By Melinda Young

A healthcare organization’s Medicare Bundled Payments for Care Improvement Advanced (BCPI Advanced) program resulted in lower hospital readmission rates.

The program reduced readmission rates from 30% to 19%, says Karen Vanaskie, DNP, CCM, ACM-RN, chief clinical officer at Innovation Care Partners in Scottsdale, AZ.

The five-year program, which started in October 2018, is scheduled to run through December 2023.

“Case management is critical in this program because the bundled payment is initiated at the hospital level,” Vanaskie explains. “When patients are admitted, on Medicare, and have a diagnosis in the bundle, case management starts that journey and lasts for 90 days.”

If the hospital miscalulates during discharge planning and sends patients to an incorrect setting, resulting in a hospital readmission, that adds to the cost of the patient’s 90 days of care, she explains.

“You have to build a program that wraps around the patient and provides a continuum of care focus, and that’s where case management is so critical,” Vanaskie says. “Case managers identify at-risk patients when they come into the hospital and then wrap the most appropriate services around them at discharge, seeing that they receive the right level of care.”

Case managers need to know how to transition patients to the best level of care for their needs.

“We do training for case managers along the continuum, and even in outpatient care,” Vanaskie says. “We bridge communication throughout the continuum, especially at handover points from hospitals to the next level of care, or from skilled nursing facilities to home health, or from home health back to the primary care provider.”

These transitions need to be handled with precision. “We built a tighter program of handoff, but call it handover of care — a gentle handover of care,” she explains. The program also provides training to the entire inpatient team, including a hospitalist and physical therapist.

“Hospitals and hospitalists have aligned risks in the event the BCPI patients should cost too much, so we work with them as a team,” Vanaskie says. “We have a tool called ‘right location’ to predict where the patient’s next level of care should be.”

As a patient’s medical situation changes, the tool’s prediction might not be accurate at the precise moment of discharge, but it is generally a critical tool in identifying risk, Vanaskie says.

“It helps us provide care at the right location when patients leave the hospital, and then it helps prevent readmissions, which would add cost to that 90-day period.”

Case managers use the tool in patient screenings. “Case managers work with the hospital team and hospitalist to make sure everyone is in agreement and can transition patients to the next care,” Vanaskie explains. “We ensure that for everyone transferring, there is a continuity of care form so we don’t miss critical pieces of information when we hand over that patient to the next level of care.”

The continuity of care form includes key information about patients’ treatments in the hospital, their medications and procedures, how long they were in the intensive care unit, and the plan of care. Transitional case managers fill out the continuity of care form on paper. It takes about 10 minutes to complete, Vanaskie says.

Everything is written on a single document so the next care team has the best information available when treating patients. Case managers review the form with the next providers. For example, they make sure intake coordinators at skilled nursing facilities understand the handover.

“Advance directives are in the continuity of care form,” Vanaskie notes. “That’s when they’re ready to leave. We want to make sure there’s the best information handed over to the next team.”

Case managers meet with patients to review the main highlights of the continuity of care form.

“The big focus is on medication and any changes to patient’s medication,” Vanaskie says. “Because we’re in a pandemic, they always go over advance directives.”

The transitional case managers work with hospital case managers, patients, and patients’ families for three to five days before discharge. They are very involved with the discharge plan, she notes.

“If we think the family is able to provide care for the patient, then we keep the primary care provider aware through the whole continuum of care, from post-acute to home with home services,” Vanaskie says. “We also help patients get to their primary care provider appointment.”

The program staffs a care coordinator in the primary care office. When home health is about to close the case, there is a discussion with the care coordinator, who helps make an appointment for the patient to meet with the primary provider.

“Then, we monitor the patient with a phone call follow-up or visit the patient, usually about 45 days after discharge,” Vanaskie says.

Since the program is financially responsible for the patient’s care for 90 days, the care coordinator’s role is important for staying on top of how that patient is doing, she adds. The transitional case management team also follows patients into the skilled nursing facility or acute rehabilitation care settings. They check up on the patients either virtually or in person, when it is safe. They attend all the patient care conferences.

“We only send patients to our preferred provider skilled nursing facilities,” Vanaskie says. “It’s key that you trust the performance of the next site of care. If they are a poor performer and have a lot of readmissions, it will impact the BCPI performance. We send patients to post-acute settings we know have high quality and lower readmissions.”

If a post-acute care provider’s performance is subpar, they are put on an action plan. Their next quarter’s data are assessed for signs of improvement.

“We have 26 preferred provider skilled nursing facilities, so we do have quite a few choices. We placed them strategically around all six of our hospitals,” Vanaskie says. “When we meet with patients, we explain that we monitor the skilled nursing facility’s quality, and so we feel confident in sending them to these post-acute providers.”

In some cases, patients who have been discharged home cannot visit their primary care provider’s office. The program employs a nurse practitioner and paramedic who can visit as part of post-acute mobile care, she notes.

“They have equipment and can do labs, breathing treatments, IVs, and medicine — like a mobile urgent care,” Vanaskie explains. “What we don’t want is for people to go back to the hospital unnecessarily, and a lot of patients don’t want to go to the hospital. It’s the last place they want to go, and Medicare pays for mobile care — like a home treatment.”