Archive for the ‘Transitions in Care’ Category

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.

Remote Care Management: Self-Monitoring Enhances Care Transitions

May 14th, 2015 by Patricia Donovan

Encouraged by reductions in hospital readmissions and almost universal patient satisfaction from its small remote patient monitoring pilot, CHRISTUS Health scaled up the initiative to more 170 participants. Luke Webster, MD, vice president and chief medical information officer for CHRISTUS Health, and Shannon Clifton, CHRISTUS director of connected care, describe the patient's responsibility in remote monitoring.

During the daily monitoring portion, the patient will do the daily self-care tasks. That includes their biometric readings, and answering questions related to their care plan, such as, how did they feel that day? Did they sleep well? Are they able to ambulate and get through their day normally or in good health? As long as they stay within those normal parameters, they will continue on with the daily monitoring and self-help management as they go.

Most patients monitor themselves in the morning, within 30 minutes of waking up. Some are directed to monitor themselves throughout the day depending on their risk: whether they’re low, medium, or moderate to high risk. That’s determined ahead of time by the nurse coach and/or the physician.

If for some reason there is an alert—such as a two- to three-pound weight gain, the patient’s not feeling well, or ran out of their prescription—any of those cues will alert the nurse that something has fallen outside that patient’s wellness parameters and their care plan. The nurse coach, at that time, will review all of the data; then the patient is called and the nurse coach will coach the patient back to their care plan.

We’ve had great success with that process; having all of that data has made the care transitions program more efficient, especially because the nurse coach has access to that day-to-day information; whereas before, our care transition program consisted of the nurse calling up to five times within 30 days.

Source: Remote Patient Monitoring for Chronic Condition Management: Leveraging Technology in a Value-Based System

remote monitoring

Remote Patient Monitoring for Chronic Condition Management: Leveraging Technology in a Value-Based System chronicles the evolution of a remote patient monitoring pilot by CHRISTUS Health. This 25-page report reviews the multi-state and international integrated delivery network's impressive early returns in cost of care, 30-day readmission rates and patient satisfaction from remote patient monitoring, as well as the challenges of program expansion.

Post-Discharge Home Visits, SNF Visits Halve Readmissions for High-Risk Population

April 27th, 2015 by Patricia Donovan

In an Ohio care transitions management initiative, post-discharge home or SNF visits to Medicare beneficiaries at high risk for readmission have helped to curb rehospitalizations by nearly 50 percent.

As one of CMS' Community-based Care Transitions Program (CCTP) demonstration projects, field coaches for the Council on Aging (COA) of Southwestern Ohio conduct home visits for high-risk Medicare fee-for-service patients in nine partner hospitals, explained Danielle Amrine, the COA's transitional care business manager during an April 2015 webinar, Home Visits: Five Pillars to Reduce Readmissions and Empower High-Risk Patients, now available for replay.

The COA of Southwestern Ohio completed 10,202 home visits from June 2012 through 2014, Ms. Amrine said. "The national readmission rate is around 21.3 percent. Those patients involved in our CCTP program experienced a readmission rate of 10.48 percent."

Home visits occur within 24 to 72 hours of a patient's discharge from the hospital; SNF visits within 10 days, to allow the patient to settle in at the SNF. For SNF visits, made to the top 10 nursing facilities where patients most often discharged, field coaches utilize the LACE readmissions tool to assess the need for a home visit post-discharge.

The intervention is designed to empower patients of any age and their caregivers to assert a more active role during their care transition.

Reinforced by a trio of follow-up phone calls, a typical home visit lasts about one hour. While geared to the patient's needs, the visit always covers the crucial medication reconciliation, which allows the coach not only to assess the patient's role in managing their medication regimen but also to identify any medication discrepancies. Medication misunderstandings are particularly common during transitions in care.

In a recent month, COA coaches identified 77 medication discrepancy issues, which, once resolved, resulted in only four of these patients from being readmitted back to the hospital.

The Southwestern Ohio program, the second in the nation to be funded by CMS to conduct home visits, is modeled on the four pillars of Eric Coleman's Care Transitions Intervention®. However, the COA has added a fifth pillar, community services, to connect patients to the COA's broad range of in-house and community-based services during the critical transition between providers or care sites.

The program relies heavily on personal health records (PHRs) to facilitate cross-site communication and ensure continuity of care data across practitioners and settings.

Success from the COA care transitions initiative also extends to emergency department utilization by this population: the national average baseline is around 11.6 percent, and CCTP participants show an admission rate of 9.39 percent, Ms. Amrine added.

About 15 percent of scheduled home visits do not occur; the program has created a number of strategies to address this falloff.

Future enhancements by the COA of Southwestern Ohio program include a behavioral health intervention and a pilot in which University of Cincinnati College of Pharmacy interns will reconcile medications via Skype® or other telemedicine application.

Home Health on Care Transitions Management: Focus on Post-Acute to Home Handoff

April 7th, 2015 by Patricia Donovan

With the hospital-to-home care transition deemed the most critical by half of healthcare organizations, home health sits on the front lines of care transitions management.

An overwhelming majority of home health organizations, which comprised approximately 10 percent of respondents to HIN's 2015 survey on Care Transitions Management, have a care transition management program in place: 80 percent versus 67 percent overall, and of those that don’t, 100 percent intend to implement one in the next 12 months, versus 56 percent overall.

Contrary to overall respondents, this sector considers the hospital to post-acute care transition key (50 percent versus 24 percent overall) as well as the post-acute care to home handoff (50 percent versus 9 percent overall).

Heart failure is the top health condition targeted by home health organizations (87 percent of respondents, versus 81 percent overall). This sector also targets acute myocardial infarction, or AMI (62 percent versus 51 percent overall), and the frail elderly, a top concern for 75 percent of this sector versus 44 percent overall.

Half of home health organizations surveyed self-developed care transitions programs (50 percent versus 34 percent overall). Similarly to most respondents, programs include medication reconciliation (87 percent versus 75 percent overall) and transition/handoff training (87 percent versus 39 percent overall). This sector also relied on telephonic follow-up (87 percent 79 percent overall) in their care transition programs.

Transition coaches were primarily responsible for coordinating care transitions, according to 37 percent of home health respondents, versus 25 percent overall.

Some ways home health organizations improved transitions of care included creation of community partnerships with acute care facilities, development of post-acute networks, and collaborations with all clinical and hospice providers.

Successful strategies for this sector included separating data input from hands-on patient discharge paperwork so clinicians doing the transition could focus more on the patient, and not typing. Also, maintaining open communication with all staff and following up on communication with the patient and/or caregiver to ensure they transitioned appropriately into the new setting helped them to identify any concerns in the hopes of avoiding an unnecessary hospitalization.

Provider engagement remains the biggest challenge to this sector’s transition management efforts, say 37 percent of home health organizations, versus 13 percent overall.

Source: 2015 Healthcare Benchmarks: Care Transitions Management

http://hin.3dcartstores.com/Chronic-Care-Management-Reimbursement-Compliance-Physician-Requirements-for-Value-Based-Revenue_p_5027.html

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 delivery of value-based care.

Communication During Care Transitions: Technology, Templates Clarify Handoff Message

March 19th, 2015 by Patricia Donovan

With communication between care sites a top barrier to efficient transitions for one quarter of respondents, HIN's fourth comprehensive Care Transitions Management survey pinpointed information tools getting the message across during patient discharge and handoff.

Technology offers a leg up by way of telehealth and remote monitoring, respondents said; 75 percent of respondents transmit patient discharge or transition information via electronic medical records (EMR).

2015 Care Transition Survey Highlights

  • Discharge summary templates are used by 45 percent of respondents.
  • Beyond the EHR, information about discharged or transitioning patients is most often transmitted via phone or fax, say 38 percent of respondents.
  • Twenty-seven percent of respondents record patient discharge instructions for patients' future access.
  • After communication, inconsistent follow-up is the most frequently reported barrier to care transition management, say 21 percent of respondents.
  • The hospital-to-home transition is the most critical transition to manage, say 50 percent of respondents.
  • Home visits for recently discharged patients are offered by 49 percent of respondents.
  • Heart failure is the top targeted health condition of care transition efforts for 81 percent of respondents.
  • A history of recent hospitalizations is the most glaring indicator of a need for care transitions management, say 81 percent of respondents.
  • Beyond the self-developed approach, the most-modeled program is CMS’ Community-Based Care Transitions Program, say 13 percent of respondents.
  • Eighty percent of respondents engage patients post-discharge via telephonic follow-up.
  • A majority of respondents—72 percent—assign responsibility for care transition management to a healthcare case manager.
  • Download an executive summary of the February 2015 Care Transitions Management survey.

SFHN Cross-Continuum Care Transitions: Dashboard, Discharge Database Streamline Patient Handoffs

March 12th, 2015 by Patricia Donovan

Dr. Michelle Schneidermann and the SFHN Care Transitions task force mine administrative data to streamline patient handoffs.

As a physician, Dr. Michelle Schneidermann is accustomed to the clinical data driving daily decision-making: blood tests, x-rays, blood pressure readings.

But as part of a multidisciplinary task force charged with improving care transitions within the San Francisco Health Network (SFHN), Dr. Schneidermann faced a "black box" of administrative data buried in more than 60 siloed databases across the health network.

During Cross-Continuum Care Transitions: A Standardized Approach to Post-Acute Patient Hand-Offs, Dr. Schneidermann described how SFHN's development of a dashboard, a database and uniform practices has helped to streamline care transitions across its care continuum.

Early on, a data analyst pulled together the siloed databases into a cohesive dashboard providing numerous insights on readmission rates, vulnerable populations, and pain points within SFHN—learnings that sparked action plans, pilots and partnerships designed to standardize patient handoffs and post-discharge follow-up.

One key strategy of the task force, which Dr. Schneidermann described as a "multidisciplinary village," was a decision to engage primary care leadership.

"Most of our patients leaving San Francisco General go home from the hospital," said Dr. Schneidermann. "Their post-acute care is in their primary care home. For that reason, we decided that engaging primary care leadership would be a key strategy for our improvement work."

The population served by the network is largely uninsured or underinsured, and at high risk for readmissions, she added.

After piloting post-discharge outreach tactics at three separate primary care clinics, the task force identified a fundamental knowledge gap: the clinics had a hard time identifying which patients had been discharged and when.

Enter a hospital discharge database retrofitted into the electronic medical record (EMR) that populates each night from hospital censuses— a tool that has improved clinic staff workflow.

Not all interventions are technology-driven. The task force has also engaged primary care physician champions, and placed pharmacists in clinics where possible.

Having concluded its second year, much work still remains. Readmission rates have not dropped as low as the task force would like; the impact of behavioral health readmissions on overall rates is now being studied. The task force also hopes to bring the patient's voice to bear.

"In theory, it would be most helpful to have representation from patients with chronic illnesses requiring significant self-management skills, who are also challenged by psycho-social barriers to care," Dr. Schneidermann concluded.

Listen to Dr. Schneidermann outline the responsibilities of the three task force sub-groups: inpatient, outpatient and pharmacy.

Aetna Compassionate Care: “Advanced Illness Care Coordination Can’t Be Measured by Numbers Alone”

September 30th, 2014 by Patricia Donovan

In its new report, "Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life," the Institute of Medicine recommends the development of measurable, actionable, and evidence-based quality standards for clinician-patient communication and advance care planning to reflect the evolving population and health system needs.

Aetna's Compassionate Care program, a case management approach for individuals in advanced stages of illness, breaks down barriers commonly encountered in this highly sensitive stage of the health continuum while positively impacting both healthcare utilization and spend. Here, Dr. Joseph Agostini, senior medical director, Aetna Medicare, shares some best practices from Aetna's Compassionate Care Program.

There are several best practices. First, there is training, which is integral to the success of the Aetna Compassionate Care program.

Second, there is the proper selection, mentoring and ongoing learning opportunities for nurse case managers. These include such things as ongoing online tutorials, in-person training, where everyone gets training in change management and motivational interviewing techniques, regular 'lunch and learns,' medical director sessions including case-based rounds of cases that are in progress right now and feedback sessions. We bring in external entities to provide specialized expertise as necessary so that nurses get continuing education throughout the process.

Another best practice for us is having Aetna case managers manage all types of members. We don’t have a specialized unit that just specializes in advanced illness care needs. We think all of the nurse case managers should have developed this critical skill of being able to manage those with advanced illness, but also be able to identify support and be advocates for patients in all phases of their lives.

We also use a variety of functional status and prognosis tools. Many of these rating scales are scores focused on functional status. That’s important to follow over time, and can be predictive of outcomes. In our program we don’t necessarily use all of these scales, but we always capture some basic functional status over time and it’s useful and necessary to view that longitudinally.

A real-life example captures the heart of what we do. A case manager writes:

'Wife stated member passed away with hospice. Much emotional support given to spouse, she talked about what a wonderful life they had together, their children, all of the people’s lives that he touched. They were married 49 years last Thursday and each year he would give her a piece of jewelry. On Tuesday when she walked into his room he had a gift and card lying on his chest, a beautiful ring that he had their daughters purchase. She was happy he gave it to her on Tuesday; on Thursday he was not alert. She stated through his business that he touched many people’s lives and they all somehow knew he was sick and he has received many flowers, meals, fruits, cakes. She stated her lawn had become overgrown and the landscaper came and cleaned up the entire property, planted over 50 mums, placed cornstalks and pumpkins all around. She said she is so grateful for the outpouring of love. Also stated that hospice is wonderful, as well as everyone at the doctor’s office and everyone here at Aetna. She tells all of her friends that when you are part of Aetna, you have a lifeline.”

And the case manager concludes, “Encouraged her to call with ongoing issues or concerns and closed to case management.”

You can really feel the depth of connection that develops between the Aetna member, or the family caregiver and the case manager. You can’t really make this happen; it occurs over time and I would suggest to everyone that advanced illness care coordination can’t be measured by numbers alone or on hospital admissions or the length of time in hospice. We need to develop quality measures that capture the degree of family, caregiver and patient support that a program like this engenders.

advanc care planning
Dr. Joseph Agostini is the senior medical director for the Aetna Medicare team. He is responsible for medical management strategy, clinical initiatives, and provider collaboration oversight for Aetna Medicare members.

Source: Case Management for Advanced Illness: Best Practices in End-of-Life Care

Community Health Network Retools Readmissions Ruler for High-Risk Heart Failure Patients

September 9th, 2014 by Patricia Donovan

From the many evidence-based health risk stratification tools available, Community Health Network has adapted a popular hospital readmissions indicator for use with medically complex patients at high risk of readmissions. Deborah Lyons, MSN, RN,NE-BC, network disease management executive director for Community Health Network, describes the adaptation process.

HIN: Where do home visits for heart failure patients enter the picture?

Deborah Lyons: We do a high-risk home assessment while we have patients in the hospital. Fully 100 percent of our patients that are admitted to inpatient status are automatically screened and ranked in terms of readmission risk. That’s where we use the LACE/ACE tool. We embedded that tool in our software so it can predictively tell us which patients to focus on.

HIN: How did you decide on the LACE tool? Is the ACE tool different than the LACE tool?

Deborah Lyons: The LACE itself is evidence-based. We work with the advisory board. And they had just done an analysis of all the predictive models out there in terms of readmission risk when we started this work. There were only two tools that were moderately predictive for risk. LACE was one of them. LACE looks at length of stay (L), acute admission (A), (meaning they came in through the emergency room), their Charleston Comorbidity score (C) and the number of ED visits (E) they’ve had in the past six months.

All this information was easily available to us at the time that we did this because we were on a different computer system. But the concern was that the L factor (length of stay), might lead us to place the patient at high risk when they were leaving the hospital. Maybe they started at low risk and then on the fourth day of stay, because they had been there four days, now they moved to high risk but they’re being discharged. You really can’t do anything at day of discharge. We first set a threshold for LACE, which we tested and validated and then ran a correlation and asked ourselves, “If this threshold is a LACE high risk, what would a correlating threshold be if we dropped the length of stay?” That’s how we moved to an ACE score.

Source: Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics

Stratifying High-Risk Patients


Stratifying High-Risk, High-Cost Patients: Benchmarks, Predictive Algorithms and Data Analytics
Reviews a range of risk stratification practices to determine candidates for health coaching, case management, home visits, remote monitoring and other initiatives designed to engage individuals with chronic illness, improve health outcomes and reduce healthcare spend.

Trained Military Medics Ease Transitions for John C. Lincoln’s Newly Discharged Patients

August 26th, 2014 by Patricia Donovan

A large part of the success of the John C. Lincoln Network accountable care organization (ACO) can be attributed to its Transition Coach Program, which uses trained military medics as care transition coaches, explains Heather Jelonek, the organization's CEO for ACOs.

We applied for a CMS Innovation grant in spring 2012. Our hypothesis was that we could take military healthcare professionals, medics and army corpsmen; these individuals are incredibly well trained. Army medics can do appendectomies in the field; they’re providing basic primary care services. However, when they’re discharged from the military, they have no equivalent licensure.

We decided to begin a program where we hired individuals we referred to as having ‘blood on their boots.’ Tom Jargon was our first transition coach; he started with us about 90 days after his last tour in Afghanistan ended. But what the program really does is bring these young men and women into our health system. They get six weeks of training, they meet with a cardiologist, they are introduced around the hospital staff, and they get to know how to use the EPIC® electronic health record to its most effective benefit.

These transition coaches go into the hospitals and meet with patients when they are admitted. They get to know the patients and develop a rapport, but they also start preparing the patients for discharge. They are doing basic things like making sure the patient has a social support system in place and transportation to their primary care or specialists’ visits. They also try to determine the patients' financial resources.

Once that patient is discharged from the hospital, our transition coaches follow them for a minimum of 30 days. They’re going into the patient’s home looking for fall risks. They’re helping the patient set up their home so that they’re a little bit safer. They’re doing a general review of cabinets: does the patient in fact have food in the refrigerator? Do they have pet food available if they have pets? Sometimes we find patients are feeding their pets rather than feeding themselves. So through our relationship with PetSmart®, we’ve been able to collect donations of animal food; we deliver those to our patients’ homes so they can afford food for themselves.

If on the other hand they’re finding evidence that the patient has pet food in the home but no food for themselves, we connect those patients with our Desert Mission Food Bank.

Transition coaches help patients learn to monitor their blood pressure. They explain their medication. They go through basic nutrition and education services. We bring in a registered dietician to work with patients who have dietary issues.

Source: Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care

Beyond the EMR Population Health Analytics


Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care
Reviews the concentrated data dig undertaken by John C. Lincoln to prepare for participation in the CMS Medicare Shared Savings Program (MSSP).