EXECUTIVE SUMMARY
A care transition program achieves readmission rate reductions through data-driven analytics to identify the most at-risk patients for care managers to call.
- Often, care managers can make just one call to the patient and improve outcomes.
- The program’s purpose is to ensure safe and effective care transitions.
- The 30-day readmission rate dropped from 16.6% to 13.3%.
Good data and a quick phone call sometimes are all it takes to keep at-risk patients well and out of the hospital.
A care transition program, often consisting of a single care manager’s call, has reduced readmission rates at one health system. The program uses data to identify the most at-risk patients. The program also has anecdotal evidence of patients who have changed their behaviors, despite many obstacles.
“We’ve seen a reduction in readmission rates in all lines of business,” says Sandra M. Mitchell, RN, assistant director of Network Care Management at Montefiore Care Management, part of Montefiore Health System in Bronx, NY.
“Our seven-day readmission rate dropped 3.9%,” Mitchell says. “Our 30-day readmission rate went from 16.6% to 13.3%.”
The program cannot measure the nurse care manager’s empathy for patients, but this emotional connection — combined with the motivational interviewing technique — has made a big difference, Mitchell adds.
“We have anecdotes of patients who change their behavior,” she says.
“The whole purpose of the program is to ensure safe and effective care transitions, to identify barriers to healthcare management including access to care, ER visits, and to overall ensure a positive patient experience,” Mitchell says.
The care transition program began as a pilot project in April 2009. The goal was to maximize the care areas and reduce readmissions, Mitchell says.
“The pilot became a program, starting with four RNs,” she says.
Now, the care transition team consists of Mitchell, three LPNs, five RNs, and one RN clinical manager. Longitudinal teams manage patients with heart failure and diabetes. People with complex needs might receive help from an integrated behavioral medical health team.
The care transition team helps to identify barriers that might prevent patients from taking care of themselves safely at home, and to ensure appropriate follow-up care, Mitchell says.
Turning care transition into a more efficient process required better data. “We had a rudimentary way of categorizing patients,” Mitchell says.
For instance, the program initially targeted patients who were 70 years or older or who had home care services after returning home.
After receiving input from data analysts, the program’s risk assessment evolved. It now looks at patients’ comorbidities, readmission risk scores, length of stay, acuity, and number of ER visits over a six-month period.
Data show that the targeted patients have multiple issues. “We know that 44% of the patients we assess have needs regarding medication issues; 25% are referred to other programs including behavioral health,” Mitchell says.
The program places the highest-risk cases with RN care managers and others with LPN care managers.
“Each morning, the RNs and LPNs get a daily report that divides up patients for each staff member, based on scores,” says Veronica Chepak, RN, BSN, MPA, clinical coordinator for the care transitions team at Montefiore Care Management.
“Once we get that report, we start making phone calls, and I will call the person I see there who will have high or moderate risk, and I’ll call the high-risk patients first,” she says. “I’ll look at when patients were discharged, and if they were discharged four days before, I’ll call them right away.”
The initial calls inquire about the problem that sent them to the hospital and what their discharge instructions are, Chepak says.
“They get a lot of calls at home, so we tell them we’re there to support them and to advocate for them, and help them stay healthier,” Chepak says. “We ask if they understand the discharge instructions because most of the time they’re so overwhelmed, they didn’t hear all the discharge instructions given to them or understand the paperwork given to them.”
The care manager discusses their symptoms, why their medications were changed, and what their follow-up should be, she says.
“I call it triage case management,” Chepak says. “I feel the RNs and LPNs have to be thinking, ‘What does this patient need? What will keep them from coming back in the hospital?’”
For instance, care managers could consider the following questions:
- Would the patient benefit from having a pharmacist call?
- Would the patient benefit from long-term case management and follow-up?
- Does the patient need additional services, such as transportation assistance?
Most of the time, one phone call will be all the extra help the patient needs, Chepak notes.
When a case does need more attention, Chepak can make extra calls for assistance.
“I may call the doctor’s office to get them an appointment or, if something is urgent with home care, touch base with the home care agency,” she says.
“I’ll touch back to tell them the outcome of that call and to move them on to a case management team or home care team or whatever team is best to meet that patient’s needs,” Chepak adds. “The call can take from 15 minutes to an hour, depending on what’s going on.”
Developing trust with the patient starts with the phone introduction. “I say, ‘My name is Veronica from Montefiore Care Management. I’m calling to see how you’re doing. We want to make sure you’re doing okay at home,’” Chepak says.
People who have just been discharged from the hospital often want to feel that someone cares for them and they weren’t just discharged and forgotten, she notes.
“Then I listen to what brought them into the hospital and what they think they need,” she adds. “If there’s something they think they need — even if I don’t think they need it — I’ll deal with whatever their pressing need is.”
By helping the person with his or her main concern, Chepak builds rapport.
The call might end with the care manager giving the person phone numbers and reassurance that someone from the home care team soon will call.
“In most cases, this is the first touch for the patient to get them along the care continuum,” Mitchell says. “We try to ensure patients have primary care visits scheduled with the doctor within seven to 10 days of discharge.”
One other aspect of the care transition program is that it keeps care managers’ time free from some of the scheduling and other details.
“The nurse is freed to make connections with the next patient and coordinate the next care plan, but she is not bogged down to do all of the little things,” Mitchell explains.
For instance, a patient might need a referral to a community-based organization like Meals on Wheels. The nurse care manager can send that referral to a case management team that will follow the patient over a longer term, she adds.
“So if a patient needs transportation, the nurse doesn’t have to make arrangements for transportation,” she says. “Patients who are on anticoagulation therapy and who can’t afford their medications or don’t understand how to take their medications, or who need medication reconciliation, are sent to the pharmacy team.”
Good data and a quick phone call sometimes are all it takes to keep at-risk patients well and out of the hospital.
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