Pay attention as patients move through the continuum
Ensure that care is coordinated
The most vulnerable patients in healthcare are those who are transitioning between levels of care, says Anne Tumlinson, senior vice president for Avalere Health, LLC, a healthcare advisory firm with headquarters in Washington, DC.
The healthcare system needs a way to ensure that, no matter how many providers treat patients after hospitalization, the care is coordinated, she says. "This makes common sense, but it’s hard to do in practice because the healthcare system is very siloed and is set up so there are no bridges between levels of care," she adds.
"Care transitions are important when patients move between levels of care because we know that this is where gaps in care may occur and patients may suffer problematic outcomes," says Elizabeth Barnett, BSN, JD, senior director of care coordination for Florida Blue, a health care insurer with headquarters in Jacksonville.
When patients transition between the acute care setting and a subacute facility, the acute hospital and home, or a subacute facility and home, it’s important for care managers to provide coordination to make sure patients understand the plan of care and that providers understand the previous episode of care, she adds. (For details on Florida Blue’s physician at home and nurse transitionist program, see subsequent article.)
"We know that patients are at risk during the first couple of days when they get home from the hospital. They may have a new disease state to learn to manage, new medications, and they need a follow-up visit with their physician," adds Claire Greco, RN, MPA, CPHM, senior manager, care management for CareOregon, a Medicaid and Medicare health plan with headquarters in Portland.
Providers and insurers should take the opportunity to provide support to patients and caregivers during the critical time just after discharge, she adds. CareOregon takes a multi-pronged approach to preventing readmissions, providing traditional telephonic post-discharge case management to at-risk patients and intensive face-to-face case management for members at highest risk. (For details, see subsequent articles.)
Patients being discharged from the hospital have to have their care managed by someone in order to avoid readmissions, Tumlinson says. "One of the biggest challenges is identifying patients who are most likely to be readmitted, engaging them, and anticipating their needs," she says.
It doesn’t matter which practice setting case managers work in, as medication reconciliation and adherence to the treatment plan are really important whether patients are transitioning from the hospital to a skilled nursing facility or rehab facility to home, Tumlinson says.
"When patients transition to home, case managers don’t always pay attention to whether they have the right support," she says. Tumlinson recommends taking the time to make sure the patients have a way to get meals, that the throw rugs have been removed from the home and grab bars installed, and that patients have transportation to the pharmacy to get their prescriptions filled and to their physician appointments.
Take time to drill down and assess patients for psycho-social issues, such as whether they can afford their medication or if the electricity was cut off while they were in the hospital. "We know that it takes more boots on the ground to manage patients than we thought in the past," she says.
Engage patients and family members early in the stay, she recommends. Case managers should have an understanding of the degree to which patients can be involved in their own care or that family members can be activated to help. Make sure that patients or family members are able to take ownership of the care process.
"People who are facing a lot of challenges in life have various degrees of motivation or abilities to solve problems on their own. Some patients may have trouble taking ownership of their own care. It’s very important for case managers to become involved with these patients and engage them in caring for themselves," she says.
Often, patients are transferred to a skilled nursing facility for rehab, then discharged to home without their primary care physician knowing the details of what happened in either setting, she adds. Case managers need to ensure that the patient’s physician is integrated into the care plan. If they are going to a skilled nursing facility, the facility staff need to know what happened in the hospital and the primary care physician should be aware of the nursing home stay.
Make sure that patients are discharged with the prescriptions they need and that the pharmacy at the receiving facility is open. "This is a huge issue, particularly for people in pain. If patients don’t have prescriptions, particularly on weekends, they may be without medication for several days," she says.
Communication is the key to good transitions, Tumlinson says. Make sure everybody involved, including the treatment team at the next level of care and the patient, is clear on what patients need to do and look for. Incorporate case management transitions into the standard of care, and make sure that what is needed for good transitions becomes part of the process of care.
Providers throughout the continuum need to get together and share information, she says. "The most effective transition programs are put in place by networking by providers who make the effort to work together," she says.
Data from Avalere’s research and a study of Medicare data shows that a typical hospital in an urban market discharges patients to an average of 50 different post-acute providers. Some large hospitals send patients to more than 130 skilled nursing facilities, she says.
"Our system is fragmented, and in order to improve care, we have to take a more coordinated and integrated approach. A case manager trying to coordinate with 130 different providers has an impossible task," she says.
Hospitals, physician offices, post-acute providers, and insurers are starting to work together and focus on care coordination across the continuum, she says. "Hospitals are just beginning to take note of who all the post-acute providers are, what services they offer, and how they perform. In the past, the focus was on lining up a bed to get patients out of the hospital. Now the incentives are changing and the focus is on the entire episode of care," she says.