Posts Tagged ‘pcp’

9 Hospital Discharge Communications Tactics to Curb Readmissions

January 27th, 2015 by Cheryl Miller

For heart failure patients making the transition from hospital to home, an effective discharge summary can mean the difference in whether the patient recovers quickly or returns to the hospital, according to two new studies from Yale School of Medicine researchers. To be effective, discharge summaries must have three key factors: they must be timely, be quickly forwarded to the outside physician, and contain detailed and useful information.

We asked the 116 respondents to the fourth annual Healthcare Intelligence Network’s (HIN) Reducing Hospital Readmissions Survey, conducted in December 2013, what hospital discharge communications tools they used to lower their readmissions rate. Following are their responses.

  • Follow-up with patient post-facility discharge by case managers embedded in our physician practices.
  • Improved communication between inpatient (hospital) care coordination and outpatient (medical group) services.
  • Follow-up appointments with the doctor and home care arrangements are made prior to discharge from the facility if appropriate. Discharge information with medications are sent to the doctor’s office by the facility doctor on discharge for availability on follow-up appointment.
  • Increased oversight of high-risk patients; increased communication among clinical teams and health providers.
  • We utilize a transitional care program to engage with patients while in facility and continue to follow with in-home visits on discharge to continue education and teach-back as well as monitor and oversee progress.
  • Post-acute touch (home health) within 24 hours of discharge; medication reconciliation, signs and symptoms education and scheduling primary care physician (PCP) office visit appointment.
  • All discharges are called by our nursing supervisor or other designee to determine their post-discharge status and ensure they keep their follow-up primary care appointment.
  • Reaching the patient within one to two days post-discharge. Assuring the patients have a follow-up appointment and transportation, understand discharge medications, red flag symptoms and who to call if necessary.
  • Follow-up in the home for 35 days post-transition to home.

Source: 2014 Healthcare Benchmarks: Reducing Hospital Readmissions

http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Reducing-Hospital-Readmissions_p_4786.html

2014 Healthcare Benchmarks: Reducing Hospital Readmissions documents the latest key initiatives and partnerships to reduce readmissions by patients with these costly conditions and others by more than 100 healthcare organizations.

WellPoint Referral Preparedness Tools Support Physician-Specialist Care Compacts

October 2nd, 2014 by Cheryl Miller

With the help of care compacts that drive accountability between primary care physicians and specialists, WellPoint has launched a medical neighborhood pilot for three specialties with clear care coordination alignment opportunities with primary care medical homes. Here, Robert Krebbs, director of payment innovation at WellPoint, Inc., discusses how Wellpoint supports the care compact model with Referral Preparedness Tools— add-ons devised for physician/specialist patient handoffs.

One thing we found interesting was the uniform request from physicians for what we call ‘Referral Preparedness Tools.’ That’s a name we made up. These are add-ons to care compacts that call out common conditions for a given specialty, the conditions for which they often get referrals or consult requests from PCPs. It specifies for that condition what the specialist would like to see for the initial consult or regular repeating referral, and what they want the PCP to do first and send to them and specifically, what they want the PCP not to do—that is, things to avoid before sending the patient over.

On the flip side, the tool lists for that condition what the specialist intends to send back to the PCP. The practice will work on this together for common conditions. The tool doesn’t list everything that could possibly happen, but rather specifies the patient flow for common conditions.

We didn’t initially include this tool in our care compact expectations. The practices asked us for this; they see this as a true opportunity to drive improvement and efficiency in the system, to avoid unneeded care and to make sure that the correct care is provided for all patients.

We’re going to monitor development of these tools throughout the pilot to determine common themes so we can provide a good template starting place on this run as well as for future pilot practices in this program. We’re excited that specialists have made this template their own. They’re hard at work identifying what they’d like to see in these scenarios.

dual eligibles care
Robert Krebbs is the director of payment innovation at WellPoint where he has accountability for the design, development and rollout of value-based payment initiatives. He works directly with network physicians and facilities on innovative performance measurement programs aimed at delivering healthcare value by promoting high quality, affordable care.

Source: Care Compacts in the Medical Neighborhood: Transforming PCP-Specialist Care Coordination

10 Things to Know About Reducing Avoidable ER Visits in 2014

September 18th, 2014 by Cheryl Miller

Despite expanded coverage available under the Affordable Care Act (ACA), the hospital emergency room (ER) remains a refuge for those unable to visit their primary care physician (PCP)— whether due to lack of access, insurance, or time, according to results from the latest Reducing Avoidable ER Visits Survey by the Healthcare Intelligence Network (HIN).

But more than half of respondents (65 percent) are confident CMS’s easing of telemedicine regulations (e.g. mandates for physician on-site hours) will help to reduce avoidable ER visits.

In the three years since HIN last administered this survey, health organizations have stepped up ER discharge follow-up efforts. Almost one-third of respondents (31 percent) in 2014 say they contact patients within 24 hours of their ER visit, versus 22 percent of respondents in 2011 who made provider appointments before discharge, and 18 percent who conducted phone follow-ups within two days of a visit.

Here are more metrics derived from the 2014 Reducing Avoidable ER Visits Survey:

  • Staffing solutions to reduce avoidable ER visits have changed: case managers, social workers and disease-specific care coordinators are increasingly utilized in the ED, replacing health educators, coaches, and nurse-only advice lines used in 2011.
  • The challenge of redirecting non-emergent patients, while still a primary barrier, decreased in priority from 29 percent in 2011 to 18 percent in 2014.
  • Insufficient care access remains a challenge, growing from 16 to 21 percent in 2014, along with PCP collaboration, which was still among the top three challenges, but decreased from 24 percent in 2011 to 18 percent in 2014.
  • The prevalence of programs to reduce avoidable ED usage remained relatively stable from 2011 to 2014, with nearly three quarters of respondents reporting such initiatives.
  • Among populations reported to generate the majority of avoidable ED visits, ER use by dual eligibles increased five-fold in the last four years, from 2 to 11 percent, while other populations — high utilizers, Medicare and Medicaid — remained roughly the same.
  • Chronic disease replaced pain management as the most frequently presented problem, at 54 percent.
  • Education and risk-based telephonic outreach are the top two patient-centered strategies used to reduce avoidable ER visits in 2014.
  • Behavioral health issues and privacy are considered two top legal and compliance obstacles in reducing avoidable ER visits, respondents say.

Source: 2014 Healthcare Benchmarks: Reducing Avoidable ER Visits

Stratifying High-Risk Patients


2014 Healthcare Benchmarks: Reducing Avoidable ER Visits
delivers actionable metrics from 125 healthcare organizations on their efforts to foster appropriate use of hospital ER departments. Enhanced with more than 50 easy-to-follow graphs and tables, this third edition of comprehensive data points presents year-over-year trends and best practices for engaging ER and hospital staff, primary care physicians, community providers and patients in reducing avoidable ED utilization.