It Pays to Reduce Preventable Readmissions Now: A Discussion of Return on Investment

Author: Eric Tate -  Director of Sales, Care Team Connect

Care Team Connect helps you transform healthcare today by answering two questions:

  • What’s the secret to sustaining viability during the transition required by healthcare reform?
  • Where’s the ROI in reducing preventable readmissions now?

Patients first – My grandmother called it the will to live. And she had it. You know the kind. Research shows patient activation stands alone as the critical success factor in managing high-risk, chronic conditions. The best environment to establish patient activation is created when the patient can focus on necessary course corrections and passionate care professionals are front and center with the patient. There are exceptions, but the distractions of a busy hospital often get in the way. Conviction for change happens in the home, in the community and in ambulatory settings that become familiar and safe. The challenge, of course, is funding this interaction between your team and the patient in an era of narrow and declining operating margins.

Real change – You must think differently to transform the organization. Act now to sustain this change by extending interaction after discharge. Commit to coordinate care between the patient and the care team member. Provide the infrastructure to simplify effort to communicate and coordinate care. With proactive efforts, you enable interactions when the patient has the energy to match the will of prepared care team members. The activation that results often builds loyalty to the care team and the ambulatory services they recommended.  If you guide the patient with a longitudinal care plan that leverages the employed physician office, the profitable clinic and available diagnostic testing capacity, you will maintain the margins necessary to provide care in the communities you serve. Care Team Connect makes the care team productive, enabling you to reach more patients after discharge. Here’s a way to look at the numbers so the initiative to coordinate care carries a strong Return on Investment (ROI).

Work the numbers – To make the math work, reframe the numbers. No matter if you begin with a goal of defending against readmission penalties in the near term or playing offense to become an Accountable Care Organization, you must elevate perspective. If you are reading this, you are familiar with the immediate objection: “By managing chronic conditions, we might manage to go out of business.” Get past the “heads in beds” question. Consider the financial impact care coordination brings to the whole health system, not just one operating division. Then, make sure your investments position your care team in direct contact with the patient.

Igniting health system performance is your offensive strategy – We know that accountable care promises to lower costs by avoiding service duplication and moving the provision of care to lower cost settings. What is less certain is the ability to build the ongoing relationship with a patient so the services are provided within your ambulatory network, by your employed physicians, engaging your excess diagnostic capacities. When determining the impact of the changes you seek, consider the impact meaningful interaction with patients will have on their decisions to access your health system. Calculate the impact of improved loyalty and preemptive care.

Begin with the concession – Your analysis will have more impact with a balanced approach. Care coordination for high risk patients is certain to improve readmission rates. Care coordination of a broader population might prevent admissions as well, but is likely to drive the remaining inpatient activity to your hospital. All said, you should work to calculate the reduction in top-line hospital revenue.   Work from a basis of cases discharged and population managed. Assess the readmission or admission rate in your target population. Set your stretch goal for the incremental rate of improvement and determine your readmissions or admissions avoided each year. What is meaningful for your analysis, however, is the amount of operating income these cases provide. Common MS-DRGs are meaningful guides, but remember care coordination makes the biggest improvement in complex cases common in returning high risk patients. Adjust your estimates of payment and cost for these avoided admissions by applying a factor to the average. Experience tells us the complex cases we will avoid are unpleasant visits for the patient and unprofitable experiences for the hospital. Remember, the objection might be grounded in the revenue, but your attention belongs on the bottom line.

The upside – Fewer admissions will create capacity. For some hospitals, this eliminates bottlenecks in the ICU or Med-Surg units and makes room for more profitable services. Other hospitals can accelerate preparation to deliver accountable care and prepare for value-based purchasing. Consider the positive impact of redirecting staffing to navigation services, clinics, ambulatory sites and employed physician offices. Quality improvements create capacity for profitable admissions and, more importantly, income in other parts of the health system. That’s the point. Care coordination will increase the patient’s compliance with follow-up physician appointments and increase visits to employed physician offices. Each physician office visit generates income. Expect physician office visits to create ancillary test or procedure income from otherwise idle capacity. Closer interaction with the patient after their return home is likely to lead your care team to conclude that more patients qualify for home care, another profitable, lower-cost setting of care. Once patients know someone cares and become activated, they will work with you to visit your profit-generating clinic more often. It all adds up.

Uncompensated care – Remember what happens in the absence of meaningful care coordination. Commonly, the medically underserved and the uninsured avoid low cost options for care and defer the visit to the health system until costs are greater. You will find many who accept this observation.  Now run the numbers to quantify the financial consequence to the organization’s bottom line. Effective care coordination will prevent ED visits. Most patients have insurance for these marginally profitable encounters. But the few that have no insurance create uncompensated care at much greater expense. All told, the expense of uncompensated care exceeds the income from those who can pay. Your mission is to heal the community. Keeping the ED open is just one part of that. Another hidden cost surfaces long after discharge: bad debt. It is real to the leaders of the revenue cycle. Make it part of your analysis. By following every patient, we will sometimes prevent readmissions from some who have no insurance. Other accounts are simply uncollectible. In this economy, a solid analysis accounts for the bad debt expense of unfunded care. Calculate the readmissions avoided, multiply by the MS-DRG payment and then multiply again by uncollectible percentage. This is direct improvement to the bottom line.

Penalty Avoidance is your defensive strategy – When the Board asks the CFO next summer how much is on the line next October, what will they say? Imagine this scenario:

“Well, the penalties of the Hospital Readmissions Reduction Program established under the Patient Protection and Affordable Care Act of 2010 weren’t defined until 2012, so I have bad news. The hospital will lose a significant amount. To put it in perspective, the penalties will be greater than our operating margin in three of the last ten years. We were reasonably comfortable with early estimates. Industry pundits determined the average hospital would lose less than $100,000 per year. And, our readmission results were better than average. Fact is, the distribution of readmission rates is narrow. The difference between the best and the worst is separated by the readmission of one or two patients each month. One day you’re the best, the next you’re in the bottom quartile. That’s where we are now, at the bottom. It will take us a year to start seeing improvement and another year to begin moving the three year average these penalties are based upon. Brace the organization for sustained pain.”

Unacceptable, you say? Then start your care coordination program now. You’ll want to know exactly what to do to affect readmission rates when penalties are on the line. Light a fire by calculating the amount at risk. This will become the compelling reason for the defensive strategy we discussed. Here’s a simple way to run the numbers. Start with a trip to the HHS Hospital Compare site.

Find your hospital – Drill into the Outcomes of Care data. Explore the readmission rate graphs. If the band of your results for any one of the three conditions reaches above the national average, your organization is in harm’s way.

Estimate your financial risk – Plan for the lesser of two penalties, calculated by two methods. The larger number is easier to calculate. Method One, the “penalty cap”:  Multiply your Base Operating DRG Amount by 1% in the fiscal year beginning October 2012. Raise it to 2% a year later and 3% beyond that. This is your maximum penalty each year. You can find the amount of all CMS reimbursements several places. Your hospital’s annual report and the American Hospital Directory are two places to look. If you can’t find it, call me. Method Two, the “excess payment”:  Compare your readmission rate to the national average. If you are higher than average, you have three numbers to multiply to calculate the excess payment:

  1. The percentage you exceed the average
  2. The average amount of your reimbursement
  3. The number of cases

If the national average is 20% and your average is 22%, you are 10% off the mark. That’s 10% of the average, not a 2% difference. This is an important distinction to CMS. They believe your health system was paid 10% too much. How much is that? Easy. Next find the average amount you are paid for the MS-DRG. Again, AHD or MedPAR reports have it. Or, contact me. Take the average payment multiplied by the percentage you exceed the average. Then, use the same sources to find how many times you discharged a patient with this diagnosis. Multiply again and you have the excess payment. Remember to add all the conditions together before comparing the total to the penalty cap. Several hundred hospitals are at risk for one condition, dozens are at risk for two and only a handful should expect penalties for all three.

Bottom line – To get the math right, you must think broadly. To affect the patient, you must interact. To sustain interaction, you must coordinate care across the continuum with a meaningful plan. Look to Care Team Connect to guide those interactions with a platform to communicate and coordinate care. Your care team will reach more patients. Your patients will touch more of your care continuum. Your health system will evolve and grow.

About the Author

Eric has worked more than two decades in the healthcare industry, founding the financial analysis necessary to support innovative healthcare information technology investments. Among his contributions, Eric accelerated adoption of one of the industry’s most popular and transformative remote computing solutions and made possible the opening of the nation’s second digital hospital. Eric studied at The Leonard Davis Institute of Health Economics, Penn’s center for research, policy analysis, and education in health systems, while earning his MBA in Finance and Marketing at The Wharton School of the University of Pennsylvania. He first joined HFMA in 1990 and earned a BA in Economics at DePauw University.

September 29, 2011 – 8:42 pm Categories: bundled payments, Health Care Reform, Transitions of Care and Home Care, Uncategorized | Post a comment

For Good or For Now: A Brief Discussion of the Medicare Spending Growth Slowdown

Author: Bill Brody

There has been some buzz recently about the altogether-welcome-but slightly-surprising slowdown in Medicare Spending Growth. Peter Orszag mentioned it here yesterday, and referenced an earlier discussion of it by Maggie Mahar on her HealthBeat blog here. Ms. Mahar even goes so far as to say in her opening paragraph that this deceleration is “eye-popping.”

Based largely upon the conversations we are engaged in I cannot say I am truly surprised by this. Our team is taking calls here every day from hospitals, health care systems, home health and home care agencies and other care providers looking to stay ahead of the curve when it comes to providing better, more effective care. Recently we attended the Cross-Setting Collaboration Summit here in Chicago, where we spoke with plenty of folks with titles like Care Navigator and Transition Coach. A year ago I don’t remember meeting a single person at a similar show sponsored by the ACMA with a title like that.

Clearly the penalties set to hit in 2013 as a result of the Affordable Care Act are casting a long shadow. But, instead of passively waiting and bracing themselves for the impact, hospitals are using this benchmarking period to examine their operations and look for ways to improve. Clearly the concept of care coordination is getting a lot of attention, as evidenced by the personnel changes and FTEs being put into place to navigate discharge and help patients transition smoothly.

As the slowdown in Medicare spending growth indicates, when hospitals put their minds to it, they can make a difference. But it’s not just their minds they are putting to it. As a recent study published in the Archives of Internal Medicine by researchers at Baylor Health, hospitals are forced to face the reality that successful care transition programs require additional capital resources. In today’s environment, preventing readmissions impacts revenue, and, of course, hiring those Care Navigators and Transition Coaches costs money. Once effective care coordination programs are in place they can be resource-intensive, often requiring multiple home visits and phone calls.

Naturally, too, hospitals are starting small, and engaging patients has proven to be difficult (another conclusion of the Baylor study). It follows then that expenses will ratchet up as hospitals look to take the success they are having and expand to more patients and other diagnoses.

To recap then, we have a slowdown in Medicare Spending Growth over the last 18 months as evidence that hospitals are proving the old adage that “what you measure will improve.” But even before any penalties hypothetically hit, these improvements come with a high cost, and that cost will surely rise as care coordination programs scale. This is the quandary faced by Ken Davis as outlined by Orszag. Taken to the extreme, hospitals can better care themselves right into difficult financial straits.

Presuming the looming penalties are a given, the most important variable here has to do with the amount of resources necessary to successfully achieve better outcomes. This is what hospitals will have to keep under control. Making the right decisions with regards to the proper personnel is crucial; equally crucial will be the IT investment. The right software platform standardizes protocols, integrates cleanly with legacy IT and helps one Transition Coach do the work of ten, or twenty, or a hundred. Only then can the financial piece start to come more into balance.

August 29, 2011 – 4:31 pm Categories: bundled payments, Health Care Reform, Transitions of Care and Home Care, Uncategorized | Post a comment

The Mysteries of Pittsburgh: Highmark’s Interesting Gamble

Author: Bill Brody

I love it when the phrase “Move away from traditional models,” appears in a health care article. It keeps me reading. After all, who wants to read about the same old, same old. It’s great to see people taking chances. It tacitly implies that the system is broken and that hey, we’re not going to just passively sit around and do nothing about it.

Yesterday’s Wall Street Journal article “Insurer’s Cost-Cut Plan: Buy Hospitals” certainly made the rounds in our offices, as it was such a startling comingling of business interest, patient interest and provider interest. The article details the financial transaction between Highmark, a non-profit insurer with 3.1 million members, and the West Penn Allegheny Health System, the area’s second largest health system behind UPMC. Highmark acquired West Penn, essentially keeping it afloat , and now intends to run the five hospitals in the system by offering incentives to deliver effective and efficient care to the doctors it will now directly employ.

The deal, which still requires state and federal approval, is an incredible “put your money where your mouth is” moment for Highmark. Consider the following complexities:

-West Penn is already $800 million in the red, and lost an estimated $22 million 1st quarter.

-West Penn’s chief competition, UPMC, has already come out against the deal, and is publicly on record as saying they will not renew their contract with Highmark.

-The newly christened Highmark-West Penn will have to wage a public relations battle to keep their patients and attract new ones, as the public generally believes that more care equals better care and that works against the new message of efficiency and elimination of excess testing etc. that will certainly be preached by a payer/provider hybrid.

-Rival insurers may not be so inclined to negotiate agreements with West Penn now that they are in bed with Highmark.

Add these all up and you can see the tremendous drama that bears following here. But we salute the stand taken by Highmark, and the gamble they have made that there are better models of care out there. Reading this story I was reminded of what happened when Bill Murray and his merry band of Ghostbusters crossed their streams. They both destroyed and saved the city. This crossing of streams in Pittsburgh will destroy a model, and only time will tell what, if anything, will be saved.

How do you see this playing out? We’d love to hear your thoughts on this payer/provider twist? Go ahead and leave us a comment.

Please also register for our free webinar on July 28, where we are turning the microphones over to our clients so that they can discuss Case Examples of Care Coordination Programs in Practice Today. You can register right here.

June 30, 2011 – 5:04 pm Categories: Health Care Reform, Transitions of Care and Home Care, Uncategorized | Comments (1)

Top Five: Reasons Why Having a Pharmacist on Your Care Team is a Good Idea

Ed. Note: This is the fourth in a series of posts that will discuss and share best practices related to transitions of care and preventing readmissions utilizing an easy-to-follow Top 5 format. Please check back weekly for updates, or follow us on Twitter at http://twitter.com/careteamconnect to be notified when new entries are published.

Author: Bill Brody

The recent launch of Partnership for Patients is the latest example of what has become a recurring theme in healthcare: Better Care, Lower Costs. A central tenet of these conversations is the interwoven relationship between hospital readmissions and adverse drug effects (ADEs), and the tremendous cost both in human and financial terms. In February 2011, NEHI (New England Health Care Institute) issued a health policy paper that identified $21 billion in health care costs associated with medication errors in both the outpatient and inpatient care and $25 billion in hospital readmissions.  Nearly 8 million Americans were significantly impacted by what essentially boils down to poor medication management in the inpatient, outpatient and transitions of care environment.

Today, in a familiar format, we are taking a closer look at the important role pharmacists play in patient follow up, patient safety and reducing the cost to care while improving outcomes, and why they should be an irreplaceable member on any solid care team.

1. Better living through chemistry – I didn’t pull numbers on this (although if I turn some up subsequently I will link them in) but asserting that a very high percentage of patients discharged from the hospital are in possession of at least one new or changed prescription seems like a safe statement. And a new prescription means a new regimen means new potential for adverse drug effects. En masse. Pharmacists kept busy filling all of these prescriptions also need to be on alert for contraindications.

2. Something for everyone – Often times patients lack the means to pay for the medications required to treat their chronic condition. With polypharmacy becoming increasingly more prevalent it follows that the risk of non-compliance due to socioeconomic factors rises as well. A pharmacist following up with a patient can assess this situation and offer options, such as a less costly generic alternative. By engaging a pharmacist as the point person on medication, these kinds of factors are no longer such great obstacles.

3. No habla farmacia – Translation: “I can’t understand the complex instructions you are putting in front of me in good times, let alone immediately after a traumatic experience.” It wouldn’t surprise me if patients viewed selecting the right medications from their crowded medicine cabinet much in the same way an amateur crime fighter would view defusing a bomb. “If I pull out the red one, what will happen?” Pharmacists following up with patients are well-positioned to answer any medication questions that emerge post discharge, when the patient has attempted to return to a semblance of normalcy and routine.

4. Out with the old, in with the hospital – In medication regimens, much as in life, our pasts come back to haunt us. Patients on one type of medication prior to hospitalization need to have their history considered when new medications are prescribed. Unfortunately, this is often compromised. Med reconciliation based on inaccurate or incomplete information happens too frequently, with ADEs frequently the result. Pharmacists are specially trained to evaluate the potential for adverse drug interactions, so giving them omniscience over a patient’s prescriptions helps combat this. Pharmacists also may have access to a community pharmacy record and/or have the time to walk through all the medications in a patient’s possession, either in person or over the phone. This is especially important in today’s day and age of siloed care, where a patient may see a large number of doctors in a given treatment period. Pharmacists oftentimes end up the links in a chain of care.

5. Pencils have erasers, people do not – Sooner or later all of us will require medical attention, and when we do, most of us place our faith in doctors and hospitals to be a solution to our health problems, not an exacerbation of them. Covering skyrocketing costs has been done to death, but it’s important to make a distinction between the costs incurred treating patients (inevitable) and the costs incurred performing damage control. The aforementioned NEHI study identified at least $21 billion in damage control, and probably more depending on how you feel about the readmissions figures. To a program (CMS) spiraling towards insolvency that’s a huge deal. Greater pharmacist involvement can only dramatically chip away at that number.

In the coming months we anticipate that more and more thought leaders will come to see pharmacists as indispensable members of the care team, and community initiatives already underway will start to incorporate both local pharmacies and the large chains into their careful planning for the future.

How about you? Any examples of pharmacists playing a crucial role in care transitions in your community? We’d love to hear from you on this or anything else related to care coordination. Drop us a comment below and we will be in touch.

Please also register for our free webinar on July 28, where we are turning the microphones over to our clients so that they can discuss Case Examples of Care Coordination Programs in Practice Today. You can register right here.

June 21, 2011 – 3:08 pm Categories: Uncategorized | Post a comment

Sound Off on ACOs

Please check back weekly for updates, or follow us on Twitter at http://twitter.com/careteamconnect to be notified when new entries are published.

Author: Bill Brody

June 6th marked the deadline for health care providers to respond to the government’s ACO proposals, however many interested parties did not wait until the last minute to do so. Under the headline “Health-Care Initiative Draws Fire” on Friday, the Wall Street Journal summarized the responses of prominent industry association leaders, among others, to the government’s outline for how ACOs need to be structured and set up. To their credit, the government essentially treated this first proposal as a rough draft, accepting feedback on the rules and notifying folks that their criticisms are being heard and will be reflected in a final rule. This is a good thing, because folks are not being shy.

The negative feedback essentially clusters itself into a few different categories, which can be pretty easily summarized.

1. Barriers to entry – lots of folks feel the requirements to apply for ACO status are too hard to fulfill, and that until the application process is made simpler, a lot of entities won’t bother. As the MGMA put it in their open letter to Dr. Berwick, “The complexity of the program has already established a bias against participation.” Well said, doctors.

2. Too much risk and not enough (cash) incentive – Start-up costs and first year operating costs have been estimated at approximately $1.8 million, with the shared savings realized after a savings threshold is met. That’s either too much risk or not enough incentive for a lot of communities to do this. The flipside, of course, is that any and all losses can be shared as well.

3. Who will we be treating? – Questions of how patients will be assigned work are giving folks pause. Again, the MGMA said it best: “It is very difficult to coordinate and manage care for a patient population which you can only identify in hindsight. It is equally difficult to assess the financial risk/reward equation for an unknown group of patients.” There’s also some colorful language about factors such as snowbirds and former patients, all around the same theme.

4. Regulatory concerns – When the DOJ and the FTC were debating about which agency was going to have jurisdiction over governing ACOS we knew that things were getting closer. Alas, some of the regulatory conflicts have put folks off as well.

Now that the deadline for feedback has passed, I am sure HHS will go back to the drawing board a bit, taking to heart the (largely) constructive criticism they received. Perhaps the final rule will be more palatable for groups who really do want to support this endeavor, but only if it makes sense.

We’d love to hear what you think about all of this. Are the rules as proposed a deterrent to you? Still a believer in this new structure? Please drop us a comment down below.

To learn more about how Care Team Connect is helping hospitals reduce preventable readmissions and improve patient outcomes, please click here and we will be in touch. Please also keep an eye on our website for future webinar announcements.

June 7, 2011 – 7:38 pm Categories: Uncategorized | Post a comment

Top 5: Reasons that Wellpoint’s New Reimbursement Model is Worth Championing

Ed. Note: This is the third in a series of posts that will discuss and share best practices related to transitions of care and preventing readmissions utilizing an easy-to-follow Top 5 format. Please check back weekly for updates, or follow us on Twitter at http://twitter.com/careteamconnect to be notified when new entries are published.

Author: Bill Brody

A few weeks ago we tweeted our appreciation for Wellpoint’s news release describing its plan to reimburse hospitals based on quality, and not quantity, of care. Just because we were not surprised does not mean the announcement was not noteworthy. Feeling very strongly that 140 characters was not enough, we filed the news away until time permitted us to explore this a little further. In keeping with our running series here, below please find five reasons why we think Wellpoint’s moxie should be celebrated and imitated by other leading payer groups.

  1. Now, change has arrived – Depending on how you feel about Obama, the word change is either cringe worthy or nostalgic. Either way, change resided in the past. Until now. The government’s health reform bill kicked the door open, but nobody knew how long it would be until the private sector walked through. Now we know they were practically holding hands. And with the government and the payers both insisting that hospital payments be tied to quality and not quantity of care, well, let’s just say it’s difficult to see how this gets walked back.
  2. Hey, what about the Patients? – In keeping with the Partnership for Patients, also announced last month, Wellpoint’s evaluation inextricably links patient safety, quality of care, and readmission prevention. It’s been interesting to watch the scope of the conversation, which initially focused primarily on the financial aspects of reducing preventable readmissions, grow to include the patient as well. Now the best initiatives and tools are designed to prevent readmissions, increase patient safety and improve quality of outcomes. All three have come to be viewed as inextricably linked, which of course is the only humane way to look at things. It seems nonsensical to even write this, but patients are now also increasingly being included in their own care, a refreshing change of approach for those inclined towards common sense.
  3. Winter wonderland comes to health care – Not every payer has the clout to do what Wellpoint did, but expect things to snowball from here to include smaller payers following the path trail blazed by Wellpoint through the trees. How quickly this becomes an avalanche probably depends on when contracts come up for renew. Here in Illinois Blue Cross/Blue Shield has a pilot program in the works. Judging by the questions from the hospitals on the introductory call, there is way more fear of change than acknowledgement that this is a positive development.
  4. The Greater Good – The motives of WellPoint have come into question from folks who think this is just a way to improve their bottom line. It’s a valid argument, of course, although kind of an unnecessary one. What Wellpoint is demanding from their hospitals benefits everyone involved, even if in the short term hospitals feel a bit of growing pains as their four walls are gradually removed and they stretch their arms. It’s the all-too-rare instance of corporate good aligning with societal good, and should be celebrated as such.
  5. Reframing the conversation – HHS’s language has centered on readmission penalties and punishing those hospitals falling into the bottom quartile. Wellpoint’s announcement chose to frame the situation more positively, describing the manner in which rewards would be doled out as positive reinforcement for successful hospitals. It’s a refreshing and welcome change.

Surely Wellpoint will not be the last payer to expect more from their hospital partners. As the popular business sentiment goes, “If you can measure it, you can improve it.” Hopefully the benefits of this approach will be felt by all, and sooner rather than later.

To learn more about how Care Team Connect is helping hospitals reduce preventable readmissions and improve patient outcomes, please click here and we will be in touch. Please also keep an eye on our website for future webinar announcements.

June 2, 2011 – 9:05 pm Categories: Uncategorized | Post a comment

Top 5: Things We Learned by Surveying You

Ed. Note: This is the second in a series of posts that will discuss and share best practices related to transitions of care and preventing readmissions utilizing an easy-to-follow Top 5 format. Please check back weekly for updates, or follow us on Twitter at http://twitter.com/careteamconnect to be notified when new entries are published.

Author: Carrie Kozlowski, OT, MBA

In preparation for the launch of our webinar series we created and distributed an online survey in early February to a list of over 11,000 names. The survey was designed to gather information on the current state of affairs with regards to readmission prevention. Two hundred and thirty responses later we had on our hands a veritable treasure trove of data, and the responses we collected allowed us to build a dynamic, informative webinar (click here to request a recording) as well as taught us quite a bit about the collective state of the health care industry in the face of this massive sea change.

Over 75% of our respondents came from a clinical setting, and their answers served to illustrate how early-stage the conversations surrounding reducing preventable readmissions are in the vast majority of locations. Indeed, the data we collected conclusively supported the importance of and need for a care coordination hub like CTC.

Clearly evident in the data were a number of trends, the top five of which we present to you below:

1) When it comes to the chief causes for preventable readmissions, in your opinion the problem begins after the hospitalization.

Hospitals overwhelmingly identified the chief causes of readmissions to be related to patient’s poor self-management skills, patient non-compliance and poor post-discharge care coordination. This effectively shifts our focus on reducing preventable readmissions to beyond  the four walls of the hospital.

2) Despite this, most hospitals are trying to solve the issue during the hospitalization.

All indications were that hospital efforts to reduce preventable readmissions were aimed at shoring up in-hospital processes and procedures (such as educational efforts during the stay) as opposed to looking at ways to extend their reach. Bottom line: time for a new approach.

3) Everyone is displeased with the status quo.

How do we know it’s time for a new approach? You told us. Of the 230 responses, only three people indicated they were fully satisfied with the scope and efficiency of their transitions of care program. Our survey numbers indicated that most folks feel they aren’t even close to getting this right, which is a scary thought in the face of the upcoming penalties.

4) Risk stratification is critical.

In a webinar we attended earlier this year, a presenter referred to a good risk profiling tool as “the holy grail.” Everything we saw in this survey supports that claim, from the lack of systems in place to formally assess readmission risk to a dearth of allocated FTEs. Over half of the respondents indicated they are basically playing a hunch or relying on their own experiences to identify who is at the greatest risk of readmission. Without any formality, it is nearly impossible to utilize limited FTEs efficiently.

5) Yes, resources are limited.

Speaking of FTEs, approximately 78% of respondents indicated their organizations have created or reallocated 3 or less FTEs to tackle readmission prevention. Translation: Getting resources is a challenge. Accepting that as fact, the goal now becomes to make the most out of the limited resources you have. This makes a scalable solution darn near an imperative. If it is going to be everyone’s job to do this (as opposed to, say, a dedicated specialist), a platform on which to coordinate everyone’s efforts becomes very appealing.

In closing, by allowing folks to free type in comments we were able to incorporate an “In your words” aspect. One of the most illuminating comments, coming in response to the question “How many FTEs has your organization created or reallocated as a result of your efforts to prevent readmissions,” answered “I don’t know, but I would love to be one of them!”

That is a strong demonstration of where hospitals are at: energetic, but confused at how and where to apply their efforts.

To learn more about the most effective ways to identify patients and allocate resources, please click here and we will be in touch. Please also sign up for our free webinar on the role of palliative care in reducing preventable readmissions here.

May 5, 2011 – 1:41 pm Categories: Uncategorized | Post a comment

Top 5: How to Identify Patients in Need of Transition Coaching

Ed. Note: This is the first in a series of posts that will discuss and share best practices related to transitions of care and preventing readmissions utilizing an easy-to-follow Top 5 format. Please check back weekly for updates, or follow us on Twitter at http://twitter.com/careteamconnect to be notified when new entries are published.

Author: Carrie Kozlowski, OT, MBA

There is a key element in creating a successful transitions of care program that is a HUGE hurdle for hundreds of hospitals. And, yet, it’s rarely discussed. Take a guess:

Nope, it’s not the lack of resources to staff the program.

Nope, it’s not even how to fund the program.

What’s the first thing you have to know to successfully transition a patient from one care setting to the next?

Which patient.

Most facilities lack the ability to accurately identify which of their patients have heart failure or pneumonia until several days after discharge when most patients are coded in an MS-DRG for billing.

The good news is that facilities have solved this problem, and you can too! Here, in our first “Top 5,” are a few solutions in use around the country.  My advice? Before you review these, pull out a sticky note and write down why you’re doing a transition of care program. Quality reasons? Physician driven ACO? CMS penalties?

1) Ignore diagnosis:

There’s only one way to avoid the inevitable gaps in the patient identification struggle. Focus on all patients that match demographic criteria like age or payer, and then provide transition-oriented care management to all of them, regardless of diagnosis. Due to the simplicity, it might be easier for your hospital and other community staff to adopt this process change since it will be applied across the board. To be most efficient, you will need to leverage a risk stratification methodology to insure effective resource utilization. Click here for more info.

2) Concurrent coding:

Look back at that sticky note. And if you’re motivated by a payer initiated financial penalty, then this might be your answer. I’m not going to prescribe the solution or process. There are several out there, but this is the one surefire way to identify who needs your services BEFORE they leave the hospital.

3) Historical payer data:

ACO? CMS penalties on your mind? This might just be the way to go. It’s not quite as accurate as concurrent coding because you could miss a few of the newly diagnosed patients, so you might want to combine this strategy with one below. But if there’s ever been a claim filed with one of your key diagnoses attached to the patient, then you’ll have a starter list.

4) Clinical criteria, i.e. a combination of specific labs, tests or medications that might indicate a diagnosis; for example, positive chest x-ray plus antibiotics equals pneumonia:

Stay focused on your mission because this strategy can lead to a lot of false positives or false negatives, especially if you try to keep it simple. Making it more accurate often requires some sophisticated technology solution to sit atop your IT system and provide the surveillance solution.  The other drawback? It can be challenging to get agreement on the criteria to use, especially if you want to address multiple diagnoses.

5) Clinician manual identification – a few disciplines that can help here:

a.       Case Management – Got your sticky note out? Quality driven? Then a few false positives aren’t a problem. Have your case managers or discharge planners identify and recommend patients. They know the patients and have some understanding of their previous history (maybe they are in for a fall this time, but had pneumonia the last three admissions), so they can help make sure you follow-up on the right patients.

b.      ED – While a diagnosis probably hasn’t been finalized this early in the game, most admissions do come in through the ED. And if you want the most successful transition out of the hospital, you’ll want to start planning for it asap. Asking these folks to identify patients might, again, cast your net wide, but you can kick off a process for transition care management much sooner in the hospitalization.

c.       Hospitalist or primary physician identification – If your physicians are engaged or even driving this initiative, then they’re going to have an opinion. I’ve sat through many a debate about the medical diagnosis of heart failure versus the coding of a patient as heart failure versus the basic assumption that the patient has heart failure and needs follow-up. If your physicians are concerned about false positives because you aren’t using a medical model, then let them take on the role of identifying patients during the admission. The caveat is that it will likely be later in the hospitalization before you get their official commitment to the diagnosis.

d.      Multi-disciplinary rounds – This one might seem obvious, but it’s not a process in place in a lot of facilities. However, if you do implement rounds, now you’ve got hospitalist, nurse and case manager in one place. Odds are that those three heads are better than one and can generate a pretty accurate list of patients.

Note: For a-d above, you’ll still need to generate the patient list for the transition of care program. The hospitalists or clinicians could check a box in your HIS, ER or Care Management system. Or, you can add a “Transition Coach” order to the order set for that diagnosis. Keep it simple though! To insure success and adoption, it must fit into the clinicians existing workflow and be time neutral.

Regardless of the strategy you employ, remember that the closer to admission you can make the identification, the better. Some facilities even put all the patients they *think* have heart failure on the same unit. So the process and workflow is consistent and the transitions are easier. You can even leverage group education opportunities.

To learn more about the most effective ways to identify patients and allocate resources, please click here and we will be in touch. Please also sign up for our free webinar on preventing readmissions here.

March 3, 2011 – 1:39 pm Categories: Health Care Reform, Transitions of Care and Home Care, Uncategorized | Post a comment

Getting the Word Out – Leveraging Your Success With Marketing

Ed. Note: This is the seventh and final entry in a series of posts that will deal directly with establishing a transitions of care program. Please check back weekly for updates to the blog, or follow us on Twitter at http://twitter.com/careteamconnect to view earlier entries and to be notified when new entries are published.

Author: Carrie Kozlowski, OT, MBA

It’s time to celebrate your success! And the best way to celebrate is to tell everyone about what you have accomplished.

There are three key constituents on which to focus:

Your Patients

From the start, you will want to have a one page letter introducing patients to your care transition service. It should be updated quarterly with new data and results supporting the value you are providing. It needs to include:

  • The cost of the service – Why? Because most of the time it’s free to the patient. And you should remind them of that.
  • What the service is – This is critical to setting and exceeding expectations. An example:

You will get 3 phone calls and 1 home visit over the next 30 days. We will arrange these at your convenience. Our time together will be spent making sure you have the medications and resources you need, and I can answer any questions as well as coach you on what to do in the event of certain symptoms.

  • Who’s providing the service – Add your name, credentials and even a picture. This is especially important if you have more than one person who might call or visit them. They should have a name and face to match the one ringing their doorbell.
  • Why you offer the service – Here’s the part where you celebrate your outcomes.

Because in our six months of providing the service, we’ve experienced a 50% reduction in patients returning to the hospital for the same reason. This means our patients spend less time in the hospital and more time at home – because they are more successfully managing their health.

Your referral sources

This could mean different things in different organizations. Referrals could come from hospitalists, community physicians, case management, floor nurses, etc. No matter who, you are going to engage and educate these folks up front about your new transitions of care program and service to garner referrals.  Just do not forget to share your success with these early champions down the road.

The model looks a lot like the outline for the patients – what, who, why. However, the method of communication might vary a bit depending on your referral source. Take advantage of all the avenues available to you:

  • Staff meetings
  • Email
  • Letters
  • Posters in the nursing or physician lounge, cafeteria, hall (this doubles as patient/ family marketing too)
  • Employee or physician newsletter

You get the idea. The key here is not just what you have achieved outcomes-wise. Add a couple of anecdotes or success stories. All clinicians like to hear the positive results. And, remind your referral source why this matters to them. For hospitalists and nurses, maybe it’s more time to focus on patients because they have fewer frequent fliers. For the primary care docs, it could be increased referrals/volume if you’re making sure patients get to their appointments. Find out what “extra” value you provide to these referral sources and sing it from the rooftops!

Your superiors

Make it easy for your boss to “manage up” by providing them with quarterly memos summarizing your success. Keep it data driven. It should be focused and concise. How many patients did you follow and what were the results? Show trends of program growth (via caseload) over time and readmission rates quarter over quarter historically. If you can, add your estimate of dollars saved via penalty avoidance. Graphs are easiest and allow them to digest your success without dedicating the time required to actually read a report.

Then, at the end, add the success story. This might be a patient whose readmission was circumvented because of what you did, a thank you note from a family member, or even the good news that the curmudgeon doctor who always complains about change finally referred a patient.

As you put together your marketing and communication strategy, use all the resources available to you. There are lots of folks who will gladly help. You can ask the enthusiastic patient who’s grateful for your transition coaching to draft a letter to the local paper or a patient experience statement you can use.  Ask the physician liaisons to communicate and share your story with the doctors they meet. Hospital marketing is always looking for successes to share. You’ve got a built in team – don’t forget to leverage it!

Sharing success is how you will change the culture and make sure your program and the great work you do will be sustained, and even grown, over the coming years. Good luck!

For examples of items you can use in your marketing kit, or to discuss other aspects of your transitions of care program, please click here to reach us and we’ll be in touch!

January 31, 2011 – 4:22 pm Categories: Uncategorized | Post a comment

Growth: Scaling the Program to Reach More Patients

Ed. Note: This is the sixth in a series of posts that will deal directly with establishing a transitions of care program. Please check back weekly for updates, or follow us on Twitter at http://twitter.com/careteamconnect to view earlier entries and to be notified when new entries are published.

Author: Carrie Kozlowski, OT, MBA

Implementing a transitions of care program can be a daunting task. However, as with everything else in this blog series, I am going to suggest you break it into steps. Trying to solve the transition and readmission issue for every patient that leaves your hospital is overwhelming. I have seen making program decisions paralyze even the most sophisticated of health systems.

Remember, there’s no right or wrong answer here. When scaling the program you just need to know:

1)      Which patients are at greatest risk in your facility?

2)      What kind of internal expertise can we leverage?

3)      How will we assess success or struggles, adjust and move forward?

4)      What kind of education and training is required and what is the best model for our organization?

The Institute for Healthcare Improvement (IHI), as referenced in the first entry of this series, recommends first analyzing where your biggest gaps are. According to research done by IHI and articles in NEJM and other publications, patients with CHF, AMI, Pneumonia, Diabetes, COPD and ESRD have some of the worst readmission rates. That would indicate an opportunity to improve their care transitions first.

We recommend looking at your internal resources and expertise and starting with the patients whose care you are best equipped to improve.  Many hospitals have clinicians with specialized knowledge about CHF, Diabetes or COPD – all great starting places.  Working with your technology vendor, create your program and establish guidelines for care. Track every element. Using a traditional Plan, Do, Study, Act (PDSA) model, you can see what works and what doesn’t, and even what might be an expectation that can’t be effectively implemented – by your team or your patients.

Once you have an effective model, it’s time to start scaling it. With the right technology partner, you can adjust the elements of the model for the next patient population. Again, using the PDSA model, take note of what works and what doesn’t across both patient populations.

A lot of hospitals ask us which patients to focus on or whether they should segment into smaller populations and whether this is ethical or fair.  You’ll need to look to your legal if you have concerns there, but all new programs have to start somewhere and it’s impossible and counterproductive to start everywhere. My suggestion is to look at the patient populations by diagnosis and age. You’ll likely see a trend in your data that will point you to a few opportunities. Then, assess your resources and internal expertise and often the best place to begin becomes clear.

Be careful not to create too many parameters for inclusion. For example, X and Y payers but not A and B.  Or X payer, Y age, B diagnosis, but not with A & D comorbities. The key to successful program development is to keep it simple. You’ll need to get not only the program resources, but also floor nurses, hospitalists, case management and maybe even registration educated to the program and referral process. Keep it simple. I’ve even seen hospitals who say any patient on in this unit, i.e. telemetry, will receive care transition services. This makes the education and referral process easy.

For more information about implementing and expanding a transitions of care program, click here to submit your question and information and we’ll be in touch!

January 11, 2011 – 2:39 pm Categories: Uncategorized | Post a comment

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