Webinar 6: Enhance Services for High-Risk Patients

Designing & Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions

Text version of Webinar slide presentation.

Slide 1: Designing & Delivering Whole-Person Transitional Care

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Designing & Delivering Whole-Person Transitional Care
The Hospital Guide to Reducing Medicaid Readmissions

Webinar 6: Enhance Services for High-Risk Patients

Slide 2: Agenda

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  • Describe strategies to enhance services for high-risk patients.
  • Give examples of how transitional care services and high utilizer programs effectively meet "whole-person needs."
  • Describe the usefulness of an emerging tool: the ED Care Plan.
  • Identify ways to reduce readmissions from the ED.

Slide 3: Objectives

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  • Enhanced services go beyond standard care to provide services and support in the post-hospital time period.
  • Adapt transitional care models to address "whole-person needs."
  • Develop new services to improve care for frequently hospitalized patients.
  • Use care plans to improve care over time and across settings.
  • Engage the ED in efforts to reduce readmissions.

Slide 4: Table of Contents

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  • Introduction.
  • Why focus on Medicaid Readmissions?
  • How to Use This Guide.
  • Analyze Your Data.
  • Survey Your Current Readmission Reduction Efforts.
  • Plan a Multi-Faceted Data-Informed Portfolio of Strategies.
  • Implement Whole-Person Transitional Care for All.
  • Reach Out to Collaborate With Cross-Continuum Providers.
  • Enhance Services for High-Risk Patients.

Image: Cover of the book, Designing & Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions.

Slide 5: List of Tools

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The guide comes with 13 customizable tools to be used in hospital teams’ day-to-day operations.

  1. Data Analysis.
  2. Readmission Review.
  3. Hospital Inventory.
  4. Community Inventory.
  5. Portfolio Design.
  6. Operational Dashboard.
  7. Portfolio Presentation.
  8. Conditions of Participation Handout.
  9. Whole-Person Transitional Care Planning.
  10. Discharge Process Checklist.
  11. Community Resource Guide.
  12. Cross Continuum Collaboration.
  13. ED Care Plan Examples.

Image: Tool icon (crossed hammer and wrench).

Slide 6: The ASPIRE Framework

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Image: The Framework is a flowchart reading from left to right. On the left is a box captioned "Reduce Medicaid Readmissions"; two lines connect this box to two boxes to its right captioned "Analysis" and "Action". Three lines each extend from "Analysis" and "Action" to connect to the elements that make up the ASPIRE acronym:

  • Analyze Your Data.
  • Survey Your Current Readmission Reduction Efforts.
  • Plan a Multi-faceted, Data-Informed Portfolio of Strategies.
  • Implement Whole-Person Transitional Care for All.
  • Reach Out and Collaborate with Cross-Continuum Providers.
  • Enhance Services for High-Risk Patients.

Slide 7: "I think that there’s always going to be a group of folks that’s always going to need somebody to help them..."

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"I think that there’s always going to be a group of folks that’s always going to need somebody to help them. That’s never going to change."

Slide 8: Enhanced Services

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  • Additional services and supports in the time following hospitalization.
  • Services not provided to all patients as part of routine care.
  • Offered to subgroups identified as "high risk" of readmission.
  • Delivered prior to and after discharge, often for 30 days.
  • Deployed at provider expense so as to reduce readmissions.
  • Delivered by hospital staff or by contracted staff from other entities.

Slide 9: High Risk Target Populations

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  • There may be several target populations at high risk of readmission identified by your data analyses.
  • Consider the following high risk target populations:
    • Adults with sickle cell disease.
    • Adults residing in group homes or other residential settings.
    • Patients discharged to short term skilled nursing facilities.
    • Adults with a personal history of repeated hospitalizations in the past year.
  • One "standard" transitional care model would not likely meet the needs and address the root causes of readmissions for all these populations.
  • Design "enhanced services" to meet the needs of each target population.

Slide 10: Transitional Care for High-Risk Patients

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Transitional Care for High-Risk Patients

Slide 11: Transitional Care Services

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"Our [navigators] are flexible, proactive, and persistent; they address all needs. Each of them has incredible interpersonal skills."

Slide 12: "Whole-Person" Adaptations to Transitional Care

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  • Navigating.
  • Hand-holding.
  • Arranging for….
  • Providing with….
  • Harm reduction.
  • Meet "where they are."
  • Patient priorities first.
  • Relationship-based.

Slide 13: Social Work-based Transitional Care

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  • "Bridge model."
  • Engage with patients with clinical, behavioral health and social needs.
  • Assess for transitional care needs.
  • Expect needs will change over time.
  • Use motivational interviewing.
  • Identify services in place.
  • Assess eligibility for services.
  • Discuss finances in context of needs and priorities.
  • Link directly to services.
  • Brief short term therapeutic support.
  • Coordinate with clinical and social service providers.

Slide 14: In Practice: Social Work Transitional Care

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Recognized as an AHRQ Service Delivery Innovation, and recently published as an evidence-based transitional care model in the Journal of the American Geriatrics Society, the Bridge Model is a social worker-led transitional care model. Social workers assess "whole-person" transitional care needs, and work with patients, their families, providers, and community service agencies to address post-hospital needs over a 30-day period. Developed at Rush University Medical Center, the Bridge Model has been implemented for a target population that includes patients with social and behavioral needs, including the following criteria: live alone, no source of emotional support, no support system in place, discharged with a social service referral, and a severe psychosocial need, among others.

The social worker calls the high-risk patient within two days of discharge, and first focuses on developing rapport with the patient or their caregiver. In more than 80 percent of cases, the social worker identifies problems to be addressed, with about three-fourths of these problems not becoming apparent until after discharge. The three most common problems are difficulty coping with change, caregiver stress, and problems managing medical care, including medications. Other common issues include trouble obtaining community services, communication breakdowns between providers, trouble managing a new treatment or diagnosis, and difficulty understanding the discharge plan.

A May 2016 external claims-based analysis demonstrated a statistically significant 20% reduction in all cause, any hospital readmissions.

Slide 15: In Practice: Community Health Workers

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Temple University Hospital started a community health worker (CHW) program to augment their efforts to reduce readmissions among heart failure and other high-risk patients. The hospital assigns a CHW to all patients with three or more readmissions in the past year. The CHWs meet with patients as early as possible during the hospitalization and try to meet with the patient multiple times before discharge. The connection while in the hospital makes it much easier to continue the relationship in the post-hospital setting. By design, CHWs meet with patients independently of doctors and nurses. CHWs have noted that patients feel more comfortable telling them about psychosocial and economic problems that may prevent them from adhering to their care plan, such as being unable to afford heat in their home or not understanding what the doctor said.

Slide 16: In Practice: Interdisciplinary Transitional Care Team

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A large safety net hospital in California has an 8-member interdisciplinary transitional care team:

  • Pharmacist.
  • COPD RN.
  • CHF RN.
  • Social worker.
  • 2 Community Health Outreach Workers.
  • Program Manager.
  • Data Analyst.

The team serves patients admitted with COPD, CHF, or HIV. They actively screen for marginal housing and substance use disorder. They describe their work as "actively support" patients—accompany, support, touch base, follow-up. They hold "drop in" visits in an outpatient conference room on site at the hospital, during which hours patients can connect with the team, have specific questions or needs addressed. Notably, all clinical members of the team do home visits. The team states their success is due to working as an interdependent, highly collaborative team.

Slide 17: Improving Care for High Utilizers

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Improving Care for High Utilizers

Slide 18: Principles to Guide High Utilizer Programs

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  • Identify the patient in real-time.
  • Engage the patient while they are on-site.
  • View utilization as a symptom of unmet needs.
  • Prioritize engagement.
  • Deploy an interdisciplinary team.
  • Be proactive in post-hospital follow up.
  • Be patient and persistent.
  • Have resources to deploy to meet short term needs.
  • Use care plans to improve care across settings and over time.

Slide 19: In Practice: High-Utilizer Program

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"We do whatever it takes."

A large community hospital designed an inpatient high-utilizer program as a component of their existing efforts to reduce readmissions. They defined high-utilizers as adults with 4 or more hospitalizations in a 12-month period. Based on prior year data, they found 400 patients met this criteria. Collectively, these 400 people utilized 2200 readmissions and as a group had a readmission rate of 40%.

The program was designed to prioritize engagement, outreach, provision of social and behavioral health care needs, and referral to palliative care, as needed. The team is comprised of 3 teams of 1 social worker and 1 community health worker each. The 3 teams are supported by a nurse care manager, pharmacist, medical director and data analyst/program manager.

The program has been successful in engaging more than 80% of the HU population and in following up with over 65 of patients with 2 days of discharge. The program is tracking 30-day readmission rates as well as pre-post intervention utilization, and will utilize an internal historical control group for comparison.

Slide 20: Using Care Plans to Improve Care Over Time and  Across Settings

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Using Care Plans to Improve Care Over Time and  Across Settings

Slide 21: Types of Care Plans: Observations from the Field

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  • Longitudinal Care Plan:
    • A comprehensive plan to achieve health-promoting goals and objectives. Specific goals regarding clinical, behavioral, and/or functional status are often included, and are measured via serial assessments over time. Longer term; care management over time.
  • Transitional Care Plan:
    • Identifies post-hospital needs, patient priorities, and readmission risks and the plan to address those needs, priorities and mitigate risks in the 30 days post discharge. Focus on ensure linkage to providers and services within the 30 day transitional period.
  • ED Care Plan:
    • Summary information for the ED provider to inform safe, effective, and consistent care in the ED and facilitate discharge with team-based follow up, as appropriate.

Slide 22: ED Care Plan: Emerging Tool in the Field

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Purpose: Improve the management of the high-risk patient the next time they come to the ED.

Audience: ED clinical staff.

Content:

  • Executive summary of prior utilization and testing.
  • Identification of the driver of hospital utilization.
  • Recommendations for consideration.
  • Identification of a point of contact.

Slide 23: ED Care Plan Template

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Image: The ED Care Plan template.

Slide 24: ED Care Plan Example 1

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Image: ED Care Plan Example 1: A high-risk patient assessment.

Slide 25: ED Care Plans: Lessons from the Field

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  • Brevity:  No more than 1 page; the essential summary information in a way that saves time and promotes quality, informed decision making.
  • Audience: Who is your intended audience? ED doc? Develop the "clinical snapshot" and recommended interventions with the end-user in mind.
  • Summarize the "utilization" part of "high utilizer:" This summary is not just a clinical summary, but a utilization profile. Quantify prior visits, admissions, tests, consults to convey what has been done in the past.
  • Delegate the synthesis, collaborate on the plan: Delegate the drafting of the care plan summary to a member of the high-risk care team. Meet as a team to develop recommendations and next steps.

Slide 26: Engage the ED in Reducing Readmissions

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Engage the ED in Reducing Readmissions

Slide 27: "In previous times, the path would’ve been to simply admit the patient..."

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"In previous times, the path would’ve been to simply admit the patient, and we’ll sort it out 5 days later. We’re becoming more accustomed to having resources in the ER to help us discharge patients from the ED. That’s a culture change."

Slide 28: Reducing Readmissions from the ED

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  1. Create a 30-day return flag on the ED Tracker Board:
    • Be sure to communicate what their desired response to the flag is.
  2. Use the 30-day return flag to notify the high risk care team:
    • Real-time notification to allow team to work with ED on safe discharge.
  3. Use care plans and care teams’ involvement in the ED:
    • Communicate baseline clinical status, recurrent utilization, next steps.
  4. Consider developing "treat and return" pathways:
    • Inventory the capabilities of post acute providers and post in ED.
  5. Engage hospitalists in decision to admit:
    • Create a collaborative culture to reduce avoidable decisions to admit.

Slide 29: In Practice: Treat and Return for SNF Patients Averts (Re)admits from ED

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A state-wide training effort was made in Massachusetts to engage all skilled nursing facilities in sending a standardized and comprehensive "transfer packet" to the ED. The transfer packet was completed in a purposeful effort to improve the quality of information flow between SNF to ED, and also to inform the ED of the facility's capabilities, specifically to notify the ED that the patient could be returned to the facility, if safe and appropriate.

The Chief of a 2-ED practice evaluated their SNF admission rates and noticed the ED admitted a very high percent of all transfers from SNF. When he queried his colleagues, their answers revealed outdated information about SNF capabilities, and an operating assumption that if the patient was "sent in," it was with the expectation of admission.

The Chief set a goal for the department to—as safe and appropriate to do so—treat and return more patients each week than the last week. Over a 9 month period, the number of treat and returns from SNF steadily, and safely, increased.

Slide 30: In Practice: High-Risk Care Team Averts (Re)admits from ED

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"Our patients look bad on their best day."

A highly successful high-risk, high-cost care management demonstration program leveraged the emergency department as an important opportunity to avert an admission or readmission. When a high-risk patient registered in the ED, a notification was sent to the care management team. The expectation was that the team would collaborate with the emergency department staff to identify whether a discharge, rather than a (re)admission. was a safe and appropriate option.

In reflecting on their success factors, the program cited the care managers' and primary care physicians' longitudinal knowledge of their patients as critical to providing context to admission decisions, stating "our patients look bad on their best day," reflecting to importance of knowing a patient's "baseline" in order to accurately determine whether an acute change in clinical status has occurred. In addition, the fact that a high cost complex patient had a "team" willing to provide timely and close follow up allowed care to be delivered in the home or other lower-cost settings.

Slide 31: Summary

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  • Deploy enhanced services for patients at high risk of readmission.
  • Match the enhanced services to the needs of the high risk patient population; consider different services for different populations.
  • Do not over-medicalize services.
  • Develop care plans for patients who are frequently hospitalized.
  • Engage the ED in your efforts to reduce readmissions.

Slide 32: Thank You

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Thank you for your commitment to reducing readmissions

Amy E. Boutwell, MD, MPP
Collaborative Healthcare Strategies
amy@collaborativehealthcarestrategies.com

Angel Bourgoin, PhD & Jim Maxwell, PhD
John Snow, Inc.
Angel_Burgoin@jsi.com; Jim_Maxwell@jsi.com

Page last reviewed October 2016
Page originally created October 2016
Internet Citation: Webinar 6: Enhance Services for High-Risk Patients. Content last reviewed October 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/medicaidreadmitguide/aspire_webinar6.html