Valley Health System’s population health program employs post-acute navigators who help coordinate care transitions to skilled nursing facilities, home health, and community providers.

  • The program has resulted in a reduction in its readmission rate.
  • Post-acute navigators and nurse navigators help patients receive all the services they need from home health and primary care physicians.
  • Valley also collaborates with Dispatch Health, a program that provides at-home urgent care services.

One of the major goals for health systems and others in healthcare is to move the care delivery model outside of the four walls of the hospital.

Now is the time to embrace the population health model, says Toni Modak, RN, BSN, director of population health at Valley Health System in Ridgewood, NJ.

“We have to think beyond the acute care model,” Modak says. “We have to follow patients throughout their journey and support them — not just focusing on the four walls, but thinking more globally.”

Healthcare is difficult to navigate. It is the case manager’s role to ensure patients are managed appropriately as they transition from one setting to another, she adds.

The program resulted in a 6.4% readmission rate in 2018, compared with a readmission rate of 14% before the population health program began, Modak says.

“We’re only managing a subset of our health system’s population because we’re managing Medicare and private payer accountable care organization patients,” she explains. “But we’re following the patients across the continuum, and making sure they’re managed efficiently.”

The program employs nine nurse navigators and three post-acute navigators who work with skilled nursing facilities (SNFs). These include two registered nurses and a physical therapist.

Here is how Valley Health System’s population health program provides warmer handoffs and an improved care continuum:

• Population health works with post-acute facilities. When patients are transitioned from the hospital to community providers, population health contacts post-acute providers.

“We sit in utilization review, work on standardization within the facilities, and we make sure patients are receiving high-quality physician care,” Modak says. “We work with facilities on appropriate length of stay.”

The goal is to ensure the organization fully supports patients throughout the care continuum, she adds. “We no longer look at what’s going on in those four hospital walls. We look into the community and follow their journey,” Modak explains.

The program employs post-acute navigators who are embedded in SNFs. They ensure patients transitioning to a SNF from the hospital are provided standardized, efficient care to ensure the best outcomes, she says.

For example, the post-acute navigator might ensure SNF staff are well-educated and trained on wound care if one particular patient needs that service, and the SNF does not specialize in wound treatment.

“We also provide diabetes education, and we ask difficult questions,” Modak says. “We ask if there has been education. Has there been reverse demonstration? Has the family been in to demonstrate injection?”

Nurse navigators spend a lot of time at the post-acute facilities, making sure the next level of care has been set up appropriately, she adds. “We’re trying to standardize all SNF care. They should be doing discharge instructions back to primary care. We’re working with all facilities to standardize that practice.”

• Post-acute navigators coordinate with home care. “We also work with the home care agency about their education on diabetes, insulin, and teach-back,” Modak says. “When the patient is discharged from the hospital, we might ask the home care agency to make an evening visit to make sure the patient’s daughter can inject the insulin correctly.”

The post-acute navigator confirms the home care agency is ready and all services are set up for the patient. When patients leave the SNF, the post-acute navigator makes a note about the patient receiving home care services. “The navigator collaborates with the home care nurse,” Modak says. “We work well with all home care agencies.”

Post-acute navigators work especially well with Valley Health System home care agencies. If a patient goes to a non-Valley agency, they contact the patient to confirm everything is going well, she says.

When the home care agency is within the same health system, it is easier to communicate and review case documentation. But when patients are sent to outside agencies, post-acute navigators collaborate to make sure patients are managed and all needs are met, she adds.

• Collaborate with community providers. “A big issue in our area is patients being transitioned to skilled nursing facilities from hospitals,” Modak says. “Physicians will say, ‘I didn’t know my patient was there.’ Their patient shows up on their doorstep two months later, and they had no idea.”

The population health program notifies providers of these care transitions, ensuring there are no surprises. “If they’re in the hospital or the next level of care, we notify the providers,” Modak says. “We know where our patients are and what they’re doing; the population health program is closing the gap.”

The program shares medication reconciliation and discharge summaries. “It’s a win-win for everyone, but mostly the patient,” Modak says. “We’re closing that communication gap.”

The program also ensures patients make appointments with their primary care providers after they are discharged home. This helps reduce the readmission rate, she says.

“When we started this program, we started the model on transitions of care, a seamless handoff, and streamlined communication with patients and families across the care continuum,” Modak says. “There’s no template to population health management; it’s a Wild West out there. We’re going to fall, but we’ll fall forward, seeing what works and what doesn’t work.”

The first step was to focus on transitions, but the population health program is evolving, broadening its scope, Modak says.

“We’re maximizing our impact with data, such as who has not filled prescriptions, who has had multiple emergency department visits but not primary care provider visits,” she explains.

• Work with alternative partners. In one case, a patient visited the ED 15 times in three months, and twice was admitted to the hospital.

“Obviously, there was a lot of potential,” Modak says. “Our population health nurse is working with her to talk about what resources are out there to prevent that ED visit.”

For instance, a mobile urgent care program called Dispatch Health can visit a person’s home. Dispatch Health sends a physician assistant, nurse practitioner, or emergency medicine technician.

“We partner with them so they can make urgent care visits,” Modak says. “If the patient can’t get out and go to her own provider, we work with her to call Dispatch Health to make a visit.”

The program deploys medical help to patients who are in need but do not have the resources to visit a community provider, and do not require ED care.

Another patient did not qualify for home care, but the population health team knew the patient was at risk, and needed a smoother transition. “We called mobile health, and they made a visit to the patient the next day, doing medication reconciliation, and making sure the patient was settled at home,” Modak says. “It was a nice transition to the next level of care, and the patient did very well with an extra layer of support through the mobile health program.”

After Dispatch Health sees patients, the program continues to follow the patient, ensuring the person receives the right community resources. “We can provide the patient with high-quality, efficient care at the right place,” Modak says. “We always say that, as caregivers, our first and foremost goal is to care for our population in the most efficient way.”

Providing post-acute care and case management ensures patients will receive better, more efficient care. “You will automatically see a decrease in costs; it goes hand-in-hand,” Modak says. “There will be patients in an acute state who are high-cost, high-spend, and we need to support them.”