A health network with more than a dozen acute care hospitals has developed teams with advanced care providers to work with Medicare at-risk patients to improve care and reduce costs. The case management-style teams also work with some privately insured patients.

The team approach has resulted in a 9.5% reduction in 30-day readmissions, according to a healthcare organization’s internal data.

The reduction occurred between 2017 and 2018 among Medicare fee-for-service patients with pneumonia, COPD, heart failure, stroke, heart attacks, coronary artery bypass surgery, and knee or hip replacement procedures, says Hallie Bleau, ACNP-BC, CCM, assistant vice president of transitional care management at Northwell Health Solutions in Manhasset, NY.

For Medicare patients who underwent elective joint replacement surgery, the 2016-2017 readmissions declined by 28% and maintained at that lower level in 2018, Bleau says.

Teams consist of physician assistants, nurse practitioners, RN care managers, social work care managers, and specially trained community health workers. The community health workers undergo training to return to their own communities and provide boots on the ground as nonlicensed care managers, she says.

“We follow our patients because we’re trying to help hospitals reduce readmission rates,” Bleau explains. “We navigate a lot of patients for a value-based purpose, regardless of the population.”

Team activities include the following:

• Recruit right people. “We’ve grown this team over the last two years,” Bleau says. “We look for a certain personality. You have to be flexible in this role and innovative, as this is an evolving environment, and you can’t be afraid of change,” she explains. “You also have to be kind, happy, smiley, and nice. We are ambassadors out there in the world of population health and value-based care, and we’re taking care of sick people, which is not an easy thing to do.”

• Engage patients in the hospital. Patients are identified and engaged in the hospital setting, she says.

Finding patients who need to be followed by the team is one of the roles of the resource coordinator, she adds.

• Establish relationships with patients. “Starting engagement in the hospital helps us establish a relationship with the patient,” Bleau says. “We give patients the phone number of the care manager who will be following them,” she adds. “Their calls ring right to the care manager’s cellphone during the day and to our call center in the off hours.”

• Stratify patients. The team stratifies patients by length of stay, comorbid conditions, and ED visits, Bleau says. They receive a number score in the electronic medical record, which is used to risk-stratify the patient.

“If the patient is high risk, the nurse practitioner will follow the patient. If the patient is medium risk, the RN care manager follows the patient,” she explains. “If the patient is clinically stable, but has social issues and needs a lot of services, then the social worker will follow the patient.”

The nonlicensed care manager takes care of low-risk patients, she adds.

• Call after 24 hours. “All patients are called within 24 hours of being discharged,” Bleau says. “We make sure they have scheduled appointments, and we review their medications,” she says.

• Follow for continuing action. Nurse practitioners or physician assistants visit high-risk patients in their homes. Medium-risk patients might be visited at home, but it depends on what happens, Bleau says.

The team calls patients at the 72-hour post-discharge window and determines how much follow-up a patient might need, she adds.

“We try to touch base with all patients at least once a week for the first 30 days,” she says.

• Create one-call shop. “We ask patients to call us first and we’ll help with whatever they need,” Bleau says. “We make sure they get to specialists and primary care providers, and we make sure their medications are correct and that they understand their discharge instructions.”

If a patient qualifies for home care, then the team ensures the home care agency is ready to visit the patient.

The team makes sure patients have everything they need to be healthy, Bleau says. “We are coordinating care and getting people back in the community, helping them with transportation issues, access to food issues, and housing issues,” Bleau says.

“Our model is to reduce the cost of care, reduce readmissions, and increase quality,” she adds. “Those are the major things our model is designed to produce.”

• Offer same services to employees. As a concierge-like service for the healthcare organization’s 66,000 employees, the same type of team-based care management plan is offered to staff, Bleau notes.

“Employees get the same level of care as the Medicare risk patients, and the same teams do all the work,” she says.

• Engage through technology. “One of the cool things we do is interact with patients through text. We offer it to every patient who is eligible for our program,” Bleau says. “They get a text message over a secure platform, and there is nothing to download.”

If the patient answers “yes,” then he or she receives a link and can answer a series of questions. This is how the team builds conversations that provide daily information and details about how patients are feeling, she explains.

“If patients report being more short of breath today than yesterday, that’s a red flag,” Bleau says. “There is an automatic alert, and whoever is assigned to the case gets an alert on their phone.”

A central team that has the job of watching the dashboard all day will contact patients when there’s a red flag alert. They call the patient to figure out what is happening, she says.

“With our mode, we touch the patient five times a month, on average. This texting platform adds another five touches to that patient, in that month,” Bleau explains.

• Support from central team. The central team consists of nurses, resource coordinators, and nonlicensed care coordinators who call the patients.

“They make phone calls and do anything the hospital team is unable to get through,” Bleau says.

• Close the case. The team closes cases after 30 days. The team calls patients at the end to ensure everything is in order, and that the patient has connected with a doctor, and has all needed resources at home.

“There are people we manage after 30 days because we don’t feel comfortable letting them go or because they’re in a complex care management program,” Bleau says. “We deal with longer-term issues that are not resolved within 30 days.”

If any patient seen by the team needs more help, the team either will help the person or find a resource that can help the person, she adds.

The healthcare organization has focused on this team-based care management program partly because of the industry’s move to value-based care, but it is mostly a better way to provide healthcare services, Bleau says.

“The main reasons we’ve gotten into this is to redesign and improve patient care,” she says.