one with current expectations, based on the Michigan Quality Improvement Consortium, which we can review online. From an evidence-based point of view, they’ve listed the evidence for many common conditions patients are seen for in medical management. This is kept up to date. This is an electronic document stored on our Web site that can only be accessed by individuals subscribed to the network. We’ve also put this on flash drives for various partners.

A second section contains actual metrics for any network contracts. The metrics appear in such a way that the highest standard is included. For example, physician providers, as long as they provide the highest level of care in the metric, can be sure they’re meeting all the metrics. Those metrics are based on HEDIS® standards.

The third section is the transition section, laid out in two to three pages. For example, a patient moves from the hospital inpatient setting to a skilled nursing facility, such as Jewish Senior Services. For that transition, the playbook documents all the necessary tools for that patient: a personal health record, a medication list, whatever is needed. Also included is any communication with the primary care physician, if that provider has been identified. Finally, this section identifies the responsibility of the sending setting—in this case, the hospital inpatient staff. What do they need to organize and make sure they’ve done before the patient leaves and starts that transition, and what is the responsibility of the receiving organization?

That framework is the same for every transition: the content and tools change according to the particular transition. A final section of the playbook details all of the tools used for care transitions. For example, in our network, we’re just now working on the use of reviews for acute care transfers, which is an INTERACT (Interventions to Reduce Acute Care Transfers) tool. In fact, many settings, including all of our SNFs, as it turns out historically, have used that tool. This tool is in the playbook, along with the reference and expectation of when that tool would be used.

Source: Post-Acute Care Trends: Cross-Setting Collaborations to Align Clinical Standards and Provider Demands

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.

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

April 7th, 2016 by Patricia Donovan

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

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

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

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

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

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

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

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

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

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

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

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

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

The Care Plan Process: 15 Trends to Know

January 21st, 2016 by Patricia Donovan

Care planning begins with a needs assessment, say the majority of respondents to HIN's 2015 survey on Care Plans.

The use of care plans increases medication adherence, patient self-management and clinical quality ratings, say 70 percent of healthcare organizations engaged in care planning, according to newly published market metrics from the Healthcare Intelligence Network (HIN).

A majority of respondents—83 percent—incorporate care plans into value-based healthcare delivery systems, according to HIN's December 2015 survey, with more than half of remaining organizations planning to do so in the coming year.

High-risk health indicators derived from health risk assessments or the imminent transition of a patient from one care site to another are the chief triggers of the care planning process, said survey respondents.

Survey Highlights:

Other findings from HIN's Care Plans survey include the following:

  • First and foremost in a care plan strategy is an assessment of needs, say 87 percent of respondents.
  • The electronic health record is the care plan maintenance and distribution tool of choice for almost two-thirds of respondents, although the retention of paper records is reported by nearly half of responding companies.
  • The principal criterion for classifying patients in need of care plans is the data derived from health risk assessments (HRAs), say nearly two-thirds of respondents, but patients transitioning between care sites also are prioritized for care planning, note 61 percent.
  • The presence of a behavioral health condition poses the greatest challenge to care planning by a large margin, said 39 percent of respondents, as compared to diagnosis of physical health problems.
  • The typical tracking time for care plans ranged from one to two months, said 24 percent, while adherence to care plans is checked monthly by 37 percent of respondents.
  • Patient engagement is the most significant barrier to care plan success, say 44 percent of respondents.
  • Patients’ healthcare utilization patterns are the most reliable indicators of care plan adherence, say 29 percent.
  • About 13 percent report ROI from care planning efforts as between 2:1 and 3:1.

Download a complimentary executive summary of 2016 Care Plan metrics to learn the value of evidence-based care plans in following high-risk patients through health episodes and transitions of care.

Guest Post: 7 Ideas to Improve Communication and Coordination between Care Sites

September 22nd, 2015 by Richard A. Royer, CEO, Primaris

With access to some of the most highly educated and trained medical professionals in the world, providing Americans with the best patient care possible should be simple. Unfortunately, that’s not often the case. Poor communication between specialists, duplicate tests and unnecessary procedures are frequently the norm rather than the exception, leading to costly, dangerous and sometimes deadly consequences. With so many specialists and resources readily on hand, how is this happening?

The problem is a lack of care coordination. Simply put, care coordination is the idea that all specialists treating a patient should communicate and share information to ensure that everyone acts as a team to meet patient needs. This includes reporting all results back to a primary care practice or to someone coordinating patient care, and ensuring that labs, specialists, hospitals, and long-term care facilities work together to communicate information quickly and appropriately. It’s about primary care physicians, nurses, technicians, specialists, and caregivers collaborating on patient care rather than working as separate entities.

The average Medicare beneficiary interacts with seven physicians in four different practices during a single year, according to the New England Journal of Medicine. For those with chronic conditions, the numbers can be even higher. And, nearly one-fifth of Medicare patients who are hospitalized are readmitted within 30 days of discharge, and 75 percent of these readmissions could have been prevented by improved care coordination.

Too often, patients discharged from hospitals don’t get the support and encouragement they need to take their medicine, follow their diets, and adhere to the regimens doctors have prescribed during their stay. Many of these problems can be solved by improving care coordination, and that starts with communication between care sites.

Here are seven suggestions for improving communication between care sites—as well as across the care continuum:

  • Start the dialog: As a rule of thumb, improving communication between care sites begins with healthcare providers asking themselves what they know that others need to know, and sharing that information with the patient’s care team. What do patients need to know when they’re referred to a specialist? What do the specialists that patients are being referred to need to be aware of, e.g. what tests have already been completed? Has the primary care physician been informed?
  • Create a team and make it accountable: Organizations should start by assigning a team of people to be accountable for managing patient care. Define the extent of their responsibilities for key activities such as following up on test results and communicating information to other physicians. Establish when specific responsibilities should be transferred to other care providers—whether that means specialty physicians, long-term care facilities, or home care providers.
  • Designate care coordinators: Designate staff that will act specifically as care coordinators can help to reduce hospital readmissions. Before patients leave the hospital, care coordinators should meet with them to make sure they understand the treatment plans they need to follow at home as well as any changes to their medication regimens. The hospital care coordinators also must follow up on any pending labs and imaging studies and contact primary care physicians to communicate updated medications, treatment plans, and test results for their patients. The likelihood of readmission drops significantly when patients leave with a clear understanding of their treatment plans and when their primary care physicians know what is necessary during follow-up care.

    This same communication protocol should also apply to patients who leave the hospital for long-term care facilities. In this instance, the hospital care coordinator should communicate discharge instructions to the long-term care staff. As soon as residents return to the long-term care facility, staff there should meet with residents to review their discharge instructions, answer their questions, and communicate with the hospital if any further clarification is needed. Long-term care staff should also follow up regularly with these residents to ensure they continue to comply with instructions the doctor has recommended and intervene if any problems arise.

  • Standardize communication processes: Create a protocol for filling out patient charts in a standard way so they are easy to interpret and key elements aren’t overlooked. You also should standardize communication by using structured forms to ensure primary care providers, specialists, and long-term care providers all have the same and necessary information.
  • Develop a referral tracking system: Creating a system to internally track and manage referrals and transitions— including consultations with specialists, hospitalizations and ER visits, and referrals to community agencies—can go a long way towards improving communication between care sites. It will help to ensure patients are well prepared for their referral visit and know what to expect afterwards. And, it simplifies follow-up with referral providers about findings, next steps and treatment plans.
  • Follow up on referrals: When a primary care physician refers a patient to a specialist, for example, office staff should follow up to make sure the appointment was made and completed. In addition, office staff needs to ensure the specialist shares his findings with the primary care physician so he can be well versed on the patient's progress and any additional steps to be taken.
  • Notify providers in the patient's medical neighborhood: Similarly, when patients visit the emergency room or are admitted to the hospital, communication should be a priority. In this instance, hospital staff should notify the primary care practice so the primary care doctor can follow the patient’s progress through discharge and institute a care plan to prevent future admissions. In addition, the practice can reach out to patients when they leave the hospital to make sure they understand discharge instructions and schedule follow-up appointments. When the patient comes in for follow-up care, the primary care physician should have a complete history of specialists seen during the hospital admission, their recommendations, and tests performed, along with the results.

The healthcare industry can no longer simply “discharge” patients. Providers must now work collaboratively with all others across the continuum of care to transition and coordinate the ongoing care of every patient. That’s what care coordination is all about.

Richard Royer

About the Author: Richard A. Royer has served as the chief executive officer of Primaris since 2001. He has extensive administrative healthcare experience and is actively involved in several statewide healthcare initiatives. In 2006 he was appointed by the Missouri governor to the Missouri Healthcare Information Technology Task Force and chaired the resources workgroup. He also serves on the board of directors as treasurer for the Excellence in Missouri Foundation. In his over 35 years of medical business experience he has held positions as chief executive officer at Cuyahoga Falls, Ohio, General Hospital; executive director of Columbia Regional Hospital in Missouri; and founder and president of Avalon Enterprises, a medical financial consulting firm.

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.

5 Reasons for Post-Acute Care to Participate in Bundled Payments

September 1st, 2015 by Patricia Donovan

Bundled payment participation put Brooks Rehabilitation on the forefront of healthcare payment reform.

Having completed more than 1,000 bundled episodes for total hip replacements, total knee replacements and hip fractures, Brooks Rehabilitation has achieved significant savings through Model 3 of the CMS Bundled Payments for Care Improvement (BPCI) Model 3. Here, Debbie Reber, MHS, OTR, vice president of clinical services for Brooks Rehabilitation, explains Brooks' rationale for participating in episode-based payment models.

Why would post-acute care be responsible for bundled payments, as opposed to the acute care provider? When CMS's original bundles came out, it looked as though they would all be driven by acute care providers. At the time that Brooks jumped in, there was not a lot of information on what our opportunity would be or how this model was going to look. To explain our rationale for jumping into bundled payments, Brooks decided it was going to participate in order to be on the forefront of learning more about payment reform. We wanted to look at how post-acute care providers could help make some of the healthcare policy changes related to the future of healthcare reimbursement.

Second, we also really wanted to serve as a catalyst for a business to begin working better as a system of care. With all of our different divisions and the way our care settings are spread over the various counties that we serve, sometimes it was difficult for us to work as a united, seamless system. We thought moving to bundled payments offered a great opportunity for us to work better as a system of care, improve our care transitions, and improve our continuum.

Third, the other huge opportunity with bundled payment is the chance to experiment with clinical redesign. We approached bundled payments as having a blank slate: we could redesign the care to look and feel however we wanted it to be. If we could do things all over again, what were the tasks or gaps or cracks in our clinical care that we could really improve upon?

Fourth, we knew we wanted to have a strong voice regarding future policy and payment reform changes. And finally, we wanted to show that, in addition to key providers, Brooks was sophisticated enough to take risk and play a primary role with that continuum of care.

Source: Bundled Payments for Post-Acute Care: Profiting from Alternative Payments and Clinical Redesign

post-acute care bundled payments

Bundled Payments for Post-Acute Care: Profiting from Alternative Payments and Clinical Redesign shares the inside details of Brooks' Complete Care program and the resulting, significant savings Brooks achieved through CMS's BPCI Model 3, which is limited to retrospective post-acute care (PAC) for select diagnosis-related groups (DRGs).

5 Drivers of San Francisco Care Transitions ‘Clearinghouse’

June 18th, 2015 by Patricia Donovan

The sole public safety net hospital in the city, San Francisco General Hospital (SFGH) serves a diverse population, of which 30 percent are uninsured. Here, Michelle Schneidermann, MD, outlines five factors that make care transitions challenging for SFGH patients and that helped to drive creation of a Care Transitions Task Force.

On any given day, around 8 to 10 percent of our inpatients are considered to be homeless. This is a population that is generally at higher than average risk for readmission stemming from a variety of factors. These include social determinants of health, like poverty and housing instability, comorbidity such as mental illness and substance use, and limited access to services in the face of complex care needs.

For the past ten years or so, there have been varied but somewhat siloed efforts to reduce post-discharge adverse events and improve the quality and safety of care transitions. In early 2012, as we approached the onset of Medicare’s readmission penalties, we had a coming-late-to-the-party-’aha’ moment, where we recognized the need to tackle care transitions and readmissions in a more structured and coordinated way.

Specifically, we recognized the need to create a comprehensive care transitions program to provide patients with the proper care and tools to stay out of the hospital. We needed to bridge those varied siloed programs by connecting them. Also, we wanted to provide a centralized clearinghouse or access point of information for the network on care transitions, and standardize and improve processes of care.

We decided, in retrospect, somewhat arbitrarily, that our aim would be to reduce readmissions by 15 percent over two years. These unmet goals led us to charter the San Francisco Health Network Care Transitions Task Force in the fall of 2012.

Source: Data-Driven Care Transition Management: Action Plans for High-Risk Patients

care transitions

Dr. Michelle Schneidermann completed her primary care internal medicine training at UCSF and joined the UCSF faculty in 2003, where she is a member of the Division of Hospital Medicine at San Francisco General Hospital (SFGH). Through her inpatient clinical work and work with ambulatory programs, she has been able to directly witness the successes and challenges of patients’ transitions and generate feedback to the providers and systems that manage their care.

At SFGH, Dr. Schneidermann leads the Care Transitions Task Force, a cross-continuum, multidisciplinary team charged with improving the quality and safety of care transitions as well as reducing preventable readmissions.

One-Fourth Operate Post-Discharge Clinics to Curb Hospital, Post-Acute Readmissions

June 4th, 2015 by Patricia Donovan

Dedicated post-discharge clinics address medication concerns so high-risk patients don't end up back in the hospital.

Almost one-quarter of healthcare organizations—24 percent—operate dedicated post-discharge clinics for patients recently discharged from the hospital, nursing home or ED, according to the April 2015 Care Transitions Management survey by the Healthcare Intelligence Network.

A post-discharge clinic is designed to address issues related to a patient's recent hospitalization and ensure that the individual's transition from hospital or post-acute facility to their primary care doctor is smooth.

In a 2014 presentation, Torrance Memorial Health System described the typical operation of its follow-up clinic, the Coordinated Care Center, which is focused on medication management, a key driver of avoidable hospital readmissions. The health system stressed that the clinic is not a replacement for follow-up primary care following a hospitalization:

“One tactic [for reducing readmissions] is to encourage each of our patients going home from the hospital and SNF to make an appointment at our post-acute clinic with the physician who does medication reconciliation. She asks the patients to bring in all the medications they were on before they went to the hospital and all those prescribed at the hospital.

"They then have a 45-minute conversation, discussing medication plans moving forward, which ones they should take and which they shouldn’t, making sure with teach-back methodology the patient has a clear understanding of expectations in terms of consuming medication once they return home later that day. Those appointments normally take place within the last 72 hours.”

A dedicated post-discharge clinic is one way to plug glaring gaps in care transition management: insufficient follow-up. More work is needed during the actual patient handoff to break down the top barrier to smooth care transitions identified by HIN's fourth annual care transitions management assessment: communications between care sites.

Source: 2015 Healthcare Benchmarks: Care Transitions Management

Care Transition Management

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 the delivery of value-based care.