Patients get support for discharge instructions
Patients get support for discharge instructions
Health plan calls members after discharge
Patients who recently were hospitalized but who may not be eligible for disease management or care management programs get support in complying with their post-discharge instructions through a care management followup program by BlueCross BlueShield of Minnesota.
"The members in the discharge follow-up program generally have not experienced catastrophic illnesses or injuries and have not yet been picked up by our disease management or case management programs. They are members who have experienced a short hospital stay and who fall into a gap where no one is touching," says Kim Quesnel, RN, director of care management.
The goal of the program is to support the discharge instructions from the hospital or short stay unit and to make sure the patient follow up with their physician after hospitalization or inpatient confinement.
"We want to coach, educate, and empower our members and their families to assume accountability for their own health and to follow up with their doctor," Quesnel says.
The company instituted its discharge follow-up program in June 2005 after many months of planning.
"If all goes well, our mission is to have an impact on reducing readmissions and emergency department visits," Quesnel says.
Before beginning the program, the health plan collected data on utilization and cost and chose the areas where the follow-up program had the potential to make a difference, eliminating those patients who were being followed by other care managers.
For instance, at the time of the data review in 2005, the health plan's most costly diagnosis group was neonatal care. "Case managers were already working with the families and hospital staff regarding the care for these infants, therefore it didn't make sense to include these patients in the discharge call back program," Quesnel says.
The health plan identified opportunities for anyone going through obesity surgery; cardiac diagnoses, including heart attacks, stents, or bypass surgery; and respiratory diagnoses such as asthma, pneumonia, bronchitis, and chronic obstructive pulmonary disease, she says.
"Because the company's behavioral health program is integrated into the medical care management model, it was also appropriate to identify which population of members with behavioral health diagnoses should be followed up on post-hospital or inpatient confinement," she says.
Children and adolescents being released from long-term treatment centers, members younger than 16 or older than 65 who have been admitted for inpatient mental health treatment, and anyone hospitalized with mood or anxiety disorders are targeted for a discharge follow-up call.
The health plan no longer requires precertification for hospitalization but does require that a provider notify it when one of their its is admitted to the hospital.
"The automatic notification allows us to know immediately when members have an acute episode of illness instead of waiting several months for claims data. It allows us to get in touch with them when we still can make a difference. The inpatient notification by the provider and has a domino effect because we can identify patients who need case management and disease management earlier, in real time," she says.
The insurer's software creates a list of new hospital admissions every day using the admissions notification data.
The care management department's support staff receives the list and compiles demographic and geographic information along with the diagnosis and anticipated discharge date. The nurse care managers call the members a few days after they are discharged.
The health plan sends a letter to all of its members eligible for the program, telling them they will receive a follow-up call and giving them a phone number to call if the care manager can't reach them or if they have any questions.
"We have found that the best window of opportunity to make a difference comes within the first 48-72 hours after discharge. Then we can reinforce the discharge instructions and help them become compliant," she says.
The nurses who make the follow-up calls ask the members if they have questions about their discharge instructions or questions that they didn't think of when they were in the hospital.
"The goal is to start a conversation with the members to find out how they are doing now that they're home," Quesnel says.
For instance, if a nurse calls someone who has had surgery, he or she would ask if the patient had taken care of the wound, if he or she has a fever, and whether the patient has made a followup appointment.
"We encourage people to call us back with any questions they have. We want to establish a good rapport with our members and be their advocates," she says.
The nurses answer any questions the members or family members have about their condition and discharge instructions. They arrange for any kind of post-discharge services the members need and provide whatever assistance they need to comply with the discharge instructions.
For instance, the care manager talked with the wife of a man who was discharged with a heart attack and lives on a farm several hours away from the hospital where he had surgery. His wife was uncertain about how to prepare the low-fat, low-sodium meals that the physician had recommended for her husband. She had no computer and was 35 miles from the nearest clinic.
The case manager asked about the patient's favorite foods, researched and found heart-healthy recipes, and sent them to her. She put the woman in touch with a dietician near their home who could help her plan and prepare meals.
"There were so many post-hospital instructions that the wife didn't even think about the diet while her husband was in the hospital. The care manager also referred the member to our disease management program so that they could begin working with the family immediately. Without this discharge call back program, this member would have fallen through the gap with their questions when he went home," she says.
There was a member who had been taking oncology drugs and was admitted to the hospital for a respiratory diagnosis. The member complained to the follow-up care manager that her oncology medicine was making her sick and that she wanted to stop it.
The care manager reinforced the importance of continuing her medications and set up a referral to the physician for a discussion about the medications' side effects. In most cases, the care manager calls the member only once for followup.
Patients who have been hospitalized for behavioral health diagnoses or for obesity surgery receive two calls: one upon discharge and another in 30 days. "It generally takes longer than a few days for these patients to get back to their normal activities or back to work. We make a follow-up call to see how things are going and to reinforce the discharge instruction and to make sure that follow up appointments with their provider have been made," she says.
Patients who recently were hospitalized but who may not be eligible for disease management or care management programs get support in complying with their post-discharge instructions through a care management followup program by BlueCross BlueShield of Minnesota.Subscribe Now for Access
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