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Following up care cuts readmissions
Post-discharge phone calls are a key
WellPoint's initiatives to reduce hospital readmissions by following up with Medicare Advantage members after discharge has decreased the readmission rate and reduced skilled nursing days, according to Karen Amstutz, MD, vice president and medical director of care management for seniors and state sponsored business for the Indianapolis-headquartered health benefits company.
"One of our key initiatives at WellPoint and across our health plans is to look at the cost of care and identify the areas where we can make the greatest impact," Amstutz says. "Our readmission prevention initiatives use a range of tactics to identify members at risk for readmissions at the time of discharge and provide the appropriate level of case management that will keep them out of the hospital."
WellPoint's post-discharge follow-up program is based on Eric Coleman's Care Transitions Intervention model. The model was developed by a University of Colorado team led by Eric A. Coleman, MD, MPH, a geriatrician and professor of medicine at the university. It has four main components, called "Four Pillars":
teaching patients medication self-management;
educating them to recognize warning signs and symptoms and what to do when they occur;
ensuring follow-up care with a primary care physician;
facilitating patients' ownership of their personal health records.
After Medicare Advantage members are discharged from the hospital, the health plan's outreach staff and case managers implement interventions that are based on the member's level of risk for readmission. Members at low risk receive telephone calls.
Based on the severity of their condition and their level of risk, other members would receive short-term telephonic case management or are enrolled in long-term complex case management.
The health plan's outreach staff call all of the Medicare Advantage population after discharge, regardless of their risk level, and are able to reach about 95% of them. These non-clinical staff members have been trained to conduct the post-discharge telephone calls and use a script developed by the health plan's multidisciplinary care coordination team.
About 10% of the low-risk members who receive calls have issues that need attention, Amstutz says. Common problems include confusion about medication or the treatment plan, untreated pain, or lack of caregiving support. In some cases, the home care nurse hasn't shown up or needed equipment hasn't been delivered. If a member is having problems or has a question, the staff can transfer the call directly to a nurse case manager.
The outreach staff members ensure that the members have a follow-up appointment with their physicians. If necessary, they can institute three-way calls with the physician office or transfer the member to a case manager to help coordinate the appointment.
Teams are assigned geographically
WellPoint's multidisciplinary Geographic Care Support Teams are a key to the success of the program, Amstutz says. The team includes medical directors, case managers, and utilization review nurses who are assigned by geographical areas, which allows them to focus on the resources and providers in their particular area.
The cross-functional teams conduct rounds on hospitalized members who have complex treatment needs and who have been in the hospital 10 days or longer without moving to the next level of care. While the patients are in the hospital, the team members discuss who is likely to be at risk for readmissions. They determine what the patients need after discharge to avoid hospitalizations and/or emergency department visits.
The health plan's utilization review nurses and case managers have separate functions, but they work as a team to coordinate care. This coordination has been the key to the program's success, Amstutz says. "We have found that it's more efficient to assign utilization review and case management responsibilities to different staffs. If one nurse is responsible for both functions, they spend a lot of time setting priorities and don't get as much work done," she adds.
Members who receive short-term case management often need help transitioning to the community. For example, a newly diagnosed diabetic might need education about managing his or her disease before being handed off to the health plan's disease management program. Members who receive long-term case management have complex needs and need interventions over a longer span of time.
WellPoint has implemented a pilot project in Georgia in which home health nurses meet face-to-face with recently discharged patients, reinforce the discharge plan, conduct medication reconciliation, and educate patients about symptoms that indicate they should call their doctor. "When someone visits members in their home, they can identify issues that might not be evident to a telephonic case manager. The pilot provides visits to a very low volume of members. Based on its success, we're working to develop ways to expand the program," she says.