Posts Tagged ‘transition coaches’

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.

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).