Post-acute transition program cuts LOS in SNFs for participants

Case managers visit facilities, collaborate with staff, patients

UnitedHealthcare's post-acute transition program has reduced the average length of stay in skilled nursing facilities by three to five days, depending on the market, for members in the program.

"Inpatient stays are some of the most stressful and unsettling health care events members experience," says Rhonda I. Randall, MD, chief medical officer for UnitedHealthcare Medicare & Retirement.

"Our care managers work collaboratively with facilities, families, and caregivers to ensure members receive the right care, in the right place, and at the right time," she adds.

The program, which began in 2005, provides face-to-face case management for Medicare Advantage members who are discharged from the acute care hospital to a skilled nursing facility.

"Our program focuses on the member and making sure the members get appropriate services at the appropriate level of care. What has resulted has been a reduction in the length of stay. We want to be good stewards of a member's medical dollars and remove the barriers so they don't experience unnecessary delays in services," says Michelle McPhillips, RN, CCM, BA, program director for the post-acute transition program.

Planning for the program started in late 2004 as a way to ensure that transitions to post-acute facilities go smoothly and that the members get the services they need in a timely manner so they don't stay longer than necessary, McPhillips says.

The program began with a pilot project in Ohio in mid-2005. During the pilot, two nurse case managers, hired in separate markets, visited participating skilled nursing facilities. They evaluated the members early in their post-acute stay, met with them every week, talked with family members, and monitored the members' progress.

"Often the people in our program are the frail and elderly patients with comorbidities who are at risk for frequent hospitalizations and require a lot of care. Many of these members are admitted to the hospital with pneumonia, heart failure, or respiratory conditions that put them at risk for frequent hospitalizations. We wanted to make sure that the transitions were smooth," McPhillips says.

Following the success of the pilot project, the health plan has instituted the program in geographic areas where there is a large population of members who could benefit from the program.

Many of the patients have multiple comorbidities such as heart failure, diabetes, a respiratory condition such as chronic obstructive pulmonary disease, or pneumonia. Many members have dementia and cognitive issues. Some have had joint replacement surgery or suffered a stroke.

The members no longer meet inpatient criteria but have had a decline in function during their hospital stay that makes a discharge to home impossible.

"They have to learn how to get back to walking or transferring, or they may need continued medical treatment such as wound care or IV antibiotics. A lot of their needs are therapy-related," McPhillips says.

The nurses work in facilities where significant numbers of members are admitted. The nurses are assigned to facilities within a geographic area. They make rounds in facilities at least once a week. When there are a lot of members in the facility, the nurse may round twice a week.

"It's a hands-on program. The nurses visit with the member every week, talk with the family and caregivers and involve them in the plan of care, and work with the interdisciplinary team at the facility," she says.

By being in the facility regularly, the case managers are viewed as part of the interdisciplinary team, McPhillips says.

"It helps us move the member along because everybody is on the same page," she says.

When a member is newly admitted, the case manager completes a comprehensive assessment and begins to develop goals for discharge.

"We invite them from day one to participate in setting their goals. Most people want to go home, but, unfortunately, that may not be realistic," she says.

Most of the members in the program are covered by United's Medicare Advantage plan. Some have a chronic illness plan.

The case manager determines the member's baseline functionality before hospitalization, what caregiver support will be available after discharge, and other services the member already has.

"When we meet with the member, we get permission to make a follow-up phone call to the family and caregiver. We review the medical record and speak with the therapist and nurse on the unit to find out how well the patient is doing medically and from a therapy standpoint," she says.

The case managers see the members a minimum of once a week.

They spend a lot of time building a rapport with members and their family and including them in developing the discharge plan.

"We want to make sure that people are medically and functionally stable to go home and that the discharge plan is as safe as possible. We give the member and family the information they need to make decisions about the discharge destination," she says.

For example, a member may want to go home, but that may not be a safe discharge option.

"This is always a difficult situation. That's why the onsite program is so beneficial to the member and to us. It's better to have difficult discussions face-to-face than over the phone. The case managers get to know the members and their families by being there consistently throughout the entire stay, and this makes it easier to talk about discharge options," she says.

They collaborate with the treatment team at the facility to develop the member's plan of care.

"We want to make sure that the services the member needs are provided in the skilled level of care, that they are receiving the appropriate modalities, and that they have the equipment they need. That's why it's so important to partner with the facility. If the case manager has questions about member needs or wants to talk to the physician, they are comfortable in asking because they have a relationship with the staff," McPhillips says.

As the day of discharge approaches, the United case managers focus on preparing members for discharge, making sure they know to get their prescriptions filled, when the follow-up with their physician is, and who to call if they don't hear from home health services.

They make sure their post-discharge needs are being met so the patients don't stay longer than necessary in the facility until home care visits are set up or durable medical equipment is delivered.

If the case manager has concerns about the member's living situation after discharge, he or she asks the skilled facility to send someone to conduct a home assessment.

The duties of the case managers focus more on making sure that the members get what they need in the skilled nursing facility and that they have what they need after discharge, rather than spending a lot of time educating them about managing their conditions after discharge.

"These patients have so many issues going on while they are in the skilled nursing facility that they aren't in the state of mind to benefit from a lot of education. We do a lot of coaching with the caregivers, and the therapists work with them to make sure they understand the capabilities of the member after they return home," she says.

The nurses often identify members who would be eligible for United's disease management or telephonic case management programs.

"Our program focuses on members while they are in the skilled facilities. When the members are discharged, the case managers collaborate on handing them off to nurses in other programs that may benefit them," she says.

The case managers give business cards to the members so they and their families call with questions or concerns. It's not unusual for a case manager to receive a phone call six months after the case is close from a member saying, "You really helped me when I needed it," McPhillips says.

The case managers typically have a caseload of 20 to 24 members at a time.

"The team is all remote, which brings challenges," she says. The nurses have home offices and start the day answering e-mails, then round in the field between 10 a.m. and 3 p.m.

At the end of the day, the nurses go back to their home office, catch up on paperwork, and communicate with family members.

The nurses are in the field four days a week and spend one day catching up on their phone calls and documentation.

The program employs nurses with a case management background who are experienced in more than one level of care so they understand the whole continuum of care. "Many on the team are certified case managers or are pursuing certification," she says.

Some of the nurses have hospital backgrounds. Others have experience in a skilled nursing or rehabilitation setting or a hospice background.

"The skill set for case managers is very important for an onsite position. The biggest part of the job is relationship-building. The nurses are on site at multiple facilities and must be able to communicate. They must collaborate with members and families in care planning and partner with the facility staff and physicians. Collaboration and communication doesn't come naturally to everyone," McPhillips says.

The program has a low turnover rate, McPhillips says.

"Most of our staff have been with the program from the day we opened up in their state. They're here because of the members. They get so much from seeing the members being able to improve and go home and from seeing the dedication and development of the caregivers. My mantra is, 'It's all about the members.' Everyone has the member's goals in mind," she says.