Strategically, Physicians Make Room for RNs

Providers are realizing that case managers are an important piece of the readmissions puzzle. That often means placing a greater emphasis on coordinating care and focusing on the patient discharge process.

As hospitals and health systems work toward a future where payments are based on the longitudinal care of patients, they have to continue to maintain their financial viability in the current and polar opposite fee-for-service reimbursement model.

Many physician leaders of hospitals, health systems, and even health plans, have admitted that it is difficult to navigate to a different payment structure, especially while trying to react to current initiatives that require timely action.

One initiative that aims to prepare healthcare leaders for a fee-for-value payment structure emphasizes reducing hospital readmissions. Readmissions penalties levied by the Centers for Medicare & Medicaid Services have forced health systems to review clinical processes to remedy a tough situation.

Different Strategies, Similar Results
Some hospitals have restarted the bygone practice of making house calls for their most frail and sickest patients. A study published in The Journal of American Geriatrics Society found that MedStar Washington Hospital had a lower rate of readmissions for the 722 patients who took part in the hospital's house call program, and also saved on average $4,200 per person per year in Medicare costs.

Others, like Albany Medical Center, the 734-bed academic medical center in Albany, NY, have tackled readmissions by focusing on the patient discharge process.

In a pilot project with CDPHP, a community-based nonprofit health plan in 24 of New York's counties, Albany Medical Center saw a 40% reduction in readmissions among CDPHP Medicare beneficiaries.

"We focused on what was happening prior to discharge," says Bruce Nash, MD, chief medical officer and senior vice president of medical affairs at CDPHP. "And, you always try to focus on the highest need population, and this is an across the board look at Medicare patients-all cause readmissions."

Another reason that CDPHP focused on its Medicare population arose from the medically and socially complex reasons that land those beneficiaries back into the hospital within 30 days of discharge.

"Hospitalization can change how they [Medicare patients] do at home," says Charlene Schlude, director of care management at CDPHP.

Curbing Return Visits to Emergency Dept. Depends on Docs

Case managers are an important piece of the readmissions puzzle, say Schlude and Nash. CDPHP has 13 case managers, and one visits each patient at bedside before discharge. The aim is threefold: patient education, medication reconciliation, and other bedside support, and coordinating the care transition.

"It's a relay race," says Schlude. "The key is the face to face evaluation of each patient at the bedside. Then the nurse at our health plan follows up by phone within two days. The case manager gets buy-in from the bedside nurse at Albany Medical Center."

There is an additional step taken, too. Medicare patients are given a business card with the name of a nurse who will follow up with them. It's an important extra step that helps patients know what is coming next. That could serve to calm their anxiety, which also can be a driving factor in readmissions from emergency departments.

"Medicare beneficiaries are skeptical about cold calls," says Schlude, who adds that the personal interaction with patients at the bedside before they are discharged gives nurses and case managers an opportunity to find out what is going on at home that could impact their care.

"It's a high leverage point," says Nash. "We first tried to reduce readmissions with a physician-centric program—providing incentives to get patients into their office, but the effect wore off after 6–9 months. It showed us we needed to get at it with active management instead of leaving it to the marketplace."

Nash estimates that by focusing on bedside factors prior to discharge, CDPHP has saved roughly $1 million on the 706 Medicare members who were part of the pilot program that began in 2013. So far this year, there have been 915 Medicare and Medicaid patients who are participating in the expanded case management pilot.

Nash also credits CDPHP's patient-centered medical home concept, called Enhanced Primary Care (EPC), with helping to reduce readmissions. "We have over 200 practices participating in EPC, and part of that program is how to work constructively with case managers," he says.

Coordinating Care Transitions
One of the biggest determinants of how a patient will fare at home is the environment they are returning to after discharge. Schlude says case managers and nurses have found that many of the patients are caregivers to someone at home, which impacted how well patients could take care of themselves.

"There's more than meets the eye at home," she says. "You find out a lot, but that's just one step of the process. Once you get their information, you then know how to develop a plan of care."

If patients don't know a lot, or enough, about their diagnosis, case managers will reach out to the primary care providers. "A provider may see someone for 15–20 minutes. We try to be a link to the provider, and to community-based services that can pick up where their Medicare coverage leaves off."

Coordinating care is more than making sure a patient has the clinical information they need, it increasingly means to cover all the bases for discharged patients, from medication reconciliation to transportation issues, says Nash.

"Where it works most smoothly is where we have embedded case managers in the practice."