Care Management

Reimagining Cross-Continuum Relationships

April 25, 2018 10:21 am

Earlier this year, CHRISTUS Trinity Mother Frances Health System embarked on a journey to enhance its participation in the Centers for Medicare & Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) Model. Based in Tyler, Texas—about 100 miles outside of Dallas—the health system is located in an area where CMS requires participation in the CJR program. CHRISTUS Mother Frances Hospital-Tyler performs many types of joint replacements, ranging from standard elective procedures to more complex cases that involve significant post-acute care and rehabilitation.

An Idea Forms

The impetus for the endeavor began when CHRISTUS Trinity Mother Frances Rehabilitation Hospital—which is jointly owned and operated by Encompass Health (formerly HealthSouth)—saw an opportunity to partner with the health system’s acute care hospital to enhance care delivery for a specific subset of joint replacement patients: those who receive a hip replacement due to fracture. “These patients often are more vulnerable because the replacement follows a fall or injury, as opposed to a planned procedure for which the patient is physically ready,” says Sharla Anderson, CEO for the inpatient rehabilitation hospital. “In these cases, the right post-acute care is a key component in patients’ long-term recovery. Although elective surgery patients may recover at home or with home health, a fracture patient needs more intensive, rehabilitative care.”

Before the inpatient rehabilitation hospital broached the idea of a collaboration with the acute care facility, they sought the assistance of their long-time strategic partner DHG Healthcare—the national healthcare practice of Dixon Hughes Goodman. Encompass Health has worked with the consulting firm on strategic planning initiatives since 2007 and values the company’s ability to provide detailed analytics and market assessment data. “For this project, DHG Healthcare developed tools to inform the conversations with CHRISTUS Mother Frances Hospital-Tyler,” says Anderson. “Using the data DHG Healthcare provided, we were able to communicate with the hospital about the challenges these vulnerable patients face once they are discharged and the importance of working together to smooth care transitions.”

DHG Healthcare provided tools that analyzed the acute care hospital’s utilization and volume patterns, teasing out historic trends by patient category. “The data revealed opportunities where the acute care and inpatient rehabilitation facilities could work together to improve care quality while keeping costs in check,” says Wanda Justus, principal, Enterprise Intelligence for DHG Healthcare. “We took that information and helped Encompass Health craft the clinical story that justified the acute care partnership.”

CHRISTUS Mother Frances Hospital-Tyler was intrigued by the proposal Encompass Health presented. “After meeting with the inpatient rehabilitation hospital’s leaders and reviewing the numbers, it became clear that we could work together to improve the clinical outcomes of fracture patients, as well as the care costs, if they went to the rehabilitation setting for post-acute care,” says Chris Glenney, president of CHRISTUS Trinity Mother Frances Health System. “We’ve enjoyed a long-standing relationship with Encompass Health. Given our existing partnership, it made a lot of sense to further align to treat fracture patients within the CJR bundle. We agreed that we could improve the outcomes for these at-risk patients by strengthening communication, collaboration, and care management.”

Launching the Initiative

The hospitals began the project in January 2018. At that time, Encompass Health became an official preferred inpatient rehabilitation provider for CHRISTUS Mother Frances Hospital-Tyler, focusing almost exclusively on hip fracture patients included within the CJR model. The acute care hospital would manage the care of these patients for a few days and then transfer them to the inpatient rehabilitation hospital where they would receive treatment. The rehabilitation hospital would then manage the patient’s care during the inpatient rehabilitation stay and telephonically after discharge during the course of the 90-day episode period. DHG Healthcare assisted Encompass Health with the framework presented to CHRISTUS Mother Frances. “We worked with the Encompass Health team to create an infrastructure that focused on key analytics, gain-sharing agreements, and care-coordination strategies,” says Justus.

Key Elements of Success

To facilitate the necessary collaboration, Encompass Health created a care navigator position that acts as the patient’s care manager during the patient’s stay within the inpatient rehabilitation hospital and afterward, for up to 90 days. The care navigator communicates with the acute care hospital’s case management staff, nurses, and physicians to identify patients who need this level of care. “By using the same person for all of a patient’s care management, we ensure the individual’s experience is consistent and communication flows freely, allowing us to catch problems early and mitigate any concerns,” says Anderson. “Also, the navigator serves as a resource for patients and families, improving their overall care experiences.”

The organizations also engaged the physician community. “We worked closely with our physician partners at CHRISTUS Trinity Clinic—a large multi-specialty group that is part of our system—to reliably identify these hip fracture patients who need more intensive, rehabilitative care,” Glenney says. “DHG Healthcare and Encompass Health assisted with this effort by supplying education materials and information for physicians to help them understand the value of the initiative, what their role would be, and the positive effect they could have on patient outcomes and satisfaction.”

Data are a Foundational Component

Anderson adds, “The importance of data has been an underlying theme for this work, and DHG Healthcare has played a big part in getting us these data. Not only did they help make the clinical case for the relationship, but they continue to provide ongoing information so we can keep demonstrating our value to the acute care organization and pinpoint further improvement opportunities.”

The data also allowed the two organizations to vary their plans. “Our strategy differs from the way many health systems approach post-operative care for fracture patients,” says Glenney. “Often providers send complex patients to skilled nursing facilities to recover after surgery, avoiding inpatient rehabilitation stays because they view this as a costlier option—going against the idea of controlling costs. However, for fracture patients, quality rehabilitation can mean the difference between a full recovery and long-term issues. By focusing on these patients and ensuring we are collaborating to provide proactive care, seamless transitions, and constant management, we are improving their outcomes, which is positively affecting our overall performance with the model. By following our mission, we are making a positive impact on both care and costs.”

A Prototype for Cross-Continuum Communication

Justus reflects on the collaboration: “The exciting thing about this project is that it can serve as a model for how acute and post-acute care providers can work together toward a common goal. CHRISTUS Trinity Mother Frances Health System and Encompass Health are combining both entities’ knowledge and experience to make these improvements and basing their care model on clear data, standardized processes, and best practice. The lessons they learn will benefit future patients: improving outcomes, decreasing readmissions, and elevating patient satisfaction. The enhanced dialogue and communication between the organizations will set the stage for future interactions, which will ultimately help them deliver better care.”

Rethinking the status quo is not easy. DHG Healthcare serves as a resourceful partner for a dynamic industry, helping organizations navigate complex projects that improve quality while reducing costs. Our consulting, assurance, and tax domain services are designed to assist organizations in defining strategies, executing transformational plans, and managing their financial health and sustainability.


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