CMs make multiple contacts to reduce readmissions

Health plan partners with hospitals, MDs

After a program to reduce readmissions showed positive results but not a clear downward trend in readmissions, Capital District Physicians Health Plan (CDPHP) is trying another tactic.

Instead of having home health nurses make one visit and a follow-up call to at-risk patients after discharge, the health plan is restructuring its efforts and providing intensive case management to at-risk patients for 30 days after discharge. The new program began Jan. 1, 2013.

"We think that contacting people multiple times during the month will be more effective than a one-time visit. We want to reduce readmissions first and foremost to improve quality of care," says Tracy Langlais, RN, vice president of medical affairs operations from CDPHP, based in Albany, NY.

In addition, the health plan is working closely with physicians to schedule follow-up appointments for members within seven days of discharge, as well as partnering with participating hospitals to reduce readmissions through quality incentive programs. Other initiatives include in-home visits to provide face-to-face case management on an ongoing basis for the frail elderly, performing in-hospital risk assessments to identify members with a high potential for readmission, and using community resources to supplement member benefits.

"The biggest disappointment with the program as previously designed was the large number of people who declined the home visits. So many people felt that they didn't need anyone to come into the home. In addition, the number of patients who saw their physician within seven days was not as high as we would have liked and the number of members linked to case management was also low," Langlais says.

The new program's telephonic outreach is less invasive ,and once a relationship is established, in-home services are still an option, she adds.

The original program focused on congestive heart failure, chronic obstructive pulmonary disease, and coronary artery disease. "We have expanded the program to provide the same quality of care for all our patients. We believe that there are a lot of opportunities to reduce readmissions," she says.

The health plan embedded RNs — called inpatient care coordinators — in local hospitals with a high volume of members to assist the hospital-based case managers in discharge planning for all CDPHP members. They meet with hospitalized patients and use a tool to assess the members' risk for readmission. Members whose score indicates a risk for readmission are referred to case management.

The case managers at the health plan call the members on Days 2, 7, 14, 21, and 28 after discharge to go over the discharge plan and answer any questions or concerns. They make sure the patients have gotten their prescriptions filled and understand their medication regimen, educate them on their treatment plan and the importance of following it, educate them on signs and symptoms that indicate they should call their doctor, and make sure they have a follow-up visit.

"We instituted a full court press to educate our primary care medical home practices on the importance of ensuring that patients get in see their doctor within seven days. We believe that when the physician's office makes an outreach call to set up an appointment, it's much more effective in getting the member into the practice in a timely manner, rather than leaving it to the member to set the appointment," she says. The health plan posts a daily discharge report for each practice that the staff can use to contact the members and get them an appointment.

The health plan partners with a case management firm to provide ongoing case management in the home for high-risk frail Medicare members.

"We are moving to a focus on preventing all-cause readmissions by looking at the whole person and his or her situation and history of readmissions. Younger members with multiple comorbidities or no support system, or social needs like transportation assistance, get the full program," she says.

Health plan representatives meet with hospital case management staff once a month and quarterly with the medical directors, case managers, and financial departments at the hospitals.

"We have a very good working relationship with the hospitals in our area. They are very excited about partnering with us to reduce readmissions. We are monitoring the effectiveness of the program on a monthly basis and will make additional changes if we don't see a downward trend in readmissions," she says.