At-risk patients who receive post-discharge phone calls from RN transitional care specialists at Ochsner Health System’s Care Coordination Center have 20% fewer readmissions than patients with similar conditions who don’t have the intervention.

The program has also resulted in an increase in scores on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questionnaire, according to Mark Green, MBA, assistant vice president of transition management for Ochsner Health System, a New Orleans-based hospital system with 23 owned, managed, and affiliated hospitals.

The Care Coordination Center was developed two years ago to improve transitions for at-risk patients who are covered by a capitated arrangement through Ochsner’s accountable care organization. It is expanding across the healthcare system with programs designed to meet the needs of each individual hospital, Green says.

The Care Coordination Center is staffed by experienced RN transitional care specialists who have achieved case management certification, Green says.

The nurses call patients within 24 to 48 hours after they are discharged from the acute care setting and, using a standardized script, ask a series of questions to determine if the patient is following his or her discharge plan and has no gaps in care. They check to see if any durable medical equipment has arrived, if any ordered home health visits have been scheduled, and if there are caregivers in the home who can assist the patients with their discharge needs.

Medication reconciliation is an important part of the call, and it is most successful when the hospital-based case managers collaborate closely with the case managers in the Care Coordination Center, Green says.

“The case managers in the hospital tell their patients to expect a call from a nurse in the Care Coordination Center and to gather all of their old medications, vitamins, supplements, and other over-the-counter products in preparation for the call,” he says.

The Care Coordination Center nurses reinforce the discharge education the patients received in the hospital. For instance, the discharge case manager or social worker teaches patients three red flags associated with their particular conditions that indicate they should call their physicians or go to the emergency department.

“The case managers make sure that patients remember the red flags and can articulate them. More often than not, patients are so overwhelmed at discharge that they have forgotten much of their discharge education. That’s why these follow-up calls are so important,” Green says.

During the follow-up conversation, the nurses work with the patient to set up a follow-up visit with a primary care provider, and specialists if appropriate. “We found that this works better than trying to set the appointments during the hospital stay when patients are overwhelmed and little sticks. We give them 24 hours to get settled and then make the appointment,” Green says.

When patients indicate that they are having problems following the treatment plan or haven’t received the equipment or services, the Care Coordination Center’s transitional care specialist can intervene on a short-term basis. If they have long-term needs, they are referred to Ochsner’s outpatient complex case management program.

To determine how to identify patients at risk, the care coordination team analyzed all of the health system’s 57,000 discharges in 2013. They used data from a software product used by nine of the system’s hospitals that codes severity of illness using a scale from 1 to 4. In each of the nine locations, patients rated at Level 3 accounted for 50% of readmissions, Green says. The number of patients rated Level 4 was lower, he adds.

“This method is not necessarily a predictor of readmissions, but it does allow us to identify patients we need to look at more closely. We have a finite set of resources and decided to target patients at Level 3 for readmission reduction initiatives and look at palliative care services for those at Level 4,” he says.

The accountable care organization’s outcomes piqued a lot of interest around the Ochsner system, Green says. The center is customizing the program to meet the needs of each individual facility, he adds. Here are three examples of how the program is being customized, according to Green:

At Ochsner Medical Center-Baton Rouge, post-discharge follow-up calls were being conducted by a group of licensed practical nurses (LPNs) who worked in the clinic setting and targeted only heart failure, heart attack, and pneumonia patients. A significant number of patients being treated by the practice were also covered through the accountable care organization, which meant that they got two follow-up calls — one from the Care Coordination Center nurses and another from the clinic LPNs.

“When they asked for our help, we proposed putting the LPNs under our department for clinical oversight only. We trained them on the scripts we use and record all calls to use as peer review, the same thing we do for the Care Coordination Center staff. We gave them back-up from the RN transitional care specialists on our staff if they need an assessment or triage,” he says.

The LPNs were calling 20 to 50 patients a month. Now, every patient discharged from the hospital to home receives a call either from an LPN in the clinic or a RN transitional care specialist in the Care Coordination Center.

Each day, Green receives a list of all the discharges from Ochsner Medical Center-Baton Rouge and sends the low-acuity 1s and 2s to the LPN staff and the patients with higher severity to the Care Coordination Center staff for follow-up calls. Readmissions have also dropped 20% for patients who received follow-up when compared to patients with similar conditions who couldn’t be reached.

At Ochsner Medical Center-North Shore in Slidel, LA, two RNs were making discharge calls for HCAHPS. “It was a feel-good type of call. We added in the clinical aspect and provide oversight to make sure their calls are consistent. They have experienced the same 20% reduction in readmission,” Green says.

The center has also collaborated with St. Tammany Parish Hospital in Covington, LA, a hospital that is not in the Ochsner system but sends patients to an Ochsner priority clinic run by a hospitalist.

“Our priority clinic functions as an ambulatory stepdown unit and provides a more intense level of care than a regular primary care clinic if patients need it. Each day, the hospital sends us a list of patients with an Ochsner primary care physician and the Center’s transitional care specialists follow up with them. It’s been a big success. The first 100 patients had a 5.2% readmission rate,” Green says.

The Care Coordination Center is also helping the hospital replicate the same process for patients who do not have an Ochsner physician.