Care coordination cuts admissions, ED visits, LOS

Complex patients are the target

Gundersen Health’s integrated care coordination program, in which a team of RN care coordinators and social workers follows the 1% to 2% most complex patients through the continuum, has resulted in a 46% decrease in average length of stay and a 64% decrease in unplanned hospital admissions or emergency department visits.

The program, which has coordinated care for more than 15,000 patients since it began in 2003, also generated a 60% drop in total charges over a two-year period among patients who were enrolled in the program for at least 24 months. The program costs about $141 per patient per month.

The health system, based in La Crosse, WI, is a partnership between Gundersen Hospital and Gundersen Clinic and includes a 325-bed hospital with a Level II trauma center, and 35 outpatient clinics.

The program began as a pilot project in 2003 and now provides care coordination for about 1,500 to 1,700 patients at a time.

“We saw the opportunity to provide higher-quality, more cost-effective care for patients with complex healthcare needs and enhance their quality of life at the same time,” says Beth Smith-Houskamp, RN, PhD, Gundersen Health’s executive director of patient and family centered care.

The care coordination staff includes 19 care coordinators, all nurses, three social workers and one FTE administrative support position. The nurses have an average of 27 years of experience in sub-specialty areas such as pediatrics, hematology, oncology, high-risk obstetrics, palliative care, and medical-surgical care. Each care coordinator is responsible for 50 to 75 patients, and each social worker is assigned to about 100 patients.

Patients are identified for the program using a two-pronged screening tool that takes into account the need for clinical care and psychosocial assistance. “We added the psycho-social component because we know that often patients’ ability to manage their care is affected by their psycho-social needs,” she says.

Patients who have had a 14-day hospital stay, returned to the hospital within 30 days after discharge, or incurred costs of $100,000 or more are automatically referred for care coordination.

“Many patients are referred to the program because of a hospital stay, but that’s not the only way to get into the program. We have a fully integrated electronic medical record that any Gundersen staff member can use to refer patients to the program from anywhere in the continuum,” Smith-Houskamp says.

Reasons for referrals include multiple diseases, multiple inpatient admissions or emergency department visits, medication management issues, lack of social support, financial issues or cognitive deficits. Some patients see multiple healthcare providers and/or have non-medical problems that impede care. The program coordinates care for eligible patients from birth until death. Many of the patients in the program are Medicare beneficiaries, but the care coordinators also work with pediatric patients, women with high-risk pregnancies, and behavioral health patients. Patients with any insurance payer are eligible for the program.

The care coordinators complete an evaluation on hospitalized patients within one business day of referral and within two weeks for those who are referred as outpatients.

Once patients are enrolled in the program, the care coordinators assess the patients’ ability to manage their healthcare needs, their support system, and complexity of needs to determine if patients need active care coordination or if they should monitor the patient but not provide interventions. “If the care coordinators don’t perceive that hospital patients will need coordination after discharge, they monitor them during the hospital stay and review the situation until the patient is discharged,” Smith-Houskamp says. The nurses also monitor high-risk patients after discharge to ensure their transition to a lower level of care has been successful.

The care coordinators interact with patients face to face while they are in the hospital and during clinic appointments and follow up by telephone and e-mail.

When patients are in the hospital, the care coordinators work closely with the inpatient care team to assist with planning for discharge and follow-up care and to assess their readiness and motivation to manage their own care in order to make sure the discharge is successful. They participate in care conferences between the hospital staff and patients and family members.

They make sure patients understand their medication regimen and have a timely follow-up appointment with their primary care physician and accompany them on their first outpatient visit to ensure continuity of care. They meet with patients receiving care as outpatients before or after provider visits and continue following them as long as needed.

The care coordinators educate patients on their conditions, their treatment plans, and what to do if they have symptoms or signs that indicate their conditions are getting worse. The health system’s electronic medical record alerts the care coordinators when patients have planned or unplanned visits to a primary care provider, visit the emergency department, or are hospitalized. The care coordinator informs the emergency department physician or the primary care provider about what has been going on with the patient.

The care coordinators and social workers may work with patients for a year or longer. Often the care coordinators are the first to identify subtle changes in the patient’s condition and alert the primary care provider, Smith-Houskamp says.

Social workers partner with the care coordinators to help identify and connect patients with community resources. The social workers provide a variety of assistance, including assisting patients in obtaining necessary medical equipment, arranging transportation to medical appointments, or helping them sign up for assistance with their prescriptions.

“This team-based approach to coordinated care improves the quality of life and reduces the cost burden of patients with complex health conditions,” Smith-Houskamp says.