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Your Provider Roadmap to Success: Transitions in Care

Healthcare

This is the fourth in a series of Silverline POV’s focused on helping healthcare organizations, as providers of healthcare services to patients, be successful in five key areas as healthcare reimbursement models shift from fee for service to fee for value. Each one is focused on how to leverage the Salesforce platform and effectively navigate patients on their healthcare journey. These POV’s are based on my twenty years’ experience in healthcare and twelve years experience creating and operationalizing patient journeys utilizing Salesforce for large healthcare systems in Texas and Colorado at the physician group, clinically integrated network (CIN) and healthcare system levels.

Here are five areas we are exploring:

  1. Provider Relationship Management
  2. Consumer & Patient Engagement
  3. Ambulatory Care Coordination
  4. Transitions in Care
  5. Specialty Care Coordination

We will view these opportunities in the context of using Salesforce and leveraging Silverline’s suite of solutions and accelerators.

Transitions in Care

The transition of a patient from one healthcare treatment setting to another is typically called care transitions or transitional care management.  Common transitions include Emergency Department or Acute Inpatient stay to home.  However, many patients require a carefully scripted “step-down” care transition from an acute stay to skilled nursing, then to outpatient rehabilitation or home health.  These transitions are often initiated by a case manager in the inpatient setting, but once the patient leaves the hospital, there’s little contact or follow-up post-discharge.

That’s the crux of the problem.  Nearly one in five Medicare patients discharged from a hospital—approximately 2.6 million seniors—are readmitted within 30 days, at a cost of over $26 billion every year.  While hospitals have traditionally served as the focal point for initiatives to reduce readmissions, it’s clear that there are multiple factors that impact readmissions involving downstream providers the patient’s return to health and home.

The key components in developing a successful Care Transitions Program include the following:

  1. Begin discharge planning before the patient is admitted
    • Obviously, this is not possible in all cases, but when the inpatient stay is planned, assess the patient’s familiarity with the procedure and follow-up care
    • Assess for barriers to care and amount of support the patient will have as they transition to home
    • Discover patient education opportunities such as never having anesthesia before or what to expect in a hospital stay
  2. Coordinate with case manager during inpatient stay
    • Identify issues for early intervention
    • Seamless handoff from case manager to care coordinator
  3. Reinforce discharge plan and instructions
    • Most patients do not remember discharge instructions given at the hospital or Emergency department in the rush to vacate the room and arrange for transportation
    • If transitioning to another care setting, educate the patient about what to expect
  4. Medication Reconciliation
    • Many patients will leave the hospital with new prescriptions for medications
    • It’s important to review all medications the patient is taking as prescribed by hospital providers, PCP and specialists
    • All providers may not share an EHR, so it’s important to provide this information to all care providers
  5. Develop and implement a follow-up/outreach plan
    • This can include a series of phone calls and assessments, virtual visits, remote monitoring devices or visits to healthcare settings such as skilled nursing facilities or long-term care centers.
    • Typically, nurses would perform nurse triage, based on reported symptoms, to determine early intervention steps such as a change in medication or scheduling a home health or physician visit

Medicare is driving many of the changes in managing care transitions.  The Affordable Care Act (ACA) created a Community Based Transitions Program (CCTP) which utilizes community-based organizations (CBO’s) to manage transitions for high-risk Medicare patients to improve the quality of care and prevent readmissions.  Medicare also created CPT codes and a fee schedule to reimburse providers (usually PCP’s) for transition care management (TCM) services.  This is a huge opportunity for physician groups to improve the quality of care for patients being discharged from the emergency department or hospital while receiving additional compensation.  Many organizations are using a centralized model and the Salesforce platform to manage these transitions in care.  Here are the requirements to bill for TCM services:

  1. The healthcare provider is a physician (any specialty) or a non-physician practitioner (NPP) such as Certified nurse-midwives (CNMs), Clinical nurse specialists (CNSs), Nurse practitioners (NPs), or Physician assistants (PAs).
  2. The healthcare provider accepts care of the beneficiary post-discharge from the facility setting without a gap and takes responsibility for the beneficiary’s care.
  3. The beneficiary has medical and/or psychosocial problems that require moderate or high complexity medical decision making.
  4. The 30-day TCM period begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days.

Many of the services for TCM are performed by the healthcare provider such as the mandatory face-to-face visit, reviewing discharge information and determining the need for additional testing and treatment. However, there is a significant role for clinical staff, such as an RN Care Coordinator, to impact the quality of care and prevent readmissions.  These services can be provided via telephone, email or face-to-face.  The following services can be managed in a remote or call center setting by dedicated nurses:

  1. An interactive contact must be made with the beneficiary and/or caregiver, as appropriate, within 2 business days following the beneficiary’s discharge to the community setting can be made by clinical staff who have the capacity for prompt interactive communication addressing patient status and needs beyond scheduling follow-up care.
  2. Communicate with agencies and community services the beneficiary uses.
  3. Provide education to the beneficiary, family, guardian, and/or caretaker to support self-management, independent living, and activities of daily living.
  4. Assess and support treatment regimen adherence and medication management.
  5. Identify available community and health resources.
  6. Assist the beneficiary and/or family in accessing needed care and services.

These services require access to a robust database of providers, facilities, services and community-based organizations to effectively manage the care transition following the 30 day TCM period,

  • Manage Acute Care Discharges: Coordinate the acute care (hospital) to home care journey for patients needing additional care settings post-hospital stay
  • Transition Care Management: Satisfy requirements for Medicare’s transition care management (TCM) program
  • Engage via Communities: Create pre-procedure and post-procedure pathways and workflows via patient communities
  • Prevent Readmissions: Provide nurse triage, education, and support to patients and caregivers through to prevent readmissions
  • Step-down Care Management: Manage transition services roadmap: Acute Care > Skilled Nursing > Rehabilitation > Home Health
  • Compliance Measures: Track interventions and compliance with Medicare Episode-based Payment Initiatives

In summary, Silverline, with its care coordination solutions and accelerators, can provide a framework for managing transitions in care and referrals to step-down care settings. You can engage patients and caregivers via communities to create pre and post procedure pathways and workflows.  Track quality and compliance by customizing reports and dashboards to meet program requirements.  Integrate your patient contact center to provide 24/7 support for your TCM patients.  Wherever you start, Silverline has the tools and the experience to help you be successful.

Download the Provider Roadmap to Success ebook to see how the five key areas come together to improve care and reduce costs.

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