Archive for the ‘Transitions in Care’ Category

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 car, 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).

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

July 29th, 2014 by Patricia Donovan

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

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

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

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

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

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

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

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

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

Snapshot of CMS Bundled Payment Care Initiative

July 1st, 2014 by Patricia Donovan

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

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

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

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

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

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

Excerpted from: Bundled Payments: Opportunities in Effective Retrospective Acute and Post Acute Care Bundles