Ensuring good transitions is just the right thing to do
CMs can help patients avoid readmissions, ED visits
Providers and payers alike are recognizing that ensuring smooth transitions when patients move between levels of care — and implementing projects to help transitioning patients avoid an emergency room visit or a hospital readmission — is the right thing to do.
"There's a great interest in how all of us in the healthcare industry can do a better job for patients. Payers and providers are developing case management programs and are making an impact on transitions in care. Not only do they improve outcomes and save money, but they improve patient and family satisfaction as well," says Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY, case management consulting firm.
Case managers are the key to successful transitions because they can work closely with patients and family members, often identifying barriers to care and psychosocial needs that, in the past, providers never knew about, Mullahy says.
Avoidable readmissions have a variety of causes, including unclear discharge instructions; patients' lack of knowledge or resources to get their medication, manage their diet, or receive follow-up care; and lack of medical follow-up, adds Randall Krakauer, MD, national medical director for Aetna. "Many readmissions are the result of a breakdown in processes after patients are discharged. Case management has demonstrated the potential to reduce avoidable readmissions by ensuring that patients have a smooth transition," he says.
Aetna adapted the University of Pennsylvania's Transitional Care Model for a pilot project in which advanced practice nurses visited at-risk Medicare patients in their home after discharge. The nurses conduct an extensive assessment of patient needs and the home situation, connect patients to whatever post-acute services and community resources they need, and educate patients and family members on the treatment plan, the need to follow it, and signs and symptoms that indicate the patient's condition is worsening. The pilot produced a savings of $439 per member per month and is being expanded to communities where there are sufficient numbers of Aetna Medicare members.
"We know from experience that good transitional care can provide a positive impact on quality and cost for home discharges and discharges to skilled nursing facilities. An admission that doesn't happen is not just a cost saving. It's also a matter of providing good quality care for the patient," Krakauer says.
Coordination of care shouldn't be limited to what happens in the hospital or the clinic but should extend across settings, adds Carol Barnes, MS, PT, GCS, executive consultant for strategic programs, CARE Management Institute, Kaiser Permanente, Oakland, CA.
Part of the problem in the past has been that clinicians typically worked in silos with little communication with their colleagues in other levels of care, Barnes says.
"When we began a project to improve transitions in care and interviewed patients, family members, and providers, we learned that care was happening in what we call 'individual towers of excellence.' The hospital was doing great work, the clinics were doing great work, and the home health nurses were doing great work, but the transitions were broken between them," Barnes says.
Some patients who were interviewed told Kaiser representatives that they were confused about their treatment plan and medication regimen, that they didn't know who to call with questions and concerns after discharge, that they didn't remember that they should make a follow-up appointment with their primary care provider, and that often their primary care provider didn't know they had been in the hospital. The organization's process improvement team developed a set of six key initiatives to improve the transition process. After a successful pilot, the program is being rolled out in Kaiser regions throughout the country.
"People go home from the hospital confused about what they should do. Some don't even know their basic diagnosis. They don't follow their treatment plan and end up back in the emergency department or the hospital," Mullahy says.
Regardless of where they work, case managers need to look backward before they go forward and determine what caused the patients' problems in the past, and then determine what can be done to remove the barriers to keeping the patient healthy, she adds.
Everyone needs to know who the at-risk patients are. Medicare and Medicaid beneficiaries represent a good portion of high-risk patients, but they aren't the only patients who may need extra help after discharge, she says.
For instance, patients may not qualify for post-acute services but they may not have anyone to make their meals. "There may not be food in the refrigerator, and someone who has just been discharged from the hospital isn't going to feel like going shopping right away. In addition, many people with chronic conditions are on modified diets and don't know how to shop. Case managers need to spend more time finding out specific patients' needs and connecting them with needed resources," Mullahy says.
Case managers bear a sizeable responsibility to ensure that patients are safe in the next place they go, whether it's back home, to an assisted living center, or skilled nursing facility, and to make sure that the hand-off to the next level of care goes smoothly, she adds. "Case managers should never treat the hand-off like a hot potato. They should continue to be accountable for what they did to get patients ready for the transition," she says.
This means that providers at all levels of care should work together to make sure that patients don't fall through the cracks when the transition happens, Mullahy says. As consumers become more savvy about healthcare choices, providers and payers both risk losing clients if they don't facilitate good transitions, she adds.
"As case managers, we've got to stop being so insulated in our own silos and learn what other organizations are doing," she says. By meeting face to face with their peers in other settings, case managers get to know each other and know who to call when there are questions about the transitions, she says.
When a patient is receiving care in any part of the healthcare system, all case managers involved with the patient should know about it, she says. Providers and payers are starting to partner with each other to improve transitions, she says.
"Hospitals are starting to establish true partnerships with medical group practices, and case managers in both settings are starting to have active conversations," Mullahy says. Insurers are embedding their case managers in group medical practices, and in some cases, in hospital settings. "This is real partnering and can only benefit the patients," she says.
Case managers at different settings should also collaborate on follow-up calls after patients are discharged from the hospital. "Follow-up calls are important because many times patients don't know what medication to take or have other questions. But it will be confusing if they get a call from the insurance case manager and the hospital case manager," she says.
Providers and payers alike are recognizing that ensuring smooth transitions when patients move between levels of care and implementing projects to help transitioning patients avoid an emergency room visit or a hospital readmission is the right thing to do.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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