Posts Tagged ‘Care Transitions’

HINfographic: Home Visits Curb Readmissions and ER Utilization

March 15th, 2017 by Melanie Matthews

Seventy percent of healthcare organizations providing care to patients in their homes attributed a reduction in either hospital readmissions or in ER utilization to those home visits, according to the December 2016 Home Visits survey by the Healthcare Intelligence Network.

A new infographic by HIN examines the populations targeted by home visits, the primary purpose during a home visit and a promising home visit protocol.

2017 Healthcare Benchmarks: Home Visits Visiting targeted patients at home, especially high utilizers and those with chronic comorbid conditions, can illuminate health-related, socioeconomic or safety determinants that might go undetected during an office visit. Increasingly, home visits have helped to reduce unplanned hospitalizations or emergency department visits by these patients.

2017 Healthcare Benchmarks: Home Visits examines the latest trends in home visits for medical purposes, from populations visited to top health tasks performed in the home to results and ROI from home interventions.

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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.

Infographic: A Journey Through Post-Acute Care

March 7th, 2016 by Melanie Matthews

With steeper penalties from the Centers for Medicare and Medicaid Services for hospital readmissions, healthcare organizations are not only looking at internal factors that impact readmissions, but are also partnering with post-acute care providers to shore up issues across the post-acute continuum that could lead to a readmission.

A new infographic by ECG Management Consultants looks at the expected path through the continuum for a high-risk, congestive heart failure patient and how this patient might be better supported in a high-functioning post-acute care model.

2015 Healthcare Benchmarks: Post-Acute Care TrendsHealthcare is exploring new post-acute care (PAC) delivery and payment models to support high-quality, coordinated and cost-effective care across the continuum—a direction that ultimately will hold PAC organizations more accountable for the care they provide. For example: two of four CMS Bundled Payments for Care Improvement (BPCI) models include PAC services; and beginning in 2018, skilled nursing facilities (SNFs) will be subject to Medicare readmissions penalties.

2015 Healthcare Benchmarks: Post-Acute Care Trends captures efforts by 92 healthcare organizations to enhance care coordination for individuals receiving post-acute services following a hospitalization—initiatives like the creation of a preferred PAC network or collaborative. Click here for more information.

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Incentives Advance PCP-Specialist Communications in Value-Based Health System

January 6th, 2015 by Cheryl Miller

In a value-based reimbursement model, primary care physicians need to be quarterbacks for their patients, taking an additional interest in their care and following them to the end zone, or to other specialists providing care, says Chip Howard, Humana’s vice president of payment innovation in the provider development center of excellence. This will foster communication between physicians and specialists, a fundamental problem of the classic fee-for-service model.

Question: How can you manage and reward the complex interactions between primary care physicians (PCPs) and sub-specialists?

Response: (Chip Howard) That’s a pretty common question in the industry these days. If you think back to the old model, the classic fee-for-service model, the PCP potentially loses track of the member as they go to a specialist. The volume-based model is very fragmented. You don’t have communication, a fundamental problem of the model. But I think we’re on a discovery to potentially address that. Some thoughts that come to mind are putting incentives in place that will promote communication between PCP and specialists.

At the end of the day in a primary care model, we’re encouraging the PCPs to be the quarterback of the member’s care, to take that additional interest and follow the member through the path to other specialists that are providing care. There are also obligations on the specialist’s part that you would have to engage because it’s a two-way street.

Some other thoughts: we are starting to explore specialist engagement programs, whether it’s looking at bundled payments or at other sorts of programs that incentivize the specialist to achieve the Triple Aim: higher quality, lower cost, best outcomes. Then, putting data and analytics into the hands of PCPs that will enable them to potentially steer those members to specialists that are proving that they can work to achieve the Triple Aim on behalf of the patient.

There are also some ideas about how to promote interactions between PCPs and sub-specialists and start the ball rolling. That is a lot easier in an integrated system-type environment where there is one system that owns the continuum of care for the most part from PCP to specialist, to outpatient, inpatient, etc.

value-based reimbursement
Chip Howard is vice president, payment innovation in the Provider Development Center of Excellence, Humana. He is responsible for advancing Humana’s Accountable Care Continuum, expanding its Provider Reward Programs, innovative payment models and programs that enable providers to become successful risk-taking population health managers.

Source: Physician Value-Based Reimbursement: Quality Rewards for Population Health

7 Lessons from a Health Network’s Home Visit Program

September 23rd, 2014 by Melanie Matthews

Home visits to patients with complex care needs can provide huge returns by identifying patient compliance barriers that are only apparent when seeing a patient in their home. Dr. Larry Greenblatt, M.D., director for the chronic care program at Durham Community Health Network for Duke University Medical Center, shares organizational lessons from using home visits as part of a care transition program to reduce avoidable hospital readmissions and emergency room utilization.

With our patient population, none of these patients in the program have simple or single diagnosis. We learned that Care Partners providing intensive and frequent service with a strong face-to-face component backed by an interdisciplinary support team can help high-utilizing patients receive their care in more effective and efficient outpatient settings.

Second, when using previous programs that focused on telephone education and advice, we discovered that the face-to-face interactions have a direct impact on these patients and their ability to change their care model.

Third, we discovered that, if effective on a larger scale, our care model could be used nationally as a significant means of reducing healthcare costs.

Fourth, this intervention reduced unplanned admission days by 77 (71 percent) in three months. This reduction greatly benefits the medical patients and gives us increased capacity for new admissions. It also improves the life and the care of those patients who are involved in the program.

Fifth, most of our pilot patients had unmet mental health and substance abuse problems and had difficulty obtaining needed services. That was another benefit of having the multidisciplinary team sitting around the table as we did care conferences on our patients on a weekly basis. We actively addressed the mental health needs to help get a patient’s medical issues taken care of and result in higher benefits from our care being linked to all of the care.

Sixth, this multidisciplinary approach, direct face-to-face contact and ongoing telephone contact is the secret in making this program work.

And finally, patients often did not have a primary care provider at the beginning of the pilot and they benefited from being linked with one. Finding them a medical home was important and made the patients feel more comfortable with continuing to keep outpatient appointments.

home visits
Dr. Larry Greenblatt, MD, is the medical director for the chronic care program at Durham Community Health Network. Dr. Greenblatt is also an associate professor of medicine at Duke University Medical Center, where he has been on the faculty since 1994. Dr Greenblatt focuses on postgraduate medical education and primary care.

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

Evolution of a Hybrid Embedded Case Management Program

August 8th, 2014 by Cheryl Miller

When a typical embedded and telephonic case management program didn’t yield desired results, namely, coordination of quality care for their high-cost, high utilizers with complex, chronic diseases, Sentara Healthcare System took steps to correct it.

Step one: Reevaluate the current program.

“When we really studied what they (RN Care managers) were doing, only about 25 percent of their time was spent doing care management. What happened was that they wound up becoming basically glorified office nurses. They were working on other projects from either the physicians or the practice manager,” says Mary M. Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara Medical Group (SMG), which is part of Sentara Healthcare System, during A Hybrid Embedded Case Management Model: Sentara Medical Group’s Approach, a recent 45-minute webinar sponsored by the Healthcare Intelligence Network.

Step two: Redefine the RN nurse care coordinators’ job descriptions.

"We were focused on reducing the total cost of care...and improving patient satisfaction. We also measured quality of life. We were looking to see if engagement with an RN care manager improved the patient’s perception of their quality of life," Morin says. To achieve this, SMG looked for RN care coordinators who could "engage patients for the long haul, know how to work with hospital-based caregivers, home health, and life care not just within their own healthcare system."

Core competencies were also established. “RN care managers are different than RNs. We were looking for people that didn’t necessarily have previous care management experience, but who had experience doing patient assessments. They had to have a strong clinical background,” Morin says.

Step three: Rebrand the model as a hybrid program.

The ideal was to establish and maintain patient-centered relationships, Morin continues. The RN care coordinators needed to conduct comprehensive initial assessments with the patient as well as ongoing assessments, so they could identify ongoing needs of the patients and possibly their caregiver, develop care plans and then provide coaching education. They also needed to provide support to both the patient and their caregivers and family members.

Step four: Reap positive rewards.

Through 2013, SMG was able to do the following:

  • Reduce ED visits by 17 percent;
  • Reduce all cause inpatient admissions by 48 percent;
  • Reduce all cause readmissions by 21 percent;
  • Improve seven-day follow-up rates by nearly double. Patients followed by a care manager had a 98 percent seven-day follow-up rate within the medical group; the average rate was 49.5;
  • Reduce total cost of care by 17 percent.

Psychological and functional health of patients was also improved, Morin says. Assessments pre-and post-engagement with care managers showed a 48 percent improvement in the first stages of depression, and a 6 percent improvement of physical health. And patient satisfaction also increased.

It all comes down to increased attention from the care manager, Morin says. One example is intense transition follow-ups, so that within 48 hours of discharge, the patient is seen or called, and given a clinical assessment. And prior to discharge? "We implemented a first call strategy. When the patient thinks of the emergency department (ED), we want them calling their care manager first."

Listen to an interview with Mary Morin here.

Key Tool for Stratifying Patients for Home Visits

May 29th, 2014 by Cheryl Miller

Tools like the Hospital Admission Risk Monitoring Systems (HARMS) 8 and 11 help to identify patients that would most benefit from a home visit, particularly critical as case loads and time demands grow, says Samantha Valcourt, MS, RN, CNS, clinical nurse specialist for Stanford Coordinated Care, a part of Stanford Hospital and Clinic.

One of the key things to think about when implementing a home visit program is which patients should receive the visits. Who is at risk for having adverse events after hospital discharge, and how do we identify those patients? Just as there are many care transition models, there are many tools that exist to help to risk-stratify those at high risk. Some of them focus on certain conditions, including myocardial infarction (MI), heart failure (HF) and pneumonia (PNA). There are even iPhone apps, into which you can plug certain criteria, like a patient's age, and whether they have they been to the emergency room (ER). They all try to predict if the patient is at high risk for readmission.

At Stanford Coordinated Care (SCC) we use a tool called the HARMS-11. It’s a modified version of the HARMS-8, a tool created by David Labby and Rebecca Ramsay at Care Oregon. It’s an admission risk monitoring system; it stands for Hospital Admission Risk Monitoring Systems. The numbers 8 and 11 refer to how many questions are on the tool or how many items there are to answer.

We use this tool in two ways: it helps me to identify patients that may need a home visit, and it also helps us to see if a patient is eligible to receive services in our clinic. Besides being a clinic for employees of the hospital and university, we focus on those employees that have chronic or complex health conditions. This tool helps us get a sense of whether they are struggling with many conditions, and what their social support is like. How many medications do they take in a day? Do they ever forget to take them or simply choose not to take them?

The HARMS is written so that the patient can take it as a self-assessment. Positive answers to these questions give us a good indication that this patient may be a good one to see at home after hospitalization. Given that all of our patients have to have multiple conditions, there’s very few that I try not to see after discharge. But as our case load continues to grow and time demands other things, we’re going to make some decisions on who we see. We’re going to go back to this tool to help us do that.

Excerpted from: Home Visits for High-Risk Patients: Tools, Timing and Outcomes.

4 Pillars of SNF/Hospital Partnerships

March 13th, 2014 by Cheryl Miller

Maintaining contact with patients long after the 30-day discharge period when the penalty phase ends for hospitals is one of the four pillars of Torrance Memorial Health System's post-acute network philosophy, says Josh Luke, Ph.D., FACHE, vice president post-acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention. This can be done telephonically or in-person, and is usually conducted by an ambulatory case manager.

The main component of our post-acute network is to go into each of the seven SNFS once a week and meet with them for a half hour at the most, covering four tactics. The first is to review a list of all of the patients that have been sent from the hospital over to the SNF, specifically focussing on which ones are discharging that week.

The second tactic is to discuss their discharge disposition, and see if they’re going to a home health agency, and if so, if it’s one that we own, or another one in the community. We distinguish this so we can do what’s called ambulatory case management of the patient, which means we want to case manage them once they go home. We don’t just want to forget about them. We want to keep an eye on them and check in on them, whether it’s telephonically or in person, making sure that they continue to do well, not just through the end of the 30-day episode after discharging from the hospital when the penalty phase ends for hospitals, but also for their long term well-being.

The third tactic is to encourage each of our patients going home from the hospital and SNF to make an appointment at our post-acute clinic (CCC) 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 they were prescribed at the hospital. They then sit and have a 45 minute conversation, including guidelines on what their medication plans are moving forward, which ones they should be taking, and which ones they shouldn’t, and making sure, with teach back methodology, that the patient has a clear understanding of what is expected from them in terms of consuming medication once they return home later that day. Those appointments normally take place within the last 72 hours.

The fourth tactic is to review what we call the ‘return to emergency room’ log. In the industry the common term is ‘return to acute’. We don’t allow our SNFs to use that term because we feel they’re responsible for the ‘return to the emergency department (ED)’. What we mean by that is we’re challenging our SNFs to say, “Take charge of what you can control. And what you can control is making sure that patient doesn’t leave your SNF unnecessarily.” We’re not here to say, “Did the patient get admitted or not to the hospital?” We’re here to ask the SNFs if they followed the guidelines that several organizations nationwide have provided that help avoid unnecessary transfers out to the hospital.

Excerpted from 5 Best Practice Prevention Protocols for Reducing Readmissions.

5 Barriers to Optimal Care in the Post-Acute Setting

January 22nd, 2014 by Jessica Fornarotto

Summa Health System's care coordination network of skilled nursing facilities (SNFs) is working to decrease fragmentation, length of stay and unnecessary readmissions while improving outcomes of care. Mike Demagall, administrator of Bath Manor & Windsong Care Center, a participant in this network, identified five barriers to patient care that originated in the acute care setting.

First, we found a lack of quality information received upon transfer from an acute care to a nursing facility and the lag time in identification of post-acute bed availability. The social worker was calling or faxing information to a facility, and the facility took up to 24 hours to respond as to whether a bed was available. That person may have been ready that day; instead it postponed that discharge another day.

We also had barriers to the patient’s acceptance of the need for post-acute care. Social workers and care coordinators at the bedside tell them when it is time for rehabilitation.

The next barrier was family expectations. Does the family feel that they need to go to the nursing home? The hospital staff and the insurers had to spot the appropriate levels of care. One of the concerns we had was, 'Is this going to send a lot of our patients — our referrals — to home healthcare and decrease our referrals by participating in this?' That happened to not be the case at all.

There was still a lack of knowledge and respect toward long-term care (LTC). All the discharge planning individuals, which were the case manager nurses and social workers, were able to tour the facility. Each facility had the opportunity to present their services and what they do. That helped with the overall cohesion of the group, and it moved this project forward.

There was also a lack of quality information received from the nursing facilities on the transfer to an emergency department (ED). That was information that we needed to get back, just as we were asking for information as those residents were coming in.

Excerpted from: 7 Patient-Centered Strategies to Generate Value-Based Reimbursement