Posts Tagged ‘Care Transitions’

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

Healthcare Business Week in Review: Insurance Deadline Extension; Specialty Pharmacies; Care Transitions

July 9th, 2013 by Cheryl Miller

Employers will have more time to comply with the ACA mandate on insurance coverage, according to a White House blog posted by Valerie Jarrett, senior advisor and assistant to the president for Intergovernmental Affairs and Public Engagement.

In response to concern from employers with more than 50 employees working more than 30 hours a week that they would not have enough time to comply with the ruling by 2014, the administration has extended it by a year, and will simplify the reporting process. Plans to open health insurance exchanges on October 1 are still going forward, the administration says. More details can be found inside.

Kidney transplant patients who use specialty pharmacies as opposed to retail pharmacies report lower healthcare costs, according to a study published in the Journal of Managed Care Pharmacy.

The one-year study conducted by Optum found that those transplant patients using individualized services provided by the pharmacies, including adherence and clinical management programs, member education, and counseling services provided by pharmacists trained in transplant pharmacology, showed 30 percent lower post-transplant-related medical costs and 13 percent lower overall healthcare costs.

Medication adherence is one area of transplant medicine that needs improvement, researchers state. While the rate of non-adherence is highest at one to three years post-transplant, it may happen at any point during lifelong therapy.

Personal time and contact with patients during care transitions — before and after their hospital discharge — significantly reduces readmission rates, according to a study conducted by the Bronx Collaborative, a group of hospitals and health insurers in the Bronx, N.Y.

Among 500 patients who received two or more of four interventions by nurse care transition managers in a special program to manage the transition between hospital and home, only 17.6 percent were readmitted to the hospital within 60 days of discharge versus 26.3 percent among a comparison group of 190 patients who received the current standard of care, the data showed.

Another 85 patients who received only one intervention for a variety of reasons had an overall readmission rate of 22.8 percent. More inside on the four interventions.

And, if you have the time, please take our latest 10 question survey on Managing the Dually Eligible. Tell us how you’re managing this population, which constitutes about 9 million individuals who are eligible for both Medicaid and Medicare in the United States, and receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

STAAR’s 4 Domains of Process Improvement to Enhance Patient Health

June 18th, 2013 by Jessica Fornarotto

Amy Boutwell, MD, MPP, president of Collaborative Healthcare Strategies, recommends hospitals follow the four domains of process improvement from the State Action on Avoidable Rehospitalizations (STAAR) in order to improve the standards of care for each patient to prevent future health woes.

During HIN’s webinar Readmission Penalties in 2013: A Cross-Continuum Approach To Lessen the Financial Impact, Boutwell listed STAAR’s four domains, which include enhanced assessments, enhanced teaching, real-time communication and timely follow-up care.

STAAR’s four general domains of process improvement do not constitute a cookbook. We recognize that hospitals need to adapt and implement these concepts in various ways to fit their settings, whether rural, urban, academic or community hospitals.

The four major domains are an invitation to reflect. If your hospital is not providing these four elements of care for every single patient leaving your care, regardless of risk, then I invite you to reflect upon why you wouldn’t do this for everyone. Why wouldn’t we make sure that we update our standard of care as people leave our hospital ‘sicker and quicker,’ and take upon themselves a greater burden and more responsibility for after-hospital care? Why wouldn’t we improve our standard of care for everyone in these four areas? The four domains are as follows:

1. Enhanced assessment. This means that we assess patients. That’s what we do in the hospitals; that’s what nurses, doctors and therapists do all the time. But this is the concept of expanding that view, especially of our frequent flyers or our frail patients to the big picture. What is the longitudinal care need beyond the acute episodic presenting need?

2. Enhanced teaching and learning. This is a change from putting packets of information on meal trays to using the three or four days of the hospitalization as a learning opportunity. Identify who is the right learner, because it’s not always the patient. Engage in that health literacy-appropriate teachback technique to convey the key elements — not the entire 85-page booklet on heart failure but the key elements of self-management as the patient transitions from our setting to the next setting.

3. Real-time communication. This is communication both to the receiving providers as well as better updates in communication to the patients and family members. It can’t be okay for us to have rounds at 7:00 or 8:00 in the morning and then tell the patient to call their daughter because they are being discharged at 2:00. This is the experience of many of our patients still. Keeping people updated as to their care plan and their after-hospital care needs is something that we identified as a major theme in many root cause analyses of early readmissions.

But even more to the point around real-time communication is that we’re still not doing a great job in letting the outpatient providers know that their patients are being admitted and discharged and defining the reasons for their hospital stay. What was their course treatment? What were the new results and what medicines were they prescribed? Root cause analyses from every community across the United States now find that real-time communication with their receiving providers is still lacking.

4. Ensuring that there is timely post-acute care follow-up. This will vary based on patient risk, but if your patient is moderate or high-risk, a call to their doctor’s office and an appointment in one to two weeks is not going to do it anymore. We have so much data. If you run your own hospital’s data as to the average time between discharge and readmission, you will find that 25 percent of your readmissions are coming back within three to four days, and 50 percent are coming back within seven to 10 days. We need to get touch points. It doesn’t need to be a follow-up appointment; there are many good models of phone calls, visiting nurses, lay-care providers, etc. We need to follow up with patients to make sure that when they get home, they understand their plan of care, they get their medications and they are not confused.

QIO Advice for Improving Care Transitions: Dig Deep Into Local Data

June 6th, 2013 by Cheryl Miller

There is no cookbook or recipe for improving care transitions.

Instead, the first step for any healthcare organization and community-based healthcare provider is to conduct a root cause analysis of readmission data, which can vary from community to community, says Alicia Goroski, MPH, senior project director for care transitions for the Colorado Foundation for Medical Care (CFMC), the Medicare Quality Improvement Organization (QIO) for Colorado. Once established, the appropriate intervention can be selected, and quality improvement methods then used to monitor, assess, and improve the implementation of those interventions.

Goroski shared these lessons and more from 14 communities that participated in the CMS Care Transition Demonstration Project (CCTP), and detailed how the program is being rolled out in 400 communities and to over 12 million Medicare beneficiaries across the country during a recent HIN webinar, Patient Engagement and Provider Collaborations Across the Healthcare Continuum to Improve Care Transitions. CFMC coordinates the work of state-based QIOs, which are contracted by the CMS and designed to work with hospitals and community providers to improve care transitions and reduce readmissions.

According to a study in the Journal of the American Medical Association (JAMA), hospital admissions and readmissions among Medicare beneficiaries declined nearly twice as much in communities where QIOs coordinated care transition programs that engaged the whole community. Some of the programs, focused on patients, providers or both groups not only lowered key Medicare readmission rates but also reduced participants’ overall admission stats.

The key is to dig into the data locally, she says, because there is no one size fits all intervention.

In Harlingen, Texas, it was discovered that over half of the 30-day readmissions coming back in their community were from skilled nursing facilities (SNFs). So they implemented the Interact intervention. They convened all the nursing homes and created a coalition dedicated to reducing the numbers. Within the 18-month intervention period, the 30-day readmission rate for nursing homes in that Harlingen community went from about 46 percent down to 19 percent.

On the flip side, in Goroski’s home community in Denver, nearly three fourths of readmissions were occurring among beneficiaries who had been discharged home with no home health services. Instead of implementing the Interact intervention, which wouldn’t have addressed the driver of readmissions, they hired three full-time coaches for those patients who were being discharged directly home.

The CTI was also useful for medication reconciliation, Goroski continues, pointing to the three main drivers of readmissions: patient and family engagement, a lack of standard and known processes, both within and across care settings, and health information exchange.

Medication reconciliation crosses all those areas, Goroski says, and up to half of all readmissions can be attributed to medication errors, whether the problem stems from a lack of reconciliation at discharge to a lack of follow-up calls once home. Care transition coaching is helpful, in terms of coaching the beneficiary on any medication discrepancies, advising their provider and then using the correlative technology. What differentiates the coach, usually a nurse, from a medical provider is that instead of making the follow-up phone call for the patient, the coach shows them how. This intervention, usually lasting one month, has been very successful, Goroski says.

But ultimately, it takes a village to effectively improve care transitions, Goroski says. Hospitals need to work with hospitals, nursing homes, home health agencies, hospice organizations, dialysis facilities and outpatient physicians to close care gaps.