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Improving Care Transitions - A Response to CMSs 9th Scope of Work

Kathy Kier, RN-BC, MPM, CCM

In the fall of 2008, shortly after the CMS 9th Scope of Work (SOW) was announced, Quality Insights of Pennsylvania the states federally designated QIO invited Excela Health to participate in a pilot project to reduce 30-day hospital readmissions. Readmission rate is one of the transitions measures that CMS uses to foster better transitions and coordination of care. A transition measure is one that expands the timeframe or number of providers in an episode of care. Rather than just evaluating through use of a quality measures specific to a hospitalization, a broader episode of time before and/or after the hospitalization is subject to the evaluation. As the time horizon expands, so does the number of providers and institutions involved in the care of a patient. Analysis of 2003-2004 Medicare claims data revealed that approximately 20% of hospitalizations were patients readmitted within 30 days following discharge from an acute care facility. This data pointed to a continuum of care problem, which by the measure of readmission rates, would improve if care outside the hospital were better coordinated. CMS awarded care transitions projects to 14 states including Pennsylvania. The state QIO led the local demonstration projects. One of the goals was to reduce All-Cause 30-day readmission rates by 2% over the course of the 3-year 9th SOW, August 1, 2008-July 31, 2011. Strategies were developed to implement community and system-wide interventions.
Preventable readmissions are issues of patient quality and safety that should improve through collaboration and strong relationships with community health care providers. The combination of improved patient quality and safety, along with the cost savings associated with decreasing readmission rates made this project imperative for providers in the community. The approaching implementation of the Affordable Care Act provided hospitals with additional incentives to improve care coordination as well as reduce preventable readmissions because there would be reductions in reimbursements tied to readmission rates for certain diagnoses. The first step in designing the pilot was to bring providers across the care continuum together in an open forum setting. These forums provided an educational setting that encouraged relationship building between participants. A variety of professionals participated in the forums from bedside providers to managers and senior leadership staff. The initial meetings provided excellent opportunities to understand the varied regulations governing clinical practices across the continuum of care and the subsequent barriers in providing accurate patient care information between settings. For instance, skilled nursing facilities, acute care hospitals and home health providers each operate in very different clinical and regulatory environments despite the similarities that also exist. The continuum of care was in reality more akin to a series of neighboring silos, which prevents the reliable transmittal of patient care information. The group quickly reached consensus on two goals: first, to improve the hand-off of patient care information between providers and second, to improve the coordination of care provided outside the hospital setting.

Excela Health is a health system in southwestern Pennsylvania with three acute care hospitals that together include 650 licensed beds. This region of Pennsylvania, about 40 miles outside of Pittsburgh, is home to a large Medicare population. Five acute care hospitals participated in this QIO-sponsored project. The Excela Cluster included all three campuses in the Excela Health system, two home health care agencies and six community-based skilled nursing facilities.

About the Organization

Historically, the providers participating in this project did not have any formal coordination of care across the continuum. At the start, all participants committed to reducing the fundamental patient information disconnects between providers. The target population of this pilot, Medicare patients, frequently has complex care needs and requires care in multiple settings so the hypothesis of the pilot project was that improving the accuracy and reliability of patient care information transmitted between those settings would assist in decreasing 30-day readmission rates. At the time of project initiation, the rate of readmission for the Medicare population was almost 20%.

Collaboration is the Starting Point

A subcommittee of the open forum group composed of members from the acute care hospitals, skilled nursing facilities, and home health care agencies met to develop a cross-setting transfer form. The form was designed to document key clinical and patient information necessary for ensuring continuity of care in the transition to the next level of care. Since regulatory needs guided some of the information required for different levels of care, the design of this transfer tool is a two-sided NCR (no carbon required) form. This form documents a patient assessment completed two hours prior to discharge/transition to the next level of care. This assessment accompanies the patient to his or her next level of care and provides a good snapshot of discharge/transfer status. The

The First Intervention - A Care Transition Tool

w w w . a c m a w e b . o r g

Improving Care Transitions - A Response to CMSs 9th Scope of Work

document is bi-directional in design so that it can handle up to three different levels of care, such as acute care hospital SNF home health, or home health SNF acute care. Side one documents information to skilled facilities and side two documents the appropriate information for discharges to home health care facilities. The hard copy of the Transitions Tool accompanies the patient at the time of discharge. Because the Transitions Tool is bidirectional, the value extends beyond the first transfer a patient makes. For example, if a patient goes to a community skilled nursing facility and needs to return to the acute care setting, the same form documents patient status for the return. The use of this transfer tool is especially useful when a patient transfers to acute hospitals via the Emergency Department (ED) during off-hours and patient information is limited. When the patient is discharged from a skilled facility to a home health care facility, the same transfer tool would again be used to document necessary patient and clinical information to provide effective transition of care information, and to ensure to the extent possible a safe transition of care. Finally, this pilot also extended to the use of the transfer tool by home health care agencies when the need arose to return a patient to the acute hospital, usually via the ED.

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The group further developed a coaching program based on the Care Transitions model developed by Dr. Eric Coleman and his colleagues at University of Colorado Health Sciences Center. The Administration on Aging (AoA) of Westmoreland County offered their collaboration on the project. This alignment was critical to the success of the coaching program because the AoA made a commitment to this project that provided dedicated staff members as coaches. Coaches were trained in the Coleman Care Transitions Model. The design of this care transitions model responds to studies conducted by Dr. Coleman and his team, who identified that lack of

The Second Intervention - Care Transition Intervention Coaching

care coordination and medication errors are among the most significant causes of avoidable readmission to the hospital within 30 days of discharge. At the heart of the care model are the patients transitions coaches. The primary goal for these coaches is to assist the patient and/or caregiver to develop lasting self-management skills to help them be a proactive partner in their own care during transitions, as well as future episodes. They do this by providing support with respect to: medication management, follow-up medical care, and identification of warning signs or symptoms that their condition is worsening and may require consultation with a physician. The AoA staff members serving as coaches received the Coleman training prior to beginning their roles. The AoA staff members who became active coaches are not clinicians, but the design of the model does not require that coaches provide clinical care. They are trained to identify potential issues that would influence the patients ability to continue his or her recovery at home, and connect the patient with appropriate resources when necessary. Again, the primary focus of this intervention was supportive in nature; providing the critical link between a patients discharge to home and first visit with the primary medical provider, identifying barriers to obtaining resources to continue home recovery and promoting self-management concepts.

Whats After Your Name?

A CM Cr ed en ti a l F o r h o s p i t a l / h e a l t h s y s t e m cas e ma n ag e me n t

Th e ACM Cred enti al

Created by ACMA in 2005, the ACM Credential is designed specifically for Hospital Case Management Professionals. This certification is unique among case management certifications because the examination specifically addresses case management in the hospital setting.

www.acmaweb.org/acm

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Improving Care Transitions - A Response to CMSs 9th Scope of Work

The pilot project began on July 2009 and is ongoing. Patients initially identified for the pilot were Medicare fee-for-service patients with diagnoses of COPD, CHF or Pneumonia. However, the pilot quickly expanded to all diagnoses for Medicare fee-forservice beneficiaries. In collaboration with the Westmoreland County AoA, a process was developed to identify potential referrals for the coaching program. Prior to discharge, case managers identify patients for referral. Patients are offered a Care Transitions Coach and provided with a clear explanation of the role the coach will play. When a patient agrees to participate, he or she receives a referral to the AoA via a telephone call and follow-up fax containing demographic information. A Care Transitions Coach visits the hospital by the following day for the first face-to-face meeting with the patient. To date, of 841 referrals, 783 have accepted participation in the program. The coach follows each patient for the first 30 days postdischarge. The patient receives a home visit within 48 hours of returning home and three telephone visits. The home visit and phone calls solicit very specific feedback from the patient. Questions assess: The patients knowledge and understanding of their medications Whether follow-up doctor appointments have been made Whether transport arrangements, if necessary, have been made If they have noticed any changes in their health conditions In addition, the coaches help patients and caregivers identify and rehearse questions they have for the physician(s) at follow-up visits. To date, the results of this pilot, including both the use of the Transitions Tool and the coaching, show a decrease in the 30-day readmission rate from approximately 21% to 19.5%. This comes very close to the 2% reduction goal set for the pilot.

The current health care environment and the demonstrated improvement in the quality of care provided across the care continuum demands that the organization continue to utilize the Care Transitions Intervention Coaching model and the Transitions Tool. An Excela Health committee is developing a sustainability plan, which will include expansion of the collaboration with the Westmoreland County AoA. The commitment of resources by the AoA is a big step towards sustaining the program. The committee is also dedicated to seeing that Excela Health sustains or improves its reduction in 30-day readmissions. Further, the committee will collaborate on an expansion of the current model to include more effective management of chronic diseases in this Medicare population across health care settings. Specifically, Excela Health will expand work with its community-based skilled nursing facility partners to improve disease-specific management of patients. With these continued efforts, the organizations ability to ensure continuity of appropriate patient care by providing safe transitions throughout the continuum will improve, and Excela Health will meet its objectives to improve the quality and safety of patient care and reduce preventable hospital readmissions. Kathy Kier, RN-BC, MPM, CCM, has worked as Manager of Clinical Resource Management at Excela Health since 2006. She earned her MPM from Carnegie Mellon University in Pittsburgh PA, her BS from St. Josephs College in Standish, ME, and her RN from St. Margaret School of Nursing in Pittsburgh. She has more than 30 years of experience in health careas clinician and case manager in community-based behavioral health in public and private settings, and as an independent consultant and clinical nurse in acute care hospitals.

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