• Innovation With Care Transitions

    By Laura Ramos Hegwer Aug 10, 2015

    Healthcare leaders continue to test better ways to move patients from one care setting to the next. From seamless data exchange to new payment structures that incentivize providers to better coordinate care, these innovations underscore the importance of managing transitions to improve population health and contain costs.

    At any emergency department (ED) across the country, at least a handful of patients revolve through the doors often enough that the staff know them by name. But at organizations like Advocate Health Care in suburban Chicago, these frequent users are returning to the ED a lot less, thanks to the efforts of care managers.

    Leaders at Advocate and other forward-thinking health systems recognize that coordinating care for high-risk patients as they move between sites of care-from the ED to primary care, from acute to post-acute, and so on-is critical for success under value-based payment models.

    "For our overall commercial and Medicare population, better care coordination has helped us hold costs flat or decrease costs 2 to 3 percent over the past three years," explains Michael J. Randall, FACHE, vice president, clinical innovation, Advocate Physician Partners, a clinically integrated organization comprised of more than 4,900 employed and aligned physicians and 12 hospitals. (Advocate extended this model of care to Medicaid patients in 2014. Initial indicators suggest similar results for this population.)

    The potential impact of better care coordination on reducing hospital admissions and other costly interventions is significant. An Institute of Medicine analysis by Mary Kay Owens, RPh, CPh, found that better care coordination could save an estimated $240 billion a year (Owens, M., "Costs of Uncoordinated Care," The Healthcare Imperative: Lowering Costs and Improving Outcomes, National Academies Press, 2010, pp. 131-36.)

    Morey Menacker, president and CEO, HackensackAlliance ACO

    Morey Menacker, DO, president and CEO, HackensackAlliance ACO, believes the lack of interoperability between IT systems is slowing providers' progress toward better care coordination. (Photo: HackensackUMC)

    Taking Steps Forward and Back

    A lot has been learned about how to successfully coordinate care in recent years. Healthcare providers and payers have been testing a number of care coordination models ("Leading the Way: Complex Care Management Program Overviews," California Healthcare Foundation, July 2013).

    Aetna, for example, has reduced readmissions and per-member-per-month costs by embedding nurse care managers in provider offices that care for its Medicare Advantage members. Other healthcare organizations are working to improve care coordination through patient-centered medical homes. (see the Adirondack Region Medical Home Pilot)

    One popular care-coordination model, the Care Transitions Intervention, developed by Eric Coleman, MD, MPH, at the University of Colorado, has been adopted by more than 900 healthcare organizations in 44 states. In addition to reducing inappropriate ED utilization, the model has been shown to decrease hospital readmissions by approximately 50 percent at 30, 90, and 180 days (Coleman, E., et al., "Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention," Journal of the American Geriatrics Society, November 2004, vol. 52, no. 11, pp. 1817-25).

    Despite the progress that has been made, several challenges are still impeding providers' progress to effectively coordinate care.

    One is the lack of interoperability between providers' IT systems. "This is a major flaw in the system that affects care coordination and our ability to manage population health," says Morey Menacker, DO, president and CEO, HackensackAlliance ACO, Hackensack, N.J. Because many post-acute providers, such as nursing homes and home health agencies, do not have electronic health records (EHRs), patient care plans developed in the hospital may get lost in the shuffle as patients move along the continuum.

    Socioeconomic barriers also cause fragmented care. As Geisinger Health System's CMO, Thomas Graf, MD, said in a recent Leadership article: "For physicians, there's nothing more frustrating than seeing a patient and knowing that his or her medical problems are maybe 10 percent of the challenge. You know you are not really going to be able to solve their medical problems unless you solve all these other issues-and you don't know where to begin." (Butcher, L., "Giving Back to the Community Brings Business Benefits," Leadership, Spring 2015.)

    Another challenge is identifying which patients to focus on first. Payers and providers need to determine how they will prioritize patients to include in their care coordination programs. Current approaches include several commercial tools that crunch claims and other data sources to predict high-risk patients, as well as internally developed risk assessments.

    Payment challenges are also a concern for providers. Medicare has started to pay physicians for non-face-to-face care coordination services (approximately $43 for 20 minutes of coordination per patient per month), assuming the physician has a certified EHR. But many believe this is far from adequate.

    For instance, reimbursement for end-of-life care coordination is problematic and under Medicare review. "We are still using a Part B billing schedule, but palliative care conversations require more time than the quick, transactional conversations that patients might have around a sore throat," says Chris Comeaux, president and CEO, Four Seasons Compassion for Life, Flat Rock, N.C. Comeaux believes that changing the payment structure will foster better quality care and reduce costs overall.

    Despite these lingering challenges, healthcare organizations are making substantial progress as they try to make care transitions more efficient and positive for patients, as shown in the following case studies.

    Cost and Quality Control Occur at All Points across the Continuum of Care
    Cost and quality control occur at all points across the continuum of care.

    HackensackAlliance ACO: Engaging Post-Acute Providers

    Leaders at HackensackAlliance ACO believe that effective care transitions helped the ACO earn a $5.27 million bonus by saving Medicare $10.75 million in 2014. Today, the ACO manages 80,000 lives, including two commercial ACO contracts and 15,000 hospital employees and their dependents.

    For the past three years, the New Jersey ACO has been using a number of strategies to improve transitions from the hospital to rehab facilities, nursing homes, and home health agencies.

    Building a preferred post-acute provider network. HackensackAlliance ACO has formed a network of preferred post- and sub-acute care providers who have read-only access to patients' medical records in Hackensack University Medical Center's EHR. "We don't send any more paper with patients," says Shafiq Rab, MD, vice president and CIO, HackensackAlliance ACO. "Every­thing is done electronically, so providers have access to all the tests, discharge plans, and the rest of the medical record. But it's not enough to be connected-you have to have the communication between providers."

    Time Spent Across the Continuum (Days)
    Time that patients spend across the healthcare continuum.

    Leveraging a web-based care plan. To improve provider communication, the ACO purchased a web-based platform that allows it to create and share a global patient care plan. The ACO also spells out specific care coordination activities for each member of the care team.

    For example, the platform alerts care coordinators about an impending patient discharge later that day or the next, so the coordinators can assist with medication reconciliation and other activities. The tool also reminds specific members of the care team when certain activities, such as a fall risk assessment or depression screening, need to occur before the transition.

    The approach has created more accountability for physicians and caregivers by giving them prescribed workflows to follow for specific groups of patients based on their disease or global health risks. "If a patient is discharged without medication reconciliation, for example, the platform can be enabled to alert the physician, the care coordinator, and everyone else on the care team," Rab says.

    Once the patient has been discharged, post-acute or home health providers use the tool to record that they have conducted the initial assessment and medication reconciliation within the first 24 hours. They also must confirm that they have access to the patient's medical record. If there is a glitch with any of these steps, the platform alerts the ACO care coordinator to get more involved.

    The platform also alerts the ACO care coordinator and primary care provider on their smart phones if there is a change in the patient's status, such as a worsening of heart failure symptoms, based on information that is received from clinical sources, such as the EHR. "At any given time, all of the caregivers know what is happening," Rab says.

    Marlene Bober of Advocate and Patricia Bracken of Advocate South Suburban Hospital

    Marlene Bober, RN, MS, vice president, acute enterprise care management at Advocate (left), and Patricia Bracken, RN, MSHA, ED care manager at Advocate South Suburban Hospital, Hazel Crest, Ill., work collaboratively to improve care transitions from the ED. (Photo credit: John Martin-Eatinger, Advocate Health Care)

    Rounding on ACO patients. Hackensack employs 10 physicians who visit ACO patients in sub-acute and post-acute settings with the goal of reducing inappropriate readmissions and minimizing duplication of services. ACO care coordinators also sit in on care management assessments at the facilities with the goal of optimizing length of stay (LOS). With care interventions, LOS may be less than the automatic, 20-day reimbursable stay from which sub-acute facilities earn the most potential payment.

    "If someone needs to stay for only five days, why keep them for 20" Menacker says. Allaying financial fears also is important. "What we have said to those facilities not wanting to discharge patients before 20 days is that if you are going to be a preferred provider, then we will make sure that the beds don't stay empty," he says.

    Planning discharge early. So far, such interventions have helped the organization cut the occurrence of 30-day hospital readmissions among ACO patients in half, compared with that of non-ACO patients. The organization also has reduced the inpatient length of stay (LOS) for ACO patients by 1.3 days, primarily because of care coordinators' efforts to initiate discharge planning immediately on admission, Menacker says. Early discharge planning has been so successful, in fact, that Hackensack is rolling the program out to all hospital patients, not just those in the ACO.

    Advocate Health Care: Facilitating Post-Emergency Care

    The registered nurses who serve as care managers in Advocate's 12 EDs follow a highly prescribed workflow that leaders designed based on Lean principles and industry best practices to drive appropriate ED utilization and prevent unnecessary inpatient admissions and readmissions.

    Web Extra: Role of the Emergency Department Care Manager: Bridging the Gap

    During peak hours, each ED has at least one care manager who prioritizes patients by acuity or chief complaint, focusing on those at high risk for readmission. A tracking board in the EHR allows the ED care manager to quickly identify patients with heart failure, chronic obstructive pulmonary disease (COPD), and other chronic conditions. The ED care manager then consults with the ED physician or nurse to determine the patient's likelihood of admission.

    If the ED care manager suspects the patient will not be admitted based on conversations with the ED staff, the care manager will schedule follow-up primary care appointments and refer the patient to other needed services, such as home health or transportation to medical appointments, as appropriate. ED care managers also create discharge plans to share with outpatient care managers embedded in Advocate's physician practices.

    When a patient is admitted, the ED care manager passes along relevant information to the inpatient care managers and hospitalists during daily huddles. "During these huddles, the ED care manager can share any discharge barriers the patient has and help the team determine what it needs to do to move the patient along the continuum," says Marlene Bober, RN, MS, vice president, acute enterprise care management.

    Janet Bull of Four Seasons Compassion for Life and a colleague discuss Bull’s palliative care research project.

    Janet Bull, MD, CMO, Four Seasons Compassion for Life, Flat Rock, N.C., discusses her palliative care research project with a colleague. (Photo credit: Four Seasons Compassion for Life)

    Supporting, not shaming, inappropriate ED users. Advocate has taken several steps to encourage patients who use EDs for non-emergent needs to choose more appropriate options for similar visits in the future. Before these patients are discharged home, ED care managers will go over an easy-to-read brochure on care options that lists urgent care sites in the community and explains when it is most appropriate to use the ED, Bober says.

    Advocate Physician Partners also has extended office hours at its practices to improve access and reduce inappropriate ED utilization.

    Gaining buy-in from clinical staff. Today, Advocate's ED physicians and nurses embrace ED care managers as vital members of the care team, but it took some time to get there, Bober says. "Physicians and nurses in the ED didn't want to be hindered during the work they do, so we set clear expectations for the ED care managers and monitored performance so we could determine their value," she says.

    A steering committee helped pilot the ED care management program at Advocate's teaching hospital and conducted six-month time studies, which demonstrated that care managers did not have a negative impact on ED productivity.

    The steering committee also worked with Advocate's clinical innovations team to create a dashboard that Bober shares with the ED medical directors during their monthly meetings. The dashboard includes metrics such as the following:

    • Ambulatory care-sensitive admissions (which are seen as potentially avoidable with appropriate primary care) per thousand
    • Visits by frequent users as a percentage of total ED visits
    • Primary care ED visits (which could be treated in an outpatient setting) per thousand
    • Total ED visits
    • Total admissions

    Advocate's Care Coordination Workflow Helps Smooth Transitions Out of the ED
    Advocate Health Care’s care coordination workflow helps smooth transitions out of the ED.

    The dashboard also tracks care management interventions by type, such as handoffs to home health agencies or referrals to medication assistance programs for patients who cannot afford their medicines.

    "The dashboard has demonstrated how care managers can help avoid admissions and improve the overall health of the population," Bober says. "As a result, I have seen a significant culture shift in our partnership with ED physicians and nurses."

    Chris Comeaux, president of Four Seasons Compassion for Life talks with volunteers about team-based palliative care.

    Chris Comeaux, president and CEO, Four Seasons Compassion for Life, talks with volunteers about their role in team-based palliative care, an overlooked piece of the care continuum that he believes is ripe for payment reform. (Photo credit: Four Seasons Compassion for Life)

    Four Seasons: Promoting Better Transitions for the Severely Ill

    Because of the nationwide shortage of palliative care providers, it might take up to seven days after a referral for severely ill patients to be seen by a palliative care physician or nurse practitioner, says Janet Bull, MD, CMO, Four Seasons Compassion for Life in Flat Rock, N.C.

    To reduce that time, her team is using value-stream mapping, a lean technique that documents, analyzes, and improves flow. This process has helped identify barriers to efficient transitions. "Ideally, we would like to see inpatients who are severely ill receive a palliative care consult before they are discharged to reveal what issues need to be addressed and help ease anxiety during the transition period," Bull says. "This also would help ensure that advanced care planning and goals of care are documented appropriately and shared with the patient's other providers."

    Bull's research team received a $9.5 million, round-two innovation grant from the Centers for Medicare & Medicaid Innovation to test a community-based palliative care model that spans inpatient and outpatient settings. Four Seasons will partner with researchers at Duke University as well as hospitals in 13 counties across North Carolina to study transitions to palliative care (i.e., care that focuses on reducing pain and symptoms caused by serious illness) and hospice care (i.e., care provided at the end of life to patients with a prognosis of six months or less). In the three-year pilot, researchers aim to enroll 8,000 individuals who represent the sickest 1 to 2 percent of the population.

    Working with hospitals to understand patients' preferences. As part of the project, Four Seasons plans to team up with hospitals on strategies to reduce readmissions in high-risk populations. In some instances, patients with advanced cancer, COPD, or heart failure could receive palliative care consults as part of a clinical pathway in the inpatient center, and then be handed off to the outpatient team as they transition to the post-acute setting.

    When readmissions occur, it is important to understand the cause. "In some instances, it may be worsening disease, but often medication errors, lack of access to needed post-acute care, or psychosocial factors come into play," Bull says. "Addressing these issues proactively is extremely important. We also know with each hospitalization, a patient's goals often change. Every readmission is an opportunity to talk to patients about what they want and to discuss the likelihood for medical therapies to align with reaching particular goals."

    Because these conversations are not a standard practice, many severely ill patients never make it into hospice care, even though that is what they might prefer. "Most people don't want to die in the hospital. And much of the care that seriously ill patients receive in the hospital doesn't impact outcomes in a positive way," Bull says. On the other hand, palliative care has been shown to improve survival and quality of life in some patient populations (Temel, J., et al., "Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer," The New England Journal of Medicine, August 19, 2010, vol. 363, pp. 733-42).

    As part of the pilot project, researchers will track multiple clinical metrics, such as pain, shortness of breath, nausea, constipation, and depression, to gauge the impact of palliative care interventions. Also, they are tracking the documentation of advance care plans, hospital readmissions, and the impact of hospice referral on LOS.

    The Goals of Care Coordination
    The goals of care coordination during patients’ transition between sites of care.

    Revamping palliative care payment. Designing a new payment structure for palliative care is another goal of the project. Most hospice care is paid for by Medicare Part A, while palliative care for Medicare patients falls under Part B. In collaboration with its partners at Duke University, Four Seasons will propose both an add-on, fee-for-service model as well as a value-based purchasing option.

    Medicare and most health plans do not offer a defined benefit for palliative care. Providing this type of team-based care is expensive in the outpatient setting, as care is often delivered in the home or long-term care facilities. Bull cites very limited reimbursement for social workers as well as nurse case managers and spiritual counselors. Many patients are too ill to travel to a clinic setting, hence the team comes to them. Time, mileage, and administrative needs are not funded. "I have yet to meet a program that is under Medicare's traditional fee-for-service model that is in the black," Bull says. "All suffer financial losses."

    As part of the project, researchers will document providers' internal costs for delivering palliative care. Then, using a statistical technique called propensity score matching, analysts will use Medicare claims data to compare the costs of care between patients who received palliative care and similar patients who did not receive palliative care on both a state and national level.

    From there, the research team will identify the "break-even" point and propose two new payment structures for community-based palliative care delivered at home or elsewhere. One would be a transitional, fee-for-service payment schedule, while the other would be a bundled, per-beneficiary-per-month approach. However, deciding who "owns" the bundled payment could be another challenge down the road, Bull says. "In the ACO world, palliative care adds tremendous benefit as studies show reduced hospitalizations, increased hospice utilization, and better disease management. Understanding which aspects of success are attributed to which services will be the challenging part," she says.

    Comeaux believes that although ACOs are moving in the right direction, financial incentives will need to continue to change before the healthcare system can truly realize the benefits. "Most of the current incentives are in shared savings. With bundles, there still has to be some logic applied based on the current fee-for-service system in order to pay providers while they are providing care until we know retrospectively whether less cost occurred. It will take awhile before we can drive while not looking at the rear view mirror," he says.

    Lessons Learned

    Although there is no quick fix for designing effective care transitions, most healthcare leaders agree on where they need to start: "The sickest patients are the top priority," Bull says. "That is why risk stratification is absolutely critical at every point along the care continuum."

    To improve care transitions, consider the following advice.

    Standardize competencies and training for care managers. Leaders at Advocate created a standardized set of competencies for ED care managers and built a comprehensive training manual around those desired skill sets. For one month, all new ED care managers shadow a preceptor from the ED or inpatient side as they learn the ropes.

    Ask post-acute providers what they need. To ease care transitions from the ED or hospital to post-acute providers, Advocate developed a homegrown, care transition tool. The tool automatically pulls the most relevant patient data points from the EHR so that the information can be printed and shared with other providers on discharge.

    "We asked more than 30 people, including discharge planners as well as liaisons from home health and nursing facilities, 'What is it that you need What tool would you like to see'" Bober says. "They didn't particularly care to get an entire chart, but they did want to see a synopsis of that patient when the patient left the hospital."

    The standardized tool includes more than 50 data elements, such as the patient's daily weight, pain score, vital signs, stressors, disabilities, and diet orders.

    Support patients as they move from the hospital to home. "The transition of care can be an anxiety-filled time," Hackensack's Menacker says. At HackensackAlliance ACO, a travel nurse visits patients within 24 hours of discharge. To support proper outpatient follow-up, the ACO care coordinator ensures patients have an appointment scheduled with a primary care physician within 72 hours of discharge.

    The ACO also provides every patient with a month's supply of all medications when discharged from the hospital to home. Afterward, patients can continue to receive medications from the hospital or transfer their prescriptions to their local pharmacy.

    Leverage mobile technology. HackensackAlliance ACO leaders have conducted several pilots using mobile apps to reduce readmissions in high-risk patients. One app requires patients to chart health indicators, such as their blood sugar levels and medication doses taken throughout the day. When patients fail to track status, the app sends an alert to an ACO care coordinator's cell phone, which then triggers the coordinator to contact the patient. In a small sample, the app helped decrease readmissions for congestive heart failure by 50 percent.

    Additionally, the ACO employs app alerts that e-mail or text not only the patient, but also a family member when the patient needs to follow up with a primary care physician for a test or another intervention. Such companion alerts help build an ally to prevent gaps in care, Rab says.

    Review data to uncover opportunities to improve. Leaders at HackensackAlliance ACO routinely conduct gap analyses to identify trends when patients are readmitted to hospital care. Drilling to the individual level helps the care team identify strategies to better stabilize patient health, such as adding nutrition support or referring to a specialist for improved chronic condition management. When patients return home, the ACO care coordinator also encourages visits with the primary care physician for ongoing care.

    At Four Seasons, leaders use rapid-cycle quality improvement to identify processes to improve based on their data. Clinicians are actively involved in this process, analyzing the evidence and implementing new strategies to improve care. Four Seasons uses a quality data assessment tool to chart and follow symptom needs, advanced care planning activities, and transition issues. Examining quarterly data allows the team to identify problem areas to address. For example, leaders noticed that COPD patients had the lowest rate of advanced care plan completion, so the organization developed an education program to address this need.

    Partner with payers on better care transitions for their members. "Commercial insurance carriers are driving a lot of this change," Menacker says. "Even though they aren't obligated to change their method of compensation (for care coordination), they recognize that doing so is the only way they are going to survive under value-based models as well." In addition to working with two commercial ACOs, HackensackAlliance ACO is partnering with several health plans to manage its Medicare Advantage populations.

    The Future: One Care Coordinator for Every Patient

    Five years from now, Menacker expects the industry will have made even greater progress toward improving care transitions, primarily because providers will be taking on more risk.

    To prepare for the shift, Menacker has a big-picture plan for his ACO in which each patient has a dedicated care coordinator, no matter where that patient is along the continuum. In such a model, care coordinators would manage groups of patients based on geography, disease, or severity of illness. As patients transition from one setting to the next, care coordinators would follow them along the way.

    Under such a model, traditional, hospital-based case management or utilization management could become a thing of the past. "In our ACO, we are moving toward eliminating the distinction between care coordinators, hospital case managers, and utilization management," Menacker says. "We recognize that as we move forward, those assisting transitions are all care coordinators, and it doesn't matter if a patient is in the hospital, in a nursing home, or at home. Patients need care coordination across the continuum."

    Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill.

    Quoted in this article:
    Marlene Bober, RN, MS, is vice president, acute enterprise care management, Advocate Health Care, Downers Grove, Ill.

    Janet Bull, MD, is CMO, Four Seasons Compassion for Life, Flat Rock, N.C.

    Chris Comeaux is president and CEO, Four Seasons Compassion for Life, Flat Rock, N.C.

    Morey Menacker, DO, is president and CEO, HackensackAlliance ACO, Hackensack, N.J.

    Shafiq Rab, MD, is vice president and CIO, HackensackAlliance ACO, Hackensack, N.J.

    Michael J. Randall, FACHE, is vice president, clinical innovation, Advocate Physician Partners, Rolling Meadows, Ill.

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