Posts Tagged ‘hospital discharge’

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

Engaging Members in Health Management Post-Discharge with Case Managers, Outreach Calls

December 17th, 2013 by Jessica Fornarotto

“Member engagement is always the challenge, and it is no different for telephonic engagement,” states Jay Hale, director of quality improvement and clinical operations at Carolina Behavioral Health Alliance (CBHA), as he discusses how CBHA engages members in their telephonic case management program post-discharge. “We’ve found multiple venues to attract attention and begin the engagement process, including letters, outreach calls to members, and partnering with the discharging hospital. We want to be part of the discharge process, so telephonic case management is as much a part of the discharge plan as their visit with the doctor or therapist, medication regime, etc.

In HIN’s special report, Telephonic Case Management Protocols to Engage Vulnerable Populations, Jay Hale further describes the engagement process for CBHA’s telephonic case management program.

We are a small regional managed behavioral healthcare organization (MBHO), so our case managers also do utilization management. They identify the cases early and are able to talk to the utilization review (UR) people at the hospital and say, “This is someone that we have identified,” which helps with that discharge process. The earlier we can talk to members, the better. We want to talk to members as quickly after discharge as possible. Having the support of that hospital adds weight to what we do, so it is key that they do not receive a random call. We want it to be something that is related to their treatment process. That is why we want to be part of that discharging.

The next step is to call the member once they have been discharged. We obtain contact information from our records or from the hospital. Our records are based on what the person gave to human resources at some point along the line, so they may not always be updated. The hospital frequently has the most recent phone contact information.

We obtain the discharge recommendation, which is part of our UR process, including appointment times. I contact the member and engage them in the process to assure that they attend their appointments. We also call their providers to say that we want to make sure that the individual attends their appointment. We are the people who are authorizing the care, and these are in-network providers for us. Therefore, that is a relatively easy process. I feel comfortable with that because it is part of the treatment payment healthcare operations process. It also lets our providers know that we are doing this, so they should support us. It also lets them know we are not there just to plan, but also support what they do.

Once we get in contact with someone, we are going to describe this service in the way of how it can help him or her. “This is a service that helps you see how well you are doing.” Other phrases we use include, “We are here to support you in your recovery,” or “We are here to help you and your son/daughter.” We speak in a positive way, and we let them know that there is no cost to them for the program. This is part of their health plan, and we provide this service to help them see how well they are doing. That phrase works for them because it has a positive tone to it.

We also want to match case managers to the members as much as possible. As we manage care, we can see that individuals are more comfortable with a male or a female based on our UR information. They may be more comfortable with someone based on their issues, so we want to try to have the appropriate person do an outreach call to them. Because of that, we may learn about varying times of day to call.

We also found it is important for the case managers to know the therapeutic language that the member has learned. Specifically in substance abuse, we want people who are familiar with that language so that they can talk about supporting recovery, working a program, avoiding old playmates and playgrounds, working the steps, the big book and sponsors. There are certain words that are very specific to that language and to that program. If we can use that language comfortably, then that increases member engagement.

Home Visits Offer ‘Eyes on the Ground’ for High-Risk Populations

October 31st, 2013 by Patricia Donovan

Despite the explosion of mobile and telehealth technologies, there’s no substitute for person-to-person contact — at least when it comes to populations at high risk of hospital admission or readmission.

That was the finding of our inaugural Home Visits study, which captured the use of health-related home visits by 155 healthcare organizations. Almost 80 percent of respondents to the August 2013 survey visit some percentage of their patients or health plan members in their homes, a practice that is dramatically increasing levels of medication adherence and patient satisfaction.

Charged with keeping costly readmissions penalties at bay, healthcare organizations are deploying healthcare workers to the homes of risk-stratified patients and health plan members in greater numbers. While the primary purpose of the visit may vary by sector (payors’ case managers performing a home assessment versus hospitals clarifying discharge instructions), the end result is keeping patients safer and healthier in their homes and curbing costlier utilizers.

The home visit may also be the time to initiate the serious conversations — the ones that address end-of-life care and support, so that individuals have more control over the healthcare services they utilize during this final stage of the care continuum. These sensitive discussions can take place in the more relaxed setting of the patient’s home rather than at the hospital bedside.

What seems likely is that home visits will continue to proliferate, and supporting the home health workers, case managers, physicians and even pharmacists who conduct these visits will be portable technologies like a common electronic health record that all care providers can access, and telehealth tools such as interactive voice response (IVR) or disease-specific devices to transmit key health metrics (A1Cs or weight, for example) to the patient’s medical home.

Of course, the data tracked by these technologies must be shared among all providers so that coordination of care is seamless and duplication of care is avoided.

Scheduled telephonic follow-up should supplement more sophisticated technologies, survey respondents emphasized.

Download an executive summary of results from the 2013 Home Visits survey.

5 Tips for Seniors to Avoid Hospital Readmissions

June 24th, 2013 by Jessica Fornarotto


Nearly one in five seniors who are hospitalized return to the hospital within 30 days, according to a recent Robert Wood Johnson Foundation report. These readmissions are not only often physically and mentally debilitating to the seniors and their families, but contribute greatly to avoidable and unnecessary expenses on the nation’s healthcare system. To help curb these numbers, SCAN Health Plan recently offered seniors five strategies to lessen the chance of readmission.

  1. Ask questions before discharge. When patients are in the hospital, they’re completely dependent on others for care. But once they’re home, they’re in charge of their own recovery, which makes understanding what to do the key. Patients being discharged from the hospital who ask questions and who have a clear understanding of their after-hospital care instruction are 30 percent less likely to be readmitted or to visit the ED than patients who lack this information, according to a recent study from the AHRQ.
  2. Understand medications. This is particularly important if there have been changes to a medication regimen while in the hospital. Upon discharge, dosages are sometimes changed or a drug is discontinued or added. Patients need to be sure about this and to write it down. They also need to be sure to fill all new prescriptions once they’re home.
  3. Make a plan for follow-up care. Patients need to know when to schedule a follow-up visit to their doctor, and to make sure that they have the transportation to get there. Even if they’re feeling good, they should go anyway. The doctor needs to see a patient in order to track how they’re doing and to gauge whether the treatment plan is working. In addition to doctors, does the patient need to schedule home healthcare with a nurse or therapist, or do they have some new durable medical equipment or home-modification needs?
  4. Communicate with care coordinators. Whether a patient has a professional in-home caregiver, a family member nearby, or resides in an assisted-living community, they need to make sure that their caregiver is up to date on the recent hospitalization and how the patient is feeling. This also goes for the patient communicating with their health plan, as many have programs and professionals in place that can assist with care coordination.
  5. Be aware of “red flags” or complications that should be reported. What is considered “normal” for a patient’s post-hospital condition? What degree of pain or swelling is expected? Patients need to know what to look for, whom to call if they are not feeling well, and to have a clear plan of action in place so they know how to respond to a complication.

Romilla Batra, M.D., vice president and medical director of SCAN, says that readmission rates for seniors can also be reduced by enrolling in a health plan that has a strong emphasis on integrated care and care management. She points to a 2012 study released by Avalere Health that compared 30-day all-cause hospital readmission rates between California dual-eligible (Medicare and Medi-Cal) individuals in traditional Medicare versus those enrolled in SCAN Health Plan. The independent study found that SCAN’s dual-eligible members had a hospital readmission rate that was 25 percent lower than those in fee-for-service.

“Industry-wide efforts are underway to bring down readmission rates including new rules passed as part of the Affordable Care Act that charge additional fees to hospitals with excessive readmissions,” said Dr. Batra. “But ultimately it is still the consumer themselves who can play the biggest role through common sense and following these five easy steps.”

Infographic: Where Do Discharged Patients Go?

September 26th, 2012 by Melanie Matthews

An analysis of 2010 Medicare claims data by Avalere Health found that discharged Medicare patients are not following their discharge plan for the next site of care.

Of the 41,859 Medicare beneficiaries coded as being discharged to short-term general hospitals for inpatient care, fewer than one in four patients actually went to another short-term general hospital. To see where patients leaving the hospital actually went for their post-acute care, view this new infographic by Avalere.

Where Do Discharged Patients Go for Post-Acute Care

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