Archive for the ‘Transitions in Care’ Category

SNF Visits to High-Risk Patients Break Down Barriers to Care Transitions

September 21st, 2017 by Patricia Donovan

For patients recently discharged from the hospital, a SNF visit covers the same ground as a home visit: medications, health status, preparing for physician conversations and care planning.

The care transitions intervention developed by the Council on Aging (COA) of Southwestern Ohio for high-risk patients starts off in the hospital with a visit by an embedded coach, and includes a home visit.

Additionally, to reduce the likelihood of a readmission, patients discharged to a skilled nursing facility (SNF) also can expect a COA field coach to stop by within 10 days of SNF admission. Here, Danielle Amrine, transitional care business manager for the COA of Southwestern Ohio, describes the typical SNF visit and her organization’s innovative solution for staffing these visits.

We conduct the home visit within 24 to 72 hours. We go over medication management, the personal health record (PHR), and follow-up with specialists and red flags. At the SNF, we do the same things with those patients, but in regards to the nursing facility: specifically, do you know what medications you’re taking? Do you know how to find out that information, especially for family members and caregivers? Do you know the status of your loved one’s care at this point? Do you know the right person to speak to about any concerns or issues?

We also ask the patients to define their goals for their SNF stay. What are your therapy goals? What discharge planning do you need? We set our SNF visit within 10 calendar days, because normally within three days, they’ve just gotten there. They’re not settled. There haven’t been any care conferences yet. We set the visit at 10 calendar days to make sure that everything is on track, to see if this person is going to stay at the SNF long-term. Our goal is to have them transition out. We provide them with all of the support, resources and program information to help them transition from the nursing facility back to independent living.

For our nursing facility visits, we also utilize the LACE readmissions tool (an index based on Length of stay, Acute admission through the emergency department (ED), Comorbidities and Emergency department visits in the past six months) to see if that person would need a visit post-discharge.

For our CMS contract, we are paid for only one visit. Generally we’re only paid for the visit we complete in the nursing home, but through our intern pilot, our interns do that second visit to the home once the patient is discharged from the nursing home. We don’t pay for our interns, and we don’t get paid for the visit. We thought that was a perfect match to impact these patients who may have a hard time transitioning from the nursing facility to home.

Source: Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients

home visits

In Post-Discharge Home Visits: 5 Pillars to Reduce Readmissions and Engage High-Risk Patients, Danielle Amrine, transitional care business manager at the Council on Aging (COA) of Southwestern Ohio, describes her organization’s home visit intervention, which is designed to encourage and empower patients of any age and their caregivers to assert a more active role during their care transition and avoid breakdowns in post-discharge care.

Infographic: Real-Time Communication Is Key to Improving Post-Acute Care Transitions

September 11th, 2017 by Melanie Matthews

When it comes to transitions between inpatient, post-acute, and home environment settings, nearly three quarters (71%) of the NEJM Catalyst Insights Council respondents to its Care Redesign survey on Strengthening the Post-Acute Care Coordination believe that improved real-time communication is the biggest opportunity to improve post-acute transitions. Survey results are highlighted in a new infographic by NEJM Catalyst.

The infographic also examines other strategies for improving post-acute care transitions.

A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics
Concerned about escalating hospital readmissions from skilled nursing facilities (SNFs) and the accompanying pinch of Medicare readmissions penalties, three Michigan healthcare organizations set competition aside to collaborate and reduce rehospitalizations from SNFs.

To solidify their coordinated approach, Henry Ford Health System (HFHS), the Detroit Medical Center and St. John’s Providence Health System formed the Tri-County SNF Collaborative with support from the Michigan Quality Improvement Organization (MPRO).

A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics, HIN’s 13th annual business forecast, is designed to support healthcare C-suite planning during this historic transition as leaders prepare for both a new year and new presidential leadership.

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MSKCC Integrated Case Management Enhances Efficiency, But Never At Patients’ Expense

August 29th, 2017 by Patricia Donovan

MSKCC’s service-based interdisciplinary team adheres to the four C’s of team-based care.

With a reputation synonymous with state-of-the-art cancer care, Memorial Sloan Kettering Cancer Center (MSKCC) shouldn’t have much to prove.

But like most healthcare providers, with the dawn of value-based care, MSKCC began to face tougher competition from hospitals with managed care contracts and limited networks. To attract and retain payors, MSKCC had to demonstrate that its care was both cost-effective and cost-efficient.

“Under managed care, you had to be able to prove your worth,” explains Laura Ostrowsky, MSKCC’s director of case management. “And worth was more than just best care, it was best care in a quality-effective manner.”

To accomplish this, MSKCC adopted a multidisciplinary, team-based care coordination approach, Ms. Ostrowsky explained during Integrated Case Management: A New Approach to Transition Planning, an August 2017 webinar now available as an on-demand rebroadcast.

Transition planning used to be referred to as discharge planning, she noted.

Integrated case management is at the heart of MSKCC’s service-based strategy, with MSKCC case managers  assigned by service. “That means that if a case manager is based on the tenth floor, which houses breast and GYN services, and one of those patients is in the ICU, they’re still being followed by the breast or GYN case manager.”

The variety of care settings is one of a half dozen reasons integrated case management is necessary, Ms. Ostrowsky added.

Communication among all team members is key, she continued, outlining the four ‘C’s’ of team-based care—so much so that some scripting has been created to keep all team members on message with patients.

However, a commitment to standards in communication and other areas should never override a patient’s need. “The clinical issues should always take priority,” Ms. Ostrowsky emphasized.

A day in the life of an MSKCC inpatient integrated case manager runs the gamut from reviewing and assessing new patients to orchestrating transition planning. “Our patients go out with all kinds of services, from infusion care to home chemotherapy to wound VACs.” Some patients are transferred to post-acute facilities, while others face end-of-life issues that include hospice care, which could be inpatient or home.

Hospice care was one area of focus for MSKCC—in particular, getting providers to speak frankly with patients about hospice and incorporating those services earlier on in the patient’s diagnosis when appropriate, both of which required a cultural shift. “Our patients didn’t come to Memorial to be told that there’s nothing that we can do for them,” she explained. “And our doctors didn’t come to work at Memorial to send people to hospice. They came here to cure cancer.”

In taking a closer look at end-of-life services, Ms. Ostrowsky found that physicians tended to refer to hospice later than she hoped that they would. “I wanted to really look at our length of stay in hospice as a way of identifying the timeliness of referral.” A longer hospice stay allows the patient to form relationships with their hospice caretakers rather than feeling abandoned and “left to die,” concluded Ms. Ostrowsky.

By placing case managers in inpatient areas and encouraging key case management-provider conversations that she shared during the program, MSKCC improved hospice referral timeliness and grew hospice length of stay. In turn, these quality improvements correlated with higher patient (and family) satisfaction.

Integrated case managers have also been key in identifying patients who can benefit from LTACH services and moving them there sooner, she added. “We can decrease length of stay within the hospital and get [patients] that kind of focused care that they need sooner.”

Listen to Laura Ostrowky describe the surprise question that can improve timeliness of hospice referrals.

Shared SNF Patients, Common Readmissions Goals Unify Three Competing Health Systems

June 15th, 2017 by Patricia Donovan

A common desire to reduce SNF readmissions resulted in the formation of Michigan's Tri-County SNF Collaborative.

A common desire to reduce SNF readmissions resulted in the formation of Michigan’s Tri-County SNF Collaborative.

Concerned about escalating hospital readmissions from skilled nursing facilities (SNFs) and the accompanying pinch of Medicare readmissions penalties, three Michigan healthcare organizations decided to set competition aside to collaborate and reduce rehospitalizations from SNFs. Here, Susan Craft, director of care coordination, family caregiver program, Office of Clinical Quality & Safety at Henry Ford Health System, describes the origins of Michigan’s Tri-County SNF Collaborative, of which her organization is a founding member.

I want to talk about the formation of the Tri-County SNF Collaborative between Henry Ford Health System, Detroit Medical Center, and St. John Providence Health System. As quality and care transition leaders from each of the health systems, we see each other frequently at various meetings. After some good conversation, we learned that each of us was partnering with our SNFs to improve quality and reduce readmissions.

We all required that they submit data to us that was very similar in nature but not exactly the same, which created a lot of burden for our SNFs to conform to multiple reporting requirements. We knew we were working with the same facilities because geographically, we are all very close to each other. We recognized that this was really a community problem, and not an individual hospital problem. Although we are all competing healthcare systems, those of us with very similar roles in the organization had very little risk from working together. And because we had so much in common, it just made sense that we create this collaborative.

We also worked with our MPRO (Michigan Quality Improvement Organization) and reviewed data that showed that about 30 percent of our patient population was shared between our three health systems. We decided it made sense to move forward. We created a partnership that was based on collaboration and transparency, even within our health systems. We identified common metrics to be used by all of our organizations and agreed upon operational definitions for each of those. We all reached out to our SNF partners to tell them about the collaborative and invite them to join, and then engaged MPRO as our objective third party. We created a charter to solidify that cooperation and collaboration.

Source: A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics

reducing SNF readmissions

A Collaborative Blueprint for Reducing SNF Readmissions: Driving Results with Quality Reporting and Performance Metrics examines the evolution of the Tri-County SNF Collaborative, as well as the set of clinical and quality targets and metrics with which it operates.

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: The Post-Acute Care Landscape

May 8th, 2017 by Melanie Matthews

Hospitals can’t just leave patient care to chance after patients leave the hospital. They must be more actively involved in managing their patients to ensure that they will receive the most appropriate post-acute care and avoid readmissions, according to a new infographic by eviCore healthcare.

The infographic examines the components of the post-acute healthcare market, guidelines for avoiding unnecessary readmissions and strategies for modernizing post-acute care.

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: 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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Touting ‘Magic’ of Home Visits, Sun Health Dispels 5 Care Transition Management Myths

April 4th, 2017 by Patricia Donovan


With an average of 299 warm, sunny days a year, Phoenix is a mecca for senior transplants. However, as Phoenix-based Sun Health knows well, when an aging population relocates far from their adult children, there’s a danger that if some of them experience cognitive decline or other health issues, no one will notice.

That’s one reason home visits are the cornerstone of Sun Health’s Care Transitions Management program. Visiting recently discharged patients at home not only tracks the individual’s progress with the hospitalization-related condition, but also pinpoints any social determinants of health (SDOH) that inhibit optimum health.

“There are a number of social determinants of health that, if not addressed, could adversely impact the medical issue,” explains Jennifer Drago, FACHE, executive vice president of population health for the Arizona non-profit organization. Ms. Drago outlined the program during A Leading Care Transitions Model: Addressing Social Health Determinants Through Targeted Home Visits, a March 2017 webinar now available for replay.

Identifying social determinants of health (SDOH) such as medication affordability, transportation, health literacy and social isolation are so important to Sun Health that SDOHs form the critical fifth pillar of its Care Transitions Program. Modeled on the Coleman Care Transitions Intervention®, SDOH identification and support balance Coleman’s four pillars of education, medication reconciliation, physician follow-up visits, and personalized plan of care.

The belief that organizations can effectively execute transitions of care programs pre-discharge or by phone only is one of five care transition myths Ms. Drago dispelled during the webinar. “You will have an impact [with phone calls], but it won’t be as great as a program incorporating dedicated staff and that home visit. I can’t tell you the magic that happens in a home visit.”

That “magic” contributed to Sun Health’s stellar performance in CMS’s recently concluded Community-Based Care Transitions Program demonstration. Sun Health was the national demo’s top performer, achieving a 56 percent reduction in Medicare 30-day readmissions—from 17.8 percent to 7.81 percent—as compared to the 14.5 percent readmission rate of other demonstration participants.

Sun Health’s multi-stepped intervention begins with a visit to the patient’s hospital bedside. “Patients are a captive audience while in the hospital,” explained Ms. Drago. That scripted bedside encounter, which boosted patients’ receptivity to the program, addresses not only the reason for the hospitalization (hip replacement, for example) but also co-occuring chronic conditions, she continued.

“The thing that will have the greatest chance of going out of whack or out of sync in their recovery period is their chronic disease, because they’re probably not eating the same, they’re more sedentary, and their medications likely have been disrupted.”

Ms. Drago went on to present some of the intervention’s tools, including care plans, daily patient check-ins, and the science behind her organization’s care transitions scripts.

After sharing six key lessons learned from care transitions management, Ms. Drago noted that while her organization participated as a mission-based endeavor, others could model Sun Health’s intervention and benefit from those readmissions savings. She also shared a video on the Sun Health Care Transitions Program:

Listen to an interview with Jennifer Drago on the science behind care transition management.

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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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.