it takes a village: managing transitions in a changing ...€¦ · value-based care, acos,...

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It Takes a Village: Managing Transitions in

a Changing Healthcare Environment

Presented By:

Lori Fox BSN, MBA, CCM

Director, Ambulatory Care Coordination

Laura Lowe BSN, MBA, ACM, IQCI

Manager, Hospital Case Management

Greenville Health System

Greenville, South Carolina


Objectives:

• Learn why care transitions are more important than ever in

the changing healthcare environment

• Learn key ingredients for a successful transitions program

• Recognize and overcome common barriers to successful

transitions


• Greenville Health System is the largest multi-hospital Health

System in South Carolina

• It is a nonprofit, patient-centered, teaching and research

institution

• The system has 1,268 licensed beds, 1,271 affiliated and

employed medical staff, and 10,925 employees dispersed

throughout five medical campuses and a variety of outpatient

and specialty facilities

• Its seven residency and seven fellowship programs provide

training for physicians, nursing, and allied health students



Value-based payment models aim to reduce spending while improving quality and

outcomes.

Value-Based Care

Managing Transitions of Care and avoiding readmissions is Critical!


Value-based Care, ACOs, Readmissions

• The Patient Protection and Affordable Care Act specifies incentives and

penalties based on readmission rates

• Among Medicare fee-for-service patients discharged from the hospital:

– 19 percent are rehospitalized within 30 days of discharge

– Estimated ¾ of readmissions may be avoidable

• Evidence suggests that the rate of avoidable rehospitalizations can be

reduced by:

– Improving transitions and care coordination

– Aligning core discharge planning and processes

– Enhanced coaching, education, and support for patient self-

management


Inpatient: Prioritize care transitions and readmission reduction

Outpatient: Prioritize high-risk individuals and referral to care management

GHS Care Model for Population Health


Care Transitions Definition

Transitional Care

• A set of actions designed to ensure the coordination and continuity of

health care as patients transfer between different locations or

different levels of care

• Representative locations include hospitals, nursing homes, the

patient’s home, primary and specialty care offices, and long-term

care / sub-acute facilities

7

Source: http://mypillarstone.com/transitional-care/


Care Transitions Definition

• Transitional care is based on a comprehensive plan of care

and the availability of health care practitioners who are well-

trained in chronic care and have current information about the

patient’s goals, preferences, and clinical status

• Transitional care includes logistical arrangements, education

of the patient and family, and coordination among the health

professionals involved in the transition

• Transitional care, which encompasses both the sending and

the receiving aspects of the transfer, is essential for persons

with complex care needs

8


Care Transition Goals

9

• Improve patient safety by improving patient’s preparedness for self

care after discharge

• Reduce overall cost of health care utilization by reducing

readmissions and post discharge emergency department visits

• Improve patient outcomes and satisfaction

• Improve transitions of care across the continuum of healthcare

providers and locations


Transitions: A Bridge in the Care Continuum

Continuum of Care

Wellness/

Preventive

Care

Primary Care/ PCMH

Specialty Care

Urgent/ Emergent Services

Acute Hospital

Care

Care Transitions

Post-Acute Care/

Home Care

End-of-Life Care


Contributing Factors to Poor Post-Discharge Outcomes

• Unresolved problems

• Availability and insufficient content of the discharge

summary at the first post-discharge visit low (12 to 34

percent)

• Lacking information regarding diagnostic test (33 to 66

percent of the time)

• Missing pending results (65 percent) or discharge

medications (2 to 40 percent of the time)

• Timely Primary access problem with a study of Medicare

patients readmitted within 30 days of discharge, finding that

more than 50 percent had no billing encounter with an

outpatient provider prior to readmission

• Medication related adverse events due to lacking

communication of complete information during transition

• Patient education regarding medications and treatments

• Patient / family social barriers

• Monitoring patient status post discharge

Patient Educationa

ccess

Medication Reconciliation

Results

Patient Monitoring

Discharge Summary

BARRIERS


Developing a Transitions Program

• Address many of the contributing factors to unplanned hospital readmission

• Provide access to care within 24-72 hours post discharge

• Assessment

• Red Flags

• Medication Reconciliation

• Schedule PCP and specialist appointments

• Coaching

• Improved bi-directional communication with the PCP

• Post hospital exchange of discharge plan

• ED avoidance

• Expand offerings of evidence-based models for self care

• Leverage Data to Manage Complex Disease

• Develop standardized transfer tools, processes and quality monitoring

• Standardized discharge sheet and communication

• Redesign and standardize patient flow/discharge planning from hospital


The Role of the Transitions Care Manager

The Transitional Care Manager ensures

the coordination and continuity of health

care as patients transfer between

locations or different levels of care.

Locations include hospitals, sub-acute

and post-acute nursing facilities, the

patient's home, primary and specialty

care offices, and long-term care

facilities.

This includes logistical arrangements,

education of the patient and family, and

coordination among the health

professionals involved in the transition.

Transitional care, both the sending and

the receiving aspects of the transfer, is

essential for persons with complex care

needs.


Primary Drivers of Transitions Success

14

• Risk Stratification and Identification

• Self Management Skills

• Coordination of Care Across the Continuum

• Adequate Follow up and Community Resources


Risk Stratification

• A means of looking across an entire population or panel of patients to

determine which of those patients are at the greatest clinical risk for

readmission and potential high utilizers of the healthcare dollar

– Prospective, trying to accurately predict future risk related to past

healthcare costs and utilization

– Indicators may include past utilization of services, current and

historic diagnoses, demographics, medications, as well as

functional and psychosocial status


Apply Risk Stratification to the Care Model


• Use a risk of readmission assessment tool

and validate it using your institution’s data

• Adopt an enhanced admission

assessment

• Make readmission risk assessments easy

for all to access and utilize

• Coordinate care using a multi-disciplinary

team including doctors, nurses, hospital

case management, pharmacists, physical

therapists, occupational therapists,

nutritionists, and respiratory therapists

• Include the patient’s primary caregiver as

a member of the healthcare team

Risk Stratification and Identification

17


Risk Cont’d

18

• Find out if the patient has a caregiver and who the caregiver is

• Communicate who the primary caregiver is to the members of

the patient’s health care team, e.g. use a whiteboard, record

important information in a standard, visible, and accessible site

in the medical chart

• Discuss with patients their palliative care and end-of-life

treatment wishes

• Design interventions to match identified needs based on risk


19

Self Management Skills

• Obtain an accurate home medication history from the patient

and/or primary caregiver at admission

• Educate patients/caregivers before discharge regarding all

medications prescribed, the purpose of these medications, the

means of obtaining them, and the instructions for taking them

• Evaluate patient’s “level of activation” or engagement in self-

management and consider implementing motivational

interviewing and activation-based coaching approaches

• Provide clearly written medication instructions using health

literacy concepts and culturally appropriate training materials


Self Management Cont’d

• Develop patient-centered educational tools that employ health

literacy concepts to teach patients about their diagnosis and

symptoms

• Use patient simulation

• Train clinical staff on teach-back using role play, and observe

their technique in the field

• Validate patient and caregiver understanding of discharge

instructions

20


Coordination of Care across the Continuum

21

• Evaluate best practices, resources, and established tools

• Determine which models will work in your organization

• Engage IT support for completing plans of care

• Determine where key information is to be stored and how it will be

compiled to complete plans of care

• Obtain accurate information about patients’ primary care physicians

at the time of admission

• Send completed discharge summaries to patients’ primary care

physicians within 48 hours of discharge


Coordination Cont’d

• Use of a concise standardized discharge transfer form

• Perform warm hand offs between hospital, ambulatory care,

and next provider of care

• Assign clear accountability for medication reconciliation and

perform reconciliation at each transition of care

– Consider a home visit to educate patients/caregivers about

their medications and to reconcile the medications in the

patients’ homes

22


Adequate Follow-up and Community Resources

• Prior to leaving the hospital, determine what post-discharge

resources and appointments will be needed, and ensure they are

addressed in the after-care plan

• Work with patients and care providers to determine any barriers to

making and attending follow-up appointment(s)

• Work with patients and caregivers to determine any barriers to other

follow-up requirements such as medications, special diet,

transportation needs, etcetera

• In addition to these hospital-driven elements, additional benefits have

been demonstrated with post-discharge interventions such as: post-

discharge phone calls, home visits, home health referrals, etcetera

– Those patients who have the highest risk of readmission may also

benefit from more intensive community resources and support

23


Follow-up Cont’d

• Consider developing or launching programs for special

populations, e.g. behavioral health patients, homeless

patients, end-stage renal disease, human

immunodeficiency virus-infected, or other complex high-

risk populations

• Identify community-based organizations, resources

available and service gaps needing to be addressed

– Collaborate to meet patient needs

• For patients without a primary care physician (PCP),

work with physicians and safety net programs to identify

PCPs

– Consider follow-up clinics run by hospitalists or nurse

practitioners if timely access to a PCP not available

24


Why Do Transitions?

25


GHS Transitions Program

Transitions Coordinators (inpatient):

• Evaluate “at risk” population to determine risk for readmission using LACE tool

• Goal is to identify those at high risk for readmission

If assessed as high risk:

• Collaborate with Hospital Case Management on discharge plan, barriers, and post-

acute services

• Ensure follow-up appointment with physician is scheduled within 6 days of discharge

• Collaboration with Ambulatory Pharmacy management for medication reconciliation,

education, and gaps

• Educate patient and family/care-giver regarding diagnosis, triggers, alerts,

medications, and preventing further admissions

• Refer patients to Ambulatory Care Managers for intensive care management post

discharge

• “Huddle” with Ambulatory Care Manager, patient, and interdisciplinary team prior to

discharge to develop Plan of Care


GHS Transitions Program

Ambulatory Care Managers:

• Follow up within 24 to 48 hours of discharge

• Collaborate with patient and PCP to develop interdisciplinary care plan and review/revise as needed

• Ensure needed services have begun/resumed and collaborate with services as needed (no less than weekly) to determine progress with goals, utilization compliance, family/social issues, and anticipated discharge date

• If no services in home, follow up with patient weekly (telephonically, in-home, or at PCP or specialist follow up) for 30 days or duration of bundle and re-evaluate for continued enrollment as appropriate

• Educate and reinforce as needed regarding disease process and medications

• Communicate with and refer to other disciplines/resources

• Assess for possible continued or new barriers to compliance with discharge plan

• Monitor appropriateness of utilization and educate regarding appropriate venues for care

• Document in EMR and communicate with PCP and/or specialist


Care Managed: Blue Choice Medicaid

Shared Savings ContractUtilization of Acute Hospital and Emergency Department (ED)

Trend 2014 – 2015

Inpatient Utilization Emergency Department

Utilization

1,790

406

1,128

268

0

200

400

600

800

1,000

1,200

1,400

1,600

1,800

2,000

Days/1,000 Admits/1,000

CY2014 CY2015

852

718

650

700

750

800

850

900

CY2014 CY2015

Utilization/1,000

Decrease of

-15.7%

Decrease

of -37%

Decrease

of -34%


Care Managed: Blue Choice MedicaidSpend of Acute Hospital and Emergency Department (ED)

Trend 2014 – 2015

Inpatient Spend Emergency Department

Spend

$15.9

$12.7

$323,054.75

$353,439.32

$300,000.00

$310,000.00

$320,000.00

$330,000.00

$340,000.00

$350,000.00

$360,000.00

$0.0

$2.0

$4.0

$6.0

$8.0

$10.0

$12.0

$14.0

$16.0

$18.0

CY2014 CY2015

Allo

wed T

ota

l

Allo

wed P

MP

M

PMPM Total Cost

Decrease of

-20.1%

$113.0

$77.7

$2,297,388.46

$2,164,719.23

$2,050,000.00

$2,100,000.00

$2,150,000.00

$2,200,000.00

$2,250,000.00

$2,300,000.00

$2,350,000.00

$0.0

$20.0

$40.0

$60.0

$80.0

$100.0

$120.0

CY2014 CY2015

Allo

wed T

ota

l

Allo

wed P

MP

M

PMPM Total Cost

Decrease of

-31.2%


Care Managed Findings: Blue Choice Medicaid(Comparison 2014 to 2015)

• Total PMPM decreased from $300 to $221 (-26.3 percent)

• 30-day all-cause readmissions decreased 20 percent

• Wellness/preventive visits per member increased 300 percent

• Decreases in outpatient setting largely from imaging, lab, and

outpatient pharmacy groupings

– Outpatient non-ER spend PMPM decreased from $20.8 to $13.8

(-33.7 percent)

– Outpatient non-ER utilization/1000 decreased from 2,533 to 1,646

(-35 percent)

• Rx scripts PMPY decreased from 8.6 to 6.6 (-23.3 percent)

• Generic usage slight down from 82.1 percent to 79.2 percent

(-3.5 percent)


Readmission Trends:


9.21% 9.91% 4.43% 5.41%8.93% 9.70% 4.19% 3.93%

0.95

1.01

0.530.51

0.91

0.98

0.49

0.36

0.00

0.20

0.40

0.60

0.80

1.00

1.20

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

Total Greenville Memorial Hospital Greer Memorial Hospital Hillcrest Hospital

Expecte

d R

eadm

issio

n R

ate

Index

Readm

issio

n R

ate

2014 Readmission Rate 2015 Readmission Rate

2014 Expected Readmission Rate Index 2015 Expected Readmission Rate Index


HCAHPS National Percentile Rank - Fiscal Year

77% 77%

85%88%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CARE TRANSITIONS

Percentile Rank

FY13 FY14 FY15TD FY16 TD

32


HCAHPS - Care Transitions

FY begins in October


HCAHPS National Percentile Rank - Fiscal Year

58% 58%

69% 69%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CARE TRANSITIONS

Percentile Rank

FY13 FY14 FY15TD FY16 TD

33

Greenville Memorial Health System

HCAHPS - Discharge

FY begins in October


Lessons Learned:

34

• Identifying multiple origins of post-acute calls

• Clinical integration efforts around post-acute calls, leader

rounding, and breaking up silos

• The need for individualized care and follow-up plans that move

with patients longitudinally over time

• Collaboration between Hospital Case Management and

Ambulatory Care Management


It Takes a Village

Communication, Collaboration, Data, Process

35


36

“The greatest opportunities for improving care

transitions center around improving communication,

building cross-setting relationships, and redesigning

our workflow.”

- Eric A. Coleman, MD, MPH

Thank You!

Lori Fox BSN, MBA, CCM

Director, Ambulatory Care Coordination


864-797-7852

[email protected]

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