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Welcome to the Regional Care Collaborative Webinar
5 Steps to Better Transitions of Care
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2
5 Steps to Better Transitions of Care
Alan Mitchell, Program Director
Primary Care Development Corp.
New York, NY
Stacey Curry, Director of Quality Improvement
Coastal Family Health Center
Biloxi, MS
Objectives for Today
• Identify solutions for common “Transitions of Care” challenges
• Understand how HIT can, and cannot, help
• Understanding how improving TOC prepares you for value-based
payment models
Transitions of Care, Defined
“A set of actions designed to ensure the coordination and
continuity of health care as patients transfer between different
locations or different levels of care within the same location.”
• Patient transitioning from one setting to another
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To/from hospital
To/from specialist
To/from behavioral health
To/from community based organizations
Goals
• Reduce hospital re-admissions
• Ensure a full picture of patients’ conditions and care
they’ve received
• Educate patients about their role in managing
transitions
• Identify frequent ER patients who may need targeted
interventions
• Standardize approach across your clinic staff
Case Study
• Catherine, a patient of Sunrise Community Clinic, is a 40-year-old
female patient with chronic hypertension who went to the Emergency
Department because of dizziness and a headache.
• The ER staff found her blood pressure to be very high. The ER doc
prescribed a second hypertension medication, and discharged her.
• When she got home, she wasn’t sure whether to take her new
medication, her old medication, or both. She decided to take only
one.
• A week later, the woman had slurred speech and couldn’t move her
left side. She was rushed to the ER. She’d had a stroke.
• Suncrest staff did not know of these hospital visits or her stroke until
the woman’s next visit three months later, when as she was entering
the exam room, they noticed she had a limp.
Problems
• Felt sick, but didn’t know she could get a same day
appointment
• Went to hospital but there was no communication with
her primary care provider
• Didn’t receive or understand info about her new
medication regimen
• Advised to follow up with her PCP, but didn’t – and no
one followed up with her.
Problems
• 17% of adults hospitalized in last two years said that info about their care had not
been communicated
• 27% said the hospital made no arrangements for follow-up visit in primary care
• 67% who were given a new prescription were not told whether to take their other
medications
• 48% reported receiving no information on medication side effects
Not just a hospital issue…Hospitals, primary care, specialists, patients
must all work together.
Source: “Taking the pulse of healthcare systems: experiences of patients with health
problems in six countries.” Health Affairs Web Exclusive, November 3, 2005, W5-5095252
Evidence and Outcomes
With a focused effort on transitions of care…
• A physician network reduced readmissions dramatically
• 30-day: from 12% to 6% and
• 180-day: from 33% to 19%.
• A New York hospital reduced 30-day readmissions for
heart failure
• And increased average number of days to readmission from 86
to 175
Source: “The Care Transitions Intervention,” caretransitions.org.
5 Steps to Better Transitions of Care
1. Clarify roles and responsibilities at both sides of the
transition
• Including with behavioral health providers
2. Expand follow-up and access to care post-discharge
3. Use Health Information Technology to solve some of the
problems
4. Educate and engage patients about transitions
5. Integrate management of transitions into your
reimbursement strategies, including value-based payment
Step 1: Clarify Roles and Responsibilities
• Use existing resources to improve transitions of care
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Carve out staff time
Clearly state roles & responsibilities
Train staff as needed to manage transitions
Revisit written agreements with local hospitals.
• Supported by:
• NCQA Patient Centered Medical Home
• HRSA requirements for FQHCs
Best Practices
• Designate staff members responsible for following up on
admission/discharge notifications
• The health center and the hospital should formalize
agreements talk to each other, and set clear
expectations for communication and care
• Support patients and families through their transitions of
care with outreach and education
Source: Safety Net Medical Home Initiative Implementation Guide, Care
Coordination: Reducing Care Fragmentation in Primary care, April 2011
Low Tech Solutions
• Referral logs
• List of specialty providers
• Care compacts
• Medication reconciliation
• Workforce training
• QI project to look at the issue and develop ideas
• Measure patient experience, readmission rates, etc.
Step 2: Follow Up After Discharge
Review with the patient
• Reasons for admission and any findings from the discharge
summary
• Anything that the patient feels is unresolved from the
ER/Inpatient
• Medication Reconciliation
• Treatment/Care plan changes
• Patient Education about disease/illness
• How to contact the health center
Step 3: Use HIT
• Shared/Community Electronic Health Records
• Track referrals
• Transfer of digital records
• 3rd party care coordination systems
• Health Information Exchange
Supported by: “Meaningful Use” and NCQA PCMH
“HIE Will Solve It”
An HIE will move info between the hospital and the health center, but…
If we don’t actively coordinate care for patients, then
HIE will simply be data moving from one place to
another.
HIE: Promise vs. Reality
• The promise
• Complete window into patient records
• Provider-to-provider communication
• Shared access to quality and utilization measures
• The reality
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Admission/discharge alerts
Incomplete patient universe
Some medical history, including prescriptions
Partially used or implemented features
Severe interoperability problems
Vendor obstacles
MS-HIN
• Mississippi Health Information Network
• A secure electronic exchange of patient information
• Allows health care providers a quick, secure, reliable access to patient health
records
• Provides a patient’s complete medical history at the point of care fostering
better quality care in a more efficient manner
• MS-HIN Goals/Projects
• Community Health Record
• Complete Network of Coast Hospitals online
• Singing River Hospital System is currently online; Memorial Hospital in Gulfport will
be online soon.
• MS-HIN Notify- Currently piloting with Coastal Family Health Center
MS-HIN Notification System
• MS-HIN uses Coastal Family Health Center Panels to notify care
coordinators in the clinics when patients are admitted and/or
discharged from the hospital
• Current Panels include patients with Diabetes, Hypertension, and Asthma
• Care Coordinators receive notifications when a patient from one of these
panels is admitted or discharged from the hospital
• Care Coordinators contact the patients and ensure that hospital follow-up
appointments are made.
MS-HIN Notification System
• Successes
• Admission and/or discharge summaries have been received quickly for patients
needing follow-up.
• Care Coordinators are able to contact the patients within 7 days of discharge to
make follow-up appointments.
• Challenges
• Inaccurate phone contact information.
• Lack of access to appointment slots for hospital follow-ups (overall)
• Lack of access to physicians at CFHC to follow up with complex patients being
discharged from the hospital.
• Multiple Care Coordinators receiving the same patient notifications.
MS-HIN Notification System:
Problems and Solutions
• Inaccurate phone contact information.
• Increased efforts for staff to ensure that patient contact information is up-to-date in
our NextGen system.
• Access to appointment slots for hospital follow-ups and lack of access to physicians at
CFHC to follow up with complex patients being discharged from the hospital.
• Opening appointment slots for physicians for complex hospital follow-up patients
only.
• Opening appointment slots for nurse practitioners to see less complex patients for
hospital follow-up.
• Ways to ensure that patients with hospital follow ups are discussing their reason for
hospitalization and making separate appointments for other health concerns.
• Multiple Care Coordinators receiving the same patient notifications.
• Standard instructions for care coordinators to document when a hospital follow-up
recall occurs.
Step 4: Educate Patients About Transitions
• Patients have a role in safe transitions
• Improve communication between your health center, the hospital,
and the patient
• The patient conveys information between the clinic and the
hospital
• HIE will not solve all issues related to transitions
• Pro-actively prepare patients before the transition
Communicate with Patients
• Create the tools and the motivation for a patient to support a safe
transition
• Low-tech solutions work
• Patients should know…
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Which medications they’re taking, and which are newly prescribed
Your clinic’s same day appointment capability
Warning signs and symptoms for their conditions
To schedule a follow-up visit with the health center
Patient Education and Engagement
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When will the education occur? More than once?
Who will perform the education?
What materials will you provide?
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Making it as easy as possible for the patient to participate in transition
Expanding and standardizing what you’re already doing
Including this education in a regular visit
Involving patients’ families and caretakers
• Document the process and train on it
Step 5: Integrate with Reimbursement Models
• Transitional Care Management codes (TCM)
• Activities suggested by CMS
• FQHCs get reimbursed for in-person visits
• More info:
• from ACP: http://bit.ly/1TlcWwW
• From CMS:
• http://go.cms.gov/1WCObhY
• http://go.cms.gov/1TVFSYt
• Value-Based Payment arrangements
TCM Services
• Eligible
• Physician, NP, CNM, CNS, PA
• An interactive contact
• Within 2 days post-discharge
• Phone, email, face-to-face
• Certain non-face-to-face services
• Review discharge info
• Assistance in scheduling follow-ups
• Provide education to patient or caregiver
• A face-to-face visit
TCM Codes
CPT CODE 99495
CPT CODE 99496
• Moderate complexity
• High complexity
• Face-to-face within 14 days
• Face-to-face within 7 days
Must document in the medical record:
• Date the patient was discharged
• Date you made an interactive contact with the patient and/or
caregiver
• Date you furnished the face-to-face visit
• The complexity of medical decision making (moderate or high)
TCM Codes and FQHCs
• FQHCs and RHCs are not paid separately by Medicare, the face-toface visit component of TCM services could qualify as a billable
visit in an FQHC or RHC.
• Physicians or other qualified providers who have a separate feefor-service practice when not working at the RHC or FQHC may
bill the CPT TCM codes
Source: CMS, http://go.cms.gov/1TVFSYt
Value-Based Payment
• Pay for outcomes and quality, not quantity of services
• Enhanced TOC reduces cost, improves quality, prepares you for
VBP
• State and regional VBP programs
• TCPI, DSRIP, SIM, CPC+, ACOs
• Practice “advanced primary care” and “reduce unnecessary
admissions”
• Enhanced “pmpm” vs. “back-end” shared savings
• Good resource:
• Centers for Medicare and Medicaid Innovation
https://innovation.cms.gov/
Active Innovation Models
References and Further Reading
• Bodenheimer, T. Coordinating Care: A Perilous Journey Through the
Health Care System, August 2007.
• Doyle, E., “Reining in readmissions: Out of the box strategies that get
results,” Today’s Hospitalist, March 2011.
• Transitions of Care, Better Health Greater Cleveland, The Center for
health Affairs, September 2009.
• Safety Net Medical Home Initiative. Horner K, Schaefer S, Wagner E.
Care Coordination: Reducing Care Fragmentation In Primary Care,
April 2011.
• Safety Net Medical Home Initiative. Horner K, Schaefer S, Wagner E.
Care Coordination: Strategies to Reduce Avoidable Emergency
Department Use, February 2012
Contact Info
Alan Mitchell
Stacey Curry
Primary Care Development Corp.
Coastal Family Health Center
New York, NY
Biloxi, MS
(212) 437-3952
(228) 374-2494
[email protected]
[email protected]
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