Posts Tagged ‘reducing hospital readmissions’

Infographic: The Post-Acute Care Landscape

May 8th, 2017 by Melanie Matthews

Hospitals can't just leave patient care to chance after patients leave the hospital. They must be more actively involved in managing their patients to ensure that they will receive the most appropriate post-acute care and avoid readmissions, according to a new infographic by eviCore healthcare.

The infographic examines the components of the post-acute healthcare market, guidelines for avoiding unnecessary readmissions and strategies for modernizing post-acute care.

Reducing SNF Readmissions: Quality Reporting Metrics Drive ImprovementsA tri-county, skilled nursing facility (SNF) collaborative in Michigan is holding the line on hospital readmission rates for the three competitive health systems participating in the program.

Henry Ford Health System, Detroit Medical Center and St. John's Providence, along with the state's Quality Improvement Organization (QIO), MPRO, developed standardized quality reporting metrics for 130 SNFs in its market. The SNFs, in turn, enter the quality metrics into a data portal created by MPRO.

During Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvements, a 45-minute webinar on May 11th at 1:30 p.m. Eastern, Susan Craft, director, care coordination, family caregiver program, Office of Clinical Quality & Safety at Henry Ford Health System, will share the key details behind this collaborative, the impact the program has had on her organization's readmission rates along with the inside details on new readmission reduction target areas born from the program's data analysis.

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Infographic: Stopping the Revolving Door of Short-Term Readmissions

April 10th, 2017 by Melanie Matthews

Transitioning eligible patients to hospice can help hospitals avoid Medicare's 30-day readmission penalty, according to a new infographic by VITAS.

The infographic examines how hospice can reduce readmission rates and increase patient satisfaction.

Reducing SNF Readmissions: Quality Reporting Metrics Drive ImprovementsA tri-county, skilled nursing facility (SNF) collaborative in Michigan is holding the line on hospital readmission rates for the three competitive health systems participating in the program.

Henry Ford Health System, Detroit Medical Center and St. John's Providence, along with the state's Quality Improvement Organization (QIO), MPRO, developed standardized quality reporting metrics for 130 SNFs in its market. The SNFs, in turn, enter the quality metrics into a data portal created by MPRO.

During Reducing SNF Readmissions: Quality Reporting Metrics Drive Improvements, a 45-minute webinar on May 11th at 1:30 p.m. Eastern, Susan Craft, director, care coordination, family caregiver program, Office of Clinical Quality & Safety at Henry Ford Health System, will share the key details behind this collaborative, the impact the program has had on her organization's readmission rates along with the inside details on new readmission reduction target areas born from the program's data analysis.

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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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Infographic: Reducing Readmissions Through Patient Education

December 18th, 2015 by Melanie Matthews

The importance of care transitions in improving patient safety is illustrated by recent data released by The Joint Commission on sentinel events compiled from January 2014 to October 2015.

The data show a total of 197 sentinel events—from suicide to falls to wrong site surgery—and the root causes included failures in patient communication (127 incidents), patient education (26 incidents) and patient rights (44 incidents). The majority of the patient education failures were related to not assessing the effectiveness of patient education or not providing education. The patient rights failures included absent or incomplete informed consent, and lack of the patient's participation in their care.

In response to these findings, the Joint Commission released an infographic to help healthcare providers in their efforts to reduce patient readmissions and improve the discharge process.

Providers who signed on for San Francisco Health Network's Care Transitions Task Force shared not only a professional passion for care transitions work but also the belief that care transitions responsibility should be spread across the healthcare continuum. And once the SFHN task force mined a 'black box' of administrative data buried in more than 60 siloed databases across its health network, continuum-wide care transition improvement seemed attainable.

Data-Driven Care Transition Management: Action Plans for High-Risk Patients documents how SFHN's deep data dive triggered the development of a data dashboard, a hospital discharge database and a set of uniform standards and practices that have streamlined care transitions within its safety net population.

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Infographic: Hospitals Overconfident, Unprepared To Reduce Readmissions

July 15th, 2015 by Melanie Matthews

While hospitals report they are confident in their ability to reduce readmissions, according to a new survey conducted by Q-Centrix, the percentage of hospitals penalized for readmissions has increased each year since CMS began imposing them.

The percentage of hospitals penalized for readmissions reached a high of 78 percent for FY 2015. Given the historical trend and the three additional diagnoses recently added, the percentage of hospitals penalized will likely be much higher than the 55 percent who reported that they expected to be penalized, according to an infographic produced by Q-Centrix on the survey results.

2014 Healthcare Benchmarks: Reducing Hospital Readmissions While great strides have been made in the reduction of 30-day all-cause hospital readmissions, CMS still penalized more than 2,200 hospitals in 2013 for exceeding 30-day readmission rates for heart failure, pneumonia and myocardial infarction. This year, CMS penalties extend to acute COPD and elective hip and knee replacements.

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.

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9 Remote Monitoring Technologies Enhance Telephonic Care Management

April 2nd, 2014 by Cheryl Miller

From home sensors that monitor daily motion and sleep abnormalities, to video visits using teleconferencing, Humana is doing its best to ensure that the frail elderly can remain at home as long as possible.

When integrated with a telephonic care management program, these remote monitoring technologies have helped Humana to avert medical emergencies and preventable hospitalizations among individuals with serious medical and functional challenges, says Gail Miller, vice president of telephonic clinical operations in Humana's care management organization, Humana Cares/SeniorBridge. The pilots are part of a continuum of care aimed at improving health outcomes, increasing satisfaction and reducing overall healthcare costs with a more holistic approach.

Most Americans are living longer, and suffering fewer deaths from acute illness, Miller said in a recent Healthcare Intelligence Network webinar, Integrating Mobile Health Remote Patient Monitoring with Telephonic Care Management for Improved Care Coordination Results. But they are also developing more chronic illnesses and functional limitations, which are often the costliest to manage.

Despite their growing frailty, however, nine out of 10 Americans prefer to age at home, she continues. To help them live independently and age gracefully at home, Humana, which has over 30 years experience in the Medicare program, and over two and a half million Medicare advantage members, launched the Humana Chronic Care Program (HCCP). Targeting the members most in need, or the sickest 20 percent, which drive 75 percent of the company’s costs, the company implemented a series of nine healthcare remote monitoring pilots for individuals with congestive heart failure (CHF) and diabetes as well those with medication adherence problems. The pilots also target those with functional challenges that make activities of daily living (ADL) challenging.

“There is a clear need to look beyond disease and address functional limitations,” Miller says.

One of the pilots includes strategically placed home-based sensors that monitor ADL levels of those with functional impairment. Algorithms detect abnormalities in the patients’ activities, i.e. erratic sleeping behaviors or toileting patterns that can signal infections, which then generate alerts for recommended interventions.

Video visits include two way audio-video communications so that care managers can interact with their sickest members as an adjunct to home visits. Members are given tablets to use for face-to-face contact with their care manager, or to go over any educational materials their care managers or physician provides them.

Ranging from passive to active monitoring, all of the technologies are senior-friendly, and designed to help members manage their conditions, reduce hospitalizations and improve the patient/member experience, Miller says.

A mobile Personal Emergency Response System (PERS), for those that live alone or have limited caregiver support, has been the most popular, Miller says. Members are mailed a cellular device that can be activated manually by a button, or automatically via an accelerometer. Once turned on, the PERS device connects the member to clinically trained emergency support. Many patients have asked if they could extend their use of this particular device once the pilot was over, Miller says. She explains why:

Besides being a health issue, I think the device also speaks to the level of safety concerns that a lot of seniors who have multiple chronic conditions, and who live alone, have. They don’t want to necessarily reach out to their neighbors all the time. This provides them some peace of mind, which is the ultimate goal of the program.

Listen to an interview with Gail Miller of Humana Cares/SeniorBridge here.

What are your organization’s efforts in remote patient monitoring? Participate in our e-survey, 10 Questions on Remote Patient Monitoring, by April 22, 2014 and you will receive a free summary of survey results once it is compiled.

6 Strategies Help Stem Hospital Readmissions, Streamline Processes and Care Transitions

February 27th, 2014 by Cheryl Miller

Development of post-acute partnerships with home health, skilled nursing facilities (SNFs) and hospice is emerging as a key strategy to stem hospital readmissions, according to new market data from the fourth annual Healthcare Intelligence Network (HIN) Reducing Hospital Readmissions Survey.

More than half of survey respondents participate in post-acute partnerships, with home health collaborations the most common (79 percent). These partnerships serve to streamline processes and care transitions, educate and align staff, and implement changes of value to patients, respondents say.

Looking at more conventional approaches, medication reconciliation and telephonic monitoring of patients post-discharge emerged as frontrunner strategies to curb readmissions. Moreover, the 2013 survey revealed significant upticks in the use of each tactic over 2012 levels: medication reconciliation is now conducted by 73 percent of respondents, versus 54 percent in 2012, while the use of telephonic monitoring jumped from 48 to 71 percent over the same 12-month period.

In other new data, almost half of respondents — 47 percent — aim programs at individuals already assessed at high risk for readmission as well as traditional Medicare (53 percent), Medicaid (28 percent) and high utilizer (23 percent).

Other key findings include the following:

  • Two-thirds of respondents to HIN’s December 2013 Readmissions e-survey have a program to reduce readmissions.
  • In a new metric from the 2013 survey, more than half — 52 percent — aim readmission reduction efforts at individuals with diabetes.
  • Case management is the most successful approach to curbing rehospitalizations, say 27 percent. The case manager retains chief responsibility for reducing readmissions, say 34 percent of respondents.
  • Heart failure remains the top condition targeted by programs, although a fifth already track readmissions for hip and knee replacements, a metric the Centers for Medicare and Medicaid Services (CMS) will examine more closely in 2015.

Excerpted from 2014 Healthcare Benchmarks: Reducing Hospital Readmissions.

Award-Winning Protocol Puts Readmission Prevention Manager in ER to Reduce Rehospitalization Rates

February 13th, 2014 by Cheryl Miller


Call it a bouncer of sorts for the emergency room: the readmissions prevention manager, or RPM for short, has helped Torrance Memorial Health System reduce all cause readmissions by nearly 5 percent, and earn its hospital system kudos from the industry, says Josh Luke, Ph.D., FACHE, vice president of post acute services at Torrance Memorial Health System and founder of the California Readmission Prevention Collaborative and the National Readmission Prevention Collaborative.

Designed to determine whether newly admitted high-risk patients are ready for the emergency room (ER), or could be placed elsewhere, the RPM is an integral part of a strategy implemented in 2013 for Total Wellness Torrance (TWT) to reduce preventable readmissions, Luke said during Award Winning Readmission Prevention Protocols: Navigating Care Transitions with Preferred SNF and Home Health Providers , a 45-minute webinar on January 8th, 2014, now available for replay.

He shared the key features of this program, which was recognized by California Association of Healthcare Facilities as a Program of Excellence in 2013. At the time, the 401-bed not-for-profit hospital was achieving readmissions rates that were in step with national averages, generally within 18 to 20 percent, and some quarters exceeding that. Torrance felt it could do better, approaching the problem from an all-cause, rather than disease-specific perspective, Luke says.

Creating the RPM was the first step in the process, he says. This person would function as the leader of the hospital readmission prevention team, making sure only patients who meet criteria and need to be hospitalized are admitted either to the observation floor or to the inpatient unit.

As Luke explains: the RPM gets a real-time email alert any time a patient comes to the ER and their social security number is entered into the hospital’s electronic system. Their number one priority is then to go right to the ED to meet the patient and work with the attending doctor, case manager and nursing team in the ER to see if this patient can be cared for at a lower level of care.

That’s essentially what the Affordable Care Act has encouraged us to do and incentivized us to do and penalized us when we don’t do that efficiently, which is not to admit patients to the hospital that don’t need to be here. We are very encouraged by the success of that program in its initial six months.

The RPM then follows those patients who were not admitted to the ED to a post-acute network facility, at all times keeping in mind patient choice. TWT includes a post-acute network of eight skilled nursing facilities (SNFs), all within five miles of the hospital, and a home health agency. Along with a home health department navigator, the RPM goes to each SNF once a week to follow up on patients, determining discharge plans and employing an ambulatory case manager if the patient goes to a home health agency outside the Torrance network, and keeps tabs on them long after the 30-day readmission period is over.

Collaboration and communication with the post-acute network (PAN) is key to success, Luke says. "Whenever I'm asked if I could name three basic things to prevent readmissions, the first thing I always refer to is telling your skilled nursing facilities to invest in predictive software because it doesn't cost you as a hospital anything. It enables you to share data with the SNFs."

That, and always be a champion of choice for your patients, Luke adds, even when they're being bounced out of the ER.

Meet Healthcare Case Manager JoAnne Vanett – Patient Advocacy, Education, Communication Keys to Success

November 20th, 2012 by Cheryl Miller

This month we provide an inside look at a healthcare case manager, the choices she made on the road to success, and the challenges ahead.

JoAnne Vanett, BSN, MA, CCM, CEN, Specialty Case Manager in Readmissions Risk Reductions for Aetna

HIN: Tell us a little about yourself and your credentials.

JoAnne Vanett: I have been a BSN for 40 years. After graduating in 1972, I began my career as a pediatric nurse. I tried various fields throughout my early years but always came back to pediatrics, and particularly pediatric oncology and children with cystic fibrosis, who at that time had a very limited life expectancy. I also pursued art as a major in high school, but dropped it once in college, since we began working in clinical (hospital experience) in sophomore year.

Once I began full-time nursing I started taking courses at the Corcoran School of Art in Washington, D.C., which is where I first heard about art therapy. I graduated with a master's in it from George Washington University, hoping to work with terminally ill patients, and was one of the first students in the art therapy program to work with medical patients using art. I continued to work full-time as a nurse during grad school and transferred to the ED so I could work nights. There I fell in love with emergency/trauma. I worked at the first pediatric trauma center in the United States, and found I could use art at work to explain things to children and realized I had been doing that for years with all my patients. However, life takes us to strange places and becoming a single parent kept me a nurse rather than furthering my career in art therapy. I became a certified emergency nurse (CEN), taught advanced cardiac life support (ACLS) and pediatric advanced life support (PALS) and trauma courses.

After a back injury, I worked as a worker’s compensation case manager. Then I made my way back to the ED until I felt it was time for a change. Eight years ago I became a case manager for Aetna and became a certified case manager (CCM). It was one of the best moves I have ever made.

What was your first job out of college and how did you get into case management?

My first job out of college, and where I spent a significant amount of years, was at Children’s National Medical Center in Washington, D.C. Truthfully, a piece of my heart is still there. After more than 30 years in clinical nursing I was ready for a change and one interview at Aetna told me this was the place I wanted to be. I met with three supervisors and their enthusiasm, positivity and excitement overwhelmed me! I never expected that I would ever work for an insurance company. What impressed me so was the respect and autonomy the nurses were given. What I learned was that Aetna approached case management as advocacy for the members; promoting education as well as finding ways for members to maximize their benefits, and it just spoke to all I believe in. I was so very impressed with the nurses who worked there, and love that case management resembles the excitement of the ER in the way you never know what the next case will bring.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

I have always wanted to be a nurse. The most valuable moments for me are when I know I have done something well for a patient and a family. If I have contributed to saving a life; made someone feel safe and not alone; sat with a dying patient; helped to prepare a patient and a family for death or cope with a devastating illness; or resolved a problem for which no one else has been able to find a solution, then I am satisfied. There is no way to quantify nursing. It is the relationship that develops between the nurse and the patient, no matter what field of nursing, whether face-to-face or over the telephone.

In brief, describe your organization.

While Aetna may be an insurance company it prides itself on the expertise of all its nurses who function in a great many roles throughout the organization, not just as case managers. Aetna is always looking for new and innovative ways to engage our members to personalize care and improve outcomes by prevention and education as well as advocacy. There has been a new focus on the mind-body connection and ways to support all of the employees to decrease stress and encourage a good work-life balance. Aetna listens to what the employees have to say and is responsive. For me, personally, I have found a number of great mentors in the supervisors and managers I have worked with over the last eight years. There is even a formal mentoring program. In addition, the medical directors welcome our input and are great resources for education and collaboration. It is very much a team approach. As many of us telework, there is a large telework network and many special employee resource groups that are available for participation. There are many ways to volunteer and Aetna promotes a giving atmosphere. There is also a focus on education. I think that as much as Aetna strives to provide excellence for its members, it strives to provide excellence in the workplace.

What are two or three important concepts or rules that you follow in case management?

  • First, listen to your patient. Find out what is most important to them and attempt to resolve it.
  • Second, help your patient/member be a better educated healthcare consumer, and know how to navigate the medical care system. No one should have to be ill and get lost in the process. People pay for their benefits and they are entitled to use them to the fullest extent but in the most cost-effective way.
  • Most importantly, be an advocate for your patient/ member. You are the voice of someone who may not be able to speak for himself.

What is the single most successful thing that your organization is doing now?

Venturing into technology for its members. There are apps for the phone as well as a Web site with tools to use to manage care. Aetna is always looking for ways to educate its members. The organization is committed to doing the “right thing for the right reason” with a high standard of excellence, and aims to treat everyone with compassion and caring.

Do you see a trend or path that you have to lock onto for 2012? 2013?

I am very interested in case managers who are embedded within physician practices. I think that collaborating with them along with facility providers to offer a team approach to support patient care and education are the wave of the future.

What is the most satisfying thing about being a case manager?

For me, the most satisfying thing about my job is hearing someone say, “I could never have gone through this without you.” It’s being able to accomplish something: find a solution, solve a problem, locate a resource, get something authorized, help someone change their life for the better, or prepare and then ease a family through a death. And best of all, it is the relationships I develop in the process.

What is the greatest challenge of case management and how are you working to overcome this challenge?

I think the greatest challenge of case management is time and communication. There are so many people we could help if we could reach them. But the difficulty is communicating with the facilities or the providers and the time it takes to do so. It is taking the time to make a connection and build a relationship in the first few minutes of a phone call. Once that connection is made then a relationship can be built. You have to convey in the first few moments of a phone call your willingness to collaborate and build a good working relationship. It is the willingness of a facility or a provider to take the time to work with an insurance case manager and understand what we can offer. We all have to work as a team and collaborate. Once the relationships are established we have so much more to offer and to improve healthcare for people.

What is the single most effective workflow, process, tool or form case managers are using today?

The most effective workflow we are currently using is our Readmission Risk Reduction program. As a specialty case manager, I work as part of a team to do intensive proactive discharge planning and collaboration with facilities, home care agencies, and physicians to assist and educate patients with the goal of preventing repeat admissions. We then follow the member with intensive communication and support and then transition to a long term case manager if needs continue past a month. While I miss the long term relationship with the patients, I like the intensive interactions and problem solving and the success we can achieve with this program.

Where did you grow up?

I grew up in Philadelphia, Penn., attended college and graduate school in Washington, D.C., and lived in the D.C. metropolitan area for a number of years afterward.

What college did you attend? Is there a moment from that time that stands out?

I attended The American University for nursing school, took art classes at the Corcoran School of Art, attended grad school at George Washington University in Washington, D.C. The time that most stands out while in college were the anti-war I demonstrations. Because our campus was private and essentially enclosed the police could not come on campus, but they shot tear gas over the buildings onto the quad. I worked as a volunteer for the Medical Committee for Human Rights during the demonstrations and was a first aid volunteer on campus and went out with a team to provide first aid in downtown D.C. and also worked in a free clinic in Georgetown.

Are you married? Do you have children?

I was married in Maryland, my son was born there, and we then returned to Pennsylvania after my divorce when he was small. My parents were involved in his care and I am now the caretaker for my 94-year-old father. My 30-year-old son is a senior software developer and architect for a technology company outside Annapolis, Md. Somehow I seem to have spent my life on the I-95 corridor!

What is your favorite hobby and how did it develop in your life?

While I would not call it a hobby, I am very involved with Mindfulness Meditation. I began with the Foundation Program at the Penn Program for Mindfulness several years ago, as a way to decrease stress. Since then I have progressed to having a daily meditation practice and continue to study with an ongoing group at the University of Pennsylvania. I still dabble in painting and drawing.

Is there a book you recently read or movie you saw that you would recommend?

I would recommend the book we used for my foundation program at Penn, Jon Kabat-Zinn’s “Full Catastrophe Living.” We do not recognize how great a role stress plays in our lives and that we have the opportunity to take the time to appreciate each moment while it lasts. No one ever knows what the future holds so it is most important to be aware of the present moment.

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