Redesigned transition system is successful
Navigator tool reduces transition fragmentation
A new model for redesigning the health care transition process could result in improved care transition, reduced care fragmentation, and revitalization for the primary care model. Best of all, it's designed by a health plan payer, which might be the signal hospitals have been waiting for that payers will begin to fund discharge planning.
Called the Health Navigator, the comprehensive health plan model is based on the medical home model and focuses on improving primary care. And the model was created by a health care payer for the purpose of rescuing health care.
"Primary care was dying in Pennsylvania; doctors were running on the mouse wheel so fast at 10 minutes a visit that they couldn't catch themselves, and they weren't doing what they wanted to do with their patients," explains Duane E. Davis, MD, vice president and chief medical officer at Geisinger Health Plan in Danville, PA.
"We saw an incredible amount of fragmentation and lack of care coordination in the care our members were receiving," he adds. "This was particularly true if they were leaving one facility, like a hospital, and heading to a nursing home."
Geisinger Health System Medical Group has 800 doctors who take care of 40% of the health plan's patients, which number about 250,000, he says.
Health Navigator has five components, including patient-centered primary care, population management, value care systems, quality, and value reimbursement, says Janet Tomcavage, RN, MSN, vice president of health services at Geisinger Health Plan.
"One of the first things we did was say, 'We're going to look at high-risk people in the hospital and alert the case manager of high-risk people in the hospital,'" Tomcavage says.
The case manager works with the hospital discharge team to help with patients' transition to home.
This includes calling patients at home within 24 hours to ask about their medications, Tomcavage says.
"We hammer down on medications," she explains. "We found out early on it's a huge contributor to errors as patients walk out the door."
For instance, one section of the patient's discharge summary might say to stop Plavix (clopidogrel bisulfate), and another section says to start the drug, she says.
"Or the patient was put on a blood pressure medication before entering the hospital, and then the patient's blood pressure is low while in the hospital, and they're taken off the drug as an inpatient," she adds. "So, there are a lot of medication-related issues on transitions."
The follow-up calls also focus on patient safety at home.
"A lot of patients want to go home, and then they find out they're pretty sick and maybe they can't take care of themselves as well as they thought they could," Tomcavage says. "And we also make sure patients have scheduled an appointment with their primary care doctor, and we make sure they can get to that office and keep that appointment within three, five, or seven days maximum post-discharge."
This model was successful for the health system and improved quality of care and transitions, says Doreen Salek, RN, BSn CCS/CPC, director of health services business operations at Geisinger Health Plan.
"We started to look at readmissions, analyzing what brought patients back to the hospital," Salek says. "We did various pilots and proactive outreach with outpatient case managers meeting with the inpatient team."
Together they built tools in medical records and processes to make sure the inpatient case management team and hospitalist team knew there were community providers ready to receive these high-risk patients, she adds.
"We don't want them to find out about this transition opportunity at the discharge summary," she says. "What's going on is that conversation should happen proactively before the discharge occurs."
The program expanded to a telemonitoring effort in which heart patients were given an automatic phone call that inquired about their weight gain and other symptoms a couple of times a week, Salek says.
"The telemonitoring calls had a set series of questions where the patient would answer 'yes' or 'no,'" she says.
When the answers indicated a health risk or problem, the telemonitoring system sent an alert to a nurse.
"The beauty of the telemonitoring is its branching logic," Tomcavage says. "If someone answers yes, then it can give more detail."
By using an electronic telemonitoring system for lower-risk patients, payers and providers save their high-end resources for matters that require a nurse or case manager, she adds.
"The telemonitoring system allows us to do proactive calls, and the actual nurse can follow up and make an outreach call," Tomcavage says.
This post-discharge service resulted in a series of four case management phone calls over four weeks, including the first call within 48 hours. Each call might entail more than a dozen questions about symptoms and actions that could signal problems, including questions about the patient's pain and whether the patient made it to follow-up appointments, Salek says.
Another Health Navigator program involves risk stratification in which emergency department nurses stratify patients according to risk when they come through the door, Tomcavage explains.
"This alerts the team that this might be a higher-risk patient," she adds.
Another change involved discharge summaries.
"When we started the program, one of the biggest complaints we received was that people didn't know anything about what happened in the hospital, because they hadn't received the discharge summary," Tomcavage says.
"So, we worked with the hospitals, telling people that primary care physicians needed discharge summaries within 24 hours 48 hours max," she adds. "We went to all the hospitals and sat down with the hospitalist team and discharge planners to say, 'How can we get this information sooner? We need to know a synopsis and what steps we need to take with the patient.'"
Changing the discharge summary process was not easy. It involved identifying key people within the hospital and scheduling meetings with them. Among these key professionals were the hospitalists and the electronic medical record managers, Tomcavage says.
They also met with primary care physicians to find out what types of items they needed to see on the discharge summary. These items included transition issues, current medications, outstanding laboratory work, X-rays, or any screenings where the results were pending, she explains.
It took nearly two years, but eventually the hospitals made this change, Tomcavage says.
"Also, with our own hospitals we actually have an inpatient team proactively reaching out to the primary care provider's office to make the appointment for the patient, so when patients leave the hospital they have a follow-up appointment written on their discharge summary," she adds.
A last step is to have the hospitals and primary care providers, who all are under the Geisinger umbrella, connected electronically, Salek says.
This way the hospital discharge team can send the discharge summary to community providers with the click of a button, she adds.
"The discharge summary will go to every doctor, including specialists," Salek says.
Sources
Duane E. Davis, MD, Vice President, Chief Medical Officer, Geisinger Health Plan, Hughes Center North, 100 North Academy Ave., Danville, PA 17822. Telephone: (570) 271-6487. E-mail: [email protected].
Doreen Salek, RN, BS, CCS/CCP, Director, Health Services Business Operations, Geisinger Health Plan,Hughes Center North, 100 North Academy Ave., Danville, PA 17822. E-mail: [email protected].
Janet Tomcavage, RN, MSN, Vice President, Health Services, Geisinger Health Plan, Hughes Center North, 100 North Academy Ave., Danville, PA 17822. E-mail: [email protected].
A new model for redesigning the health care transition process could result in improved care transition, reduced care fragmentation, and revitalization for the primary care model. Best of all, it's designed by a health plan payer, which might be the signal hospitals have been waiting for that payers will begin to fund discharge planning.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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