Physicians, health plan, hospital team up

At least a 30% drop in rehospitalizations

When a health plan, a physician network, and a hospital teamed up to reverse the trend of Medicare hospital readmissions within 30 days of discharge, readmissions dropped by 30% or more over an eight-month period when compared to the readmission rate in the same hospital the previous year.

According to data compiled through September 2010, patients in the program had a 9.25% readmission rate compared to 16.5% for a similar group in 2009.

"Hospital readmissions are a costly problem for everyone. The triple goals of this program are to improve quality of care and the patient experience while reducing readmissions Each prevented readmission will keep patients healthier and could save almost $10,000 per patient," says Barry Baines, MD, associate medical director of U-Care, an independent, nonprofit health plan.

The project is a joint effort of U-Care, based in Minneapolis; Fairview Physicians Associates (FPA), a large network of primary care and specialty providers; and Fairview Southdale Hospital, both located in Edina, MN.

The initiative involves collaboration between the hospitalist, the discharge planner, and the pharmacist at the hospital — and the case manager and the primary care provider, Baines says.

"All of these professionals work together to ensure that the patient is safely discharged back home. We ensure a safe transition by making sure the patient knows what medication to take and when to take it, that they have the equipment and post-acute care they need, and that they have a timely follow-up visit."

U-Care provides an incentive to the primary care physicians to see patients within five days after discharge and provides funds to the hospital for a pharmacist to evaluate patients in the program.

The pilot project, which began Feb. 1, 2010, targets patients covered by U-Care for Seniors Medicare Advantage plan who are hospitalized and who have diabetes, chronic obstructive pulmonary disease, or heart disease, or a combination of the three, Baines says.

"Because they are seniors, many of our members admitted to the hospital have one or more of these conditions," Baines says.

When a patient is admitted to Fairview Southdale Hospital, the case manager at Fairview Physicians Associates is notified within 24 hours, according to Becky Schmidt, RN-BC, manager of care delivery and clinical operations for the physician organization.

The hospital and FPA case managers use software that allows direct communication between the case manager and the staff at the hospital.

"We get a notification every morning listing all of our patients who have been hospitalized. When a U-Care for Seniors patient is identified through the admission report, we activate our tool so that the social workers, nursing staff, hospitalists, health information management system, and pharmacy staff are aware that the patient is in the pilot," Schmidt says.

Because the physician network provides case management for all of its patients, the FPA case managers have information about the patients' conditions and the care they have been receiving, as well as any services that are in place or they have had in the past, Schmidt says. For instance, some congestive heart failure patients are on a self-management program. Others may be receiving telemanagement. The case managers also have a record of any post-acute services, such as home health, that the patient has used in the past.

"The case manager informs the hospital social worker about what has been going on with the patient before hospitalization. That way, they don't have to re-create the wheel," Schmidt says.

The FPA case managers visit the patient in the hospital to check on his or her condition and to help coordinate any care the patient may need after discharge.

They follow up with the hospital social worker by phone or by electronic communication.

"This communication puts everyone on the same page, so there are no surprises at discharge," Baines says.

Before discharge, the patient is visited by a pharmacist, who completes medication therapy management and discusses the medication regimen with the patient.

"Pharmaceutical reconciliation or issues with medication are the reason for between a third and a half of readmissions. In some cases, the patient is taking medication he shouldn't take. In other instances, he or she is taking a generic prescribed before admission and an identical drug prescribed in the hospital or simply hasn't gotten the prescriptions filled," Baines says.

The pharmacist's role goes beyond typical medication reconciliation, Schmidt says.

"The pharmacist is not simply handing the patient a list of what new medications he's taking and what he came in with. He's looking at the big picture. A congestive heart patient may be managing multiple medications very well, but if one is changed, it could be confusing. We take a proactive approach to eliminating any medication problems that could occur after discharge," she says.

The Fairview Physician Associates case manager works with the hospital discharge planner to make sure the patient has everything set up, such as durable medical equipment and oxygen, and making sure home health is in place if that's appropriate, Baines says.

"One of the more important aspects of the program is to ensure that the patient has a follow-up visit with a primary care provider within five days," he says.

The hospitalists also are alerted when a patient is in the pilot project. Their responsibility is to emphasize that the patient needs a follow-up appointment within five days after discharge and to provide a discharge summary to the primary care physician within 24 hours of discharge, Schmidt says.

"We know that the primary care physician is at the heart of the care plan. Our communications tool alerts the hospitalists when a patient in the pilot is in the hospital. They know to facilitate a follow-up appointment," Schmidt says.

The primary care clinics have accepted the responsibility of seeing patients within five business days by being flexible and getting patients in, she adds. When a patient has a primary care visit, the case manager receives a visit summary from the clinic.

The case managers at FPA call the patients within 24 to 48 hours of discharge, then again at 14 days and 28 days after discharge.

"These phone calls are instrumental in identifying what problems are occurring before the patient winds up back in the hospital," Baines says.

The case managers reinforce the education the patients received in the hospital and find out if they need anything else. "If they haven't made a follow-up appointment, we offer to help them call the clinic," Schmidt says.

"The case managers work to engage the patients in their own care. They don't just tell patients to do something. They provide an explanation and education. We are looking at the big picture and partnering with the patients to make the discharge safe and successful," she says.

Fairview Physician Associates has always had case management as part of its contract with U-Care for Seniors, Baines says.

"All our care systems offer complex medical case management. For this project, FPA reallocated some of their case managers to the program and are taking more of a broad focus using predictive modeling to assess the most at risk patients," he says.