A program with embedded care managers in primary care practices has lowered readmission rates.

  • At-risk patients are followed throughout the continuum of care.
  • The program also has resulted in healthcare cost savings.
  • It’s involved with a Medicare Shared Savings Plan.

Accountable care organizations (ACOs) that involve case management in the entire care continuum often build post-acute care relationships to help their teams find solutions to patients’ social determinants of health issues.

For instance, one organization has RN transitional care managers and social workers embedded in primary care practices.

“We provide care and have eyes and influence on our patients, all the way through the continuum of care,” says Peggy Tyndall, RN, MBA, director of the care management program at Innovation Care Partners in Scottsdale, AZ.

Innovation Care Partners has two ACOs, five hospitals, and acute and post-acute services. “Essentially, we have an integrated physician network with 1,700 physicians, and about 300 of them are primary care providers,” Tyndall says. “We have about 75,000 or more patients in our network.”

With the focus on the care continuum and transitional case management, the organization has had significant healthcare cost savings, sharing the savings with CMS through its Medicare Shared Savings Program. It also has dramatically decreased its readmission rate, Tyndall says.

“In 2014, when it started, the readmission rate was 11%,” she says. “In 2016, it was 5%.”

The organization’s backbone is its health information exchange, which collects data on all patients through their primary care to their hospital medical record. Through a state health information exchange, Innovation Care Partners also can obtain information about patients who visit hospitals out of its network.

“The bottom line is we’re able with our core technologies to know where our patients are, and our staff knows where they are, and can outreach to them and make sure we manage our patients through the care continuum,” Tyndall says. “We work collaboratively with the case manager, making sure our patients have what they need when they’re discharged,” she says.

Another strategy has embedded care coordinators focus on the moderate-to-high-risk patient population, Tyndall notes. “We have a software tool that can identify those patients by primary care practice, and we share that information with our care coordinators, who are embedded in the practices.”

This permits proactive outreach to patients. Care coordinators can make sure patients have everything they need to stay safe and secure. Patients who sign up for the care coordination program receive intakes and patient activation testing, which is a way to find out how involved patients are in their own healthcare. They also are screened for depression and quality of life, she says.

Data show that patients in the program show improvement at the six-month follow-up test. “We’ve seen that after six months, there’s a significant decrease in the percentage of patients that were severely depressed when tested, and we see a 15% increase in their mental quality of life,” Tyndall says. “We also see a significantly higher engagement in their own care.”

This reflects the success of patient activation in which the program helps patients set goals, identify what they need, and become more involved in their own healthcare.

The program addresses patients’ social determinants of health, partly by utilizing a community resource network.

“We can connect people through their insurance or Medicare for [equipment and other] things that are covered and that, frequently, they didn’t realize they could get,” Tyndall says. “Sometimes, we’ve had the ability to get things like walkers and shower benches that are donated or reasonably priced, and we tap into community resources, including one grant that allowed us to purchase some equipment.”

The program’s embedded care managers follow a care coordination model and do not provide any clinical services. Also, there are guardrails established for how often care coordinators call and reach out to patients, Tyndall explains.

“Most of the help is around social community resource support,” she says. “We also communicate back to the primary care provider about what’s going on with the patient.”

Care coordinators help physicians identify home health service needs, for instance.

Typically, a care coordinator’s caseload is between 90 and 110 patients. Their follow-up can last six months to a year.

Social workers follow patients in post-acute settings, including skilled nursing facilities and rehabilitation services. “Post-acute social workers go to the skilled facilities to see patients there, and they go to care conferences,” Tyndall says.

The RN transitional care managers see all new admissions to the hospital and work with inpatient case management discharge staff.

“Their goal for all groups of staff is to make sure coordination of care is appropriate and patients are getting what they need,” Tyndall says.