New CM model strives for more efficient transitions
Goal is to improve quality & efficiency
Executive Summary
An efficient transition of care system can provide faster transitions from acute care facilities to skilled nursing facilities.
- A Maine organization developed a faster transition model after noting that patients often were transitioned too slowly due to approval lag times.
- Transitions were particularly problematic over weekend periods.
- The new model gives providers the chance to make transitions when medically necessary without prior authorization.
One of the healthcare problems that case management can address involves effective transitions of care from acute care facilities to skilled nursing facilities (SNFs). When these transitions go well, patients benefit and healthcare resources are used efficiently.
The Affordable Care Act created the Community-based Care Transitions Program to test models for improving care transitions from the hospital to other settings and to reduce readmissions among high-risk Medicare patients. CMS has encouraged all organizations to create their own models.
One Maine organization recognized early in 2014 the need to improve their members’ transitions from acute care to SNFs. The transitions were not as effective or as speedy as they needed to be, partly because of a prior approval requirement, says Maggie J. Kelley, MSN, APRN-CNP, COHN-S, director of medical services for complex care management at Maine Community Health Options in Lewiston.
“We re-evaluated that experience and said that when members need SNF, we should make that experience happen quickly,” Kelley says. “So we removed the authorization requirement and communicated that to the network providers.”
Network providers were told that if a transition — over a weekend or holiday period — was medically necessary then they should go ahead and transition the person. “Then we ask them to submit clinical documentation,” Kelley says.
Previously, providers had to wait for approval to move a patient. Now they make the transition, and simply seek approval within three days of the transition. This takes care of weekend transitions and prevents patients from being kept in the acute care facility longer than medically appropriate.
“It’s worked out fabulously well,” Kelley says.
This simple change also meets CMS goals for improving care transition, she notes.
“CMS was looking at quality of care, timeliness, member experience, improving population health, and reducing costs,” Kelley notes.
“It’s a three-pronged approach of providing high-value services, exemplary member experience, and then reducing costs,” Kelley says. “And that’s the baseline of our approach.”
This is one example of changes the organization made to be more nimble with care transition and to overcome barriers, says Melissa M. Gerry, RN, CCM, lead care manager of complex care management at Maine Community Health Options.
Another example involves a care/case manager (CM) finding community resources to help a patient receive the care she needed at her own home, Gerry says.
“We had a member who was in her 40s and diagnosed with brain cancer,” she explains. “She had a young child and was married to a person who was the sole provider of a business. When she became impaired neurologically, she was unable to take care of herself and had to have 24/7 care.”
The woman’s husband took her to different providers, and a care manager became involved with the case, Gerry recalls.
“The care manager connected with the spouse,” she notes. “The member’s neurological changes did not allow her to have conversations with the care manager.”
After her disease progressed and treatment options were exhausted, the woman needed to live in a skilled nursing facility — at least until she regained her strength enough to function at home, Gerry says.
“She ended up accepting hospice care at the skilled nursing facility, and she really wanted to go home,” she adds. “The benefit plan doesn’t provide for custodial care, so the care manager went through an alternative plan of care process, looking at what this member needed and what was medically necessary.”
After assessing community resources and family support, the CM created an alternative plan that included a cost-benefit analysis for proposed in-home coverage of eight hours per day, five days a week. This was the time the spouse needed to manage his business, Gerry says.
“We were able to make this happen, and the member was able to go home with hospice support,” she adds.
Alternative plans of care go into effect only under extraordinary circumstances, Kelley notes.
The driver for implementing an alternative plan of care is what type of care the member needs and the CM being an advocate for the patient, Gerry says.
“We have to balance it with stewardship, which is why it’s a rigorous process of looking at what’s appropriate for the member,” she adds.
Once an organization focuses on CMS’ three-pronged approach, case managers and leaders can come up with other ways to improve care, as well as costs.
For instance, a value-based insurance design promotes high-value care that aligns member incentives with out-of-pocket cost, guided by evidence-based outcomes in treatment of chronic conditions such as asthma, coronary artery disease, chronic obstructive pulmonary disease, diabetes, and hypertension, Kelley says.
“With those conditions, there is strong evidence that if the individual follows guidelines for routine management, they’ll have better outcomes and improved costs,” she explains. “So we eliminated out-of-pocket costs.”
Also, while most health plans provide diabetic patients with a glucometer, but not the strips, they’ve included test strips for up to 150 every three months and they’ll consider more if needed, Kelley says.
In the area of behavioral health, the plan removes the out-of-pocket costs for the first three behavioral health visits, including counseling and psychiatric management, she says.
“We help members get the right care at the right time,” Kelley adds.
For instance, if a member has been in an acute inpatient psychiatric setting and needs to see a medical provider after discharge, the plan will allow a same day visit because transportation can be a barrier for patients, and the connection with the outside provider might prevent the person’s relapse and readmission, Kelley explains.
“We’ve contracted with community care teams to put boots on the ground if needed,” she adds.
“So if we have a very vulnerable member, we can use the care team’s service,” Kelley says. “We also have behavioral health clinicians on our care management team, as well as RNs and MSWs.”
An efficient transition of care system can provide faster transitions from acute care facilities to skilled nursing facilities.
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