Initiatives reduce readmission rates

Health plan partners with hospitals, PCPs

After two successful pilot projects aimed at reducing readmission rates, Capital District Physicians' Health Plan Inc. (CDPHP) has implemented a program aimed at ensuring that its Medicare Advantage members get the care they need after discharge to avoid a return trip to the hospital.

The pilot projects produced significantly improved readmission rates, dropping from an average of 13% to 14% for members in CDPHP's Medicare Choices plan to an average of 6% to 8% for patients in the pilot, according to Kirk Panneton, MD, medical director of senior services at the Albany, NY-based health plan.

"When our Medicare members are admitted to the hospital, we partner with the hospitals and the primary care physicians and follow the patient to their home to make sure their medication is reconciled and that they get back to see their primary care physician in less than seven days," he says.

The readmission rate nationwide for beneficiaries with fee-for-service Medicare is 20%, while it's 15% on average for people who are in Medicare Advantage programs, Panneton points out.

"Right off the bat, Medicare Advantage plans touch people more effectively to keep them out of the hospital. At CDPHP, we offer more than most Medicare Advantage programs and provide more support and education to help prevent readmissions," he says.

The health plan's readmission prevention program, which began in July, "takes the best elements of both pilot programs," Panneton says.

In one pilot, the health plan placed RNs, called inpatient care coordinators, in local hospitals to assist the hospital-based case managers in coordinating care for all CDPHP members.

When a Medicare Choice member in the pilot project was going home, the inpatient care coordinator alerted the health plan's case managers, who called the primary care physician to arrange a follow-up appointment within seven days.

In the other pilot project, the health plan arranged for visiting nurses to see patients in the hospital and introduce themselves, then followed up within 24 hours after the patient was discharged. When the nurse visited these patients after discharge, he or she examined all the medications the patient was taking, evaluated the patient for care needs, and helped set up a follow-up appointment with a primary care physician.

For the pilot projects, the health plan focused on patients who received primary care at several big medical groups in the area with no regard to diagnosis.

"In the pilots, every Medicare Choice member who was chosen to participate received the services regardless of diagnosis. Going forward, we're going to provide the follow-up services for patients who can most benefit," he says.

The vast majority of Medicare members who are hospitalized have heart failure, chronic obstructive pulmonary disease, or coronary artery disease, Panneton points out.

The program focuses on patients with those three diagnoses and any others who the health plan's onsite inpatient care coordinators feel could benefit from the program.

For instance, a patient with a fractured hip may not need follow-up care unless he or she has limited support at home, has several chronic diseases, or is taking multiple medications.

The new program combines the best approaches from the two pilot programs, Panneton says.

While the new program will cover all lines of business that CDPHP serves, the majority of members served will be within its Medicare population.

Members identified for the program will be seen by a nurse in the hospital, then receive a home visit from a nurse within 24 hours of discharge.

The home visit part of the program strives to reconcile medications, ensure that care needs are being met, and schedule a follow-up appointment with the patient's primary care physician. The nurse will then conduct a follow-up call seven days later to ensure that these processes, and the patient's recovery, remain on track.

Before the pilot projects began, representatives from CDPHP met with representatives of the hospitals in their area, the visiting nurse organizations, and primary care group practices to educate them about the project's goals and to get their buy-in.

"Everybody in health care is trying to reduce readmissions, but those who are the most successful are those that are collaborating with other organizations. When the payer, the hospital, and the primary care provider come together, they are able to make a program happen," he says.

It's a win-win situation for everyone, Panneton says.

"Hospitals have an interest in reducing readmissions because they aren't going to get paid. The visiting nurse agencies are anxious to get more business. The providers are willing to participate because we are giving them extra reimbursement for seeing patients within seven days of discharge," he says.

Capital District Physicians' Health Plan was started 26 years ago by a community of physicians in the greater Albany area, according to Kevin Mowll, vice president of Medicare products.

The health plan has about 25,500 members enrolled in its Medicare Choice program, a Medicare Advantage plan. The figure includes about 8,000 retirees who are part of an employer group, Mowll says.

CDPHP expanded its Medicare case management program when Panneton, a physician with years of experience in geriatric medicine, came on board in June 2008.

"At the time, we had only one case manager dedicated to our Medicare population. As the membership has grown, we have expanded the program and now have six case managers dedicated to Medicare beneficiaries," Panneton says.

The health plan created the CDPHP Health Ally program, a voluntary case management program for the health plan's Medicare Choice members and their caregivers, Panneton says.

The program was developed specifically for the Medicare population and takes into account the unique needs of that population and provides support, education, access to the health plan's benefits, and community-based services, he adds.

The health plan makes three outreach calls to Medicare Choice members shortly after their enrollment.

When members enroll in Medicare Choice, they receive a verification call from the health plan's outreach staff to make sure they understand the plan. When they become eligible, the outreach staff call again to walk them through the benefits and ensure that they understand what benefits are available to them, Mowll says.

The third welcome call is from a case manager who completes an assessment that stratifies the members into three groups based on their likelihood of using health care services, Panneton adds.

"Our Health Ally program is designed to touch all new Medicare members by the telephone and to conduct a brief health survey," Panneton says.

Based on their response to the health survey and probability of needing health care resources, the members are referred to health plan programs that can meet their needs.

Members who are fairly healthy are referred to the health plan's SeniorFit program, a free health, exercise, and wellness program for older adults.

Seniors with one or two chronic diseases, such as a diabetic with hypertension, are referred to disease management, where they receive education on their chronic condition and how to keep it under control and are encouraged to see their physician regularly.

About 5% to 10% of beneficiaries in the program are among the most frail and sick members and are assigned a case manager, who contacts them regularly and offers support and counseling and helps them find resources to meet their needs.

"Our case management program has grown significantly, and our Health Ally program has helped us stratify the members and help them get the services they need," Panneton says.

The advantage of the Health Ally program is that CDPHP is able to identify the needs of members without waiting for claims data, Panneton point out.

"If we wait for claims to come in, we are always three to four months behind. Our program helps us find out more about the membership when they enroll and start working with them to help them avoid unnecessary hospitalizations and emergency room visits. Our case managers work with our members to help them keep their conditions under control and educate them so they can make informed decisions," he says.

"The Health Ally program was a big strategic move to meet the challenge of finding out more about the membership so we can take a proactive approach to help them manage their health care," he says.