TCM Programs - How to Prevent Readmissions

To effectively position a healthcare facility for successful outcomes in reducing readmissions and either avoiding a penalty from CMS or achieving pay for performance goals it is recommended that a Transitional Care Team be put in place. This will allow the healthcare entity to be in a position to establish a systematic approach to transition patients from Hospital to Home. The primary purpose of the transition team is to assess, risk stratify and identify patients at risk for readmission and poor outcomes. The team would then focus on education of the patient about their ambulatory care sensitive diagnosis on how to better manage their chronic disease state with a primary outcome of reducing unnecessary re-hospitalizations and decreasing the overall cost expenditure by the chronic condition patient.

To have a highly successful team it should include the following structure to manage 50 Medicare beneficiaries per week on a rolling basis.

» 2 RN Navigators

» 2 RN Transitional Care Managers

» 2 Social Workers

» 1 Advanced Nurse Practitioner

» 2 Pharm Techs

» 3 Pharmacists

» 1 Health Coach

» 1 case manager assistant (CMA)

» 1 Administrative Assistant

Surveys of readmitted patients have led to understanding some of the key drivers for emergency room visits with the top four reasons being as follows:

1. Poor understanding of the discharge plan

2. Lack of transport to pick up medications at a pharmacy and to drive to follow up appointments.

3. Lack of an ability to follow dietary instructions.

4. Lack of support systems

Social determinants of readmissions have been highly discussed in the past few years with some studies indicating that there is a correlation with a lack of support systems that increases readmissions and mortality[1] Some of the psychosocial variables that affect outcomes include social network, depressive symptoms, emotional support, instrumental support, and treatment compliance in the physician’s discharge plan. Cavilli-King et al[2] found various factors that included social environment (housing stability social support) behavioral (adherence, smoking, substance use), socio-cognitive (language proficiency), and neighborhood (rurality, distance to hospital) as predictors of poor outcomes.

Social workers assigned to the team can complete comprehensive assessments for determinants that can result in poor outcomes and work to place services in place to support the patients that will decrease the possibility of a rehospitalization based on psychosocial issues. They will have sufficient time to spend with each patient/family to allow for a more detailed transition from the hospital to home. Additionally, they can also interview each readmission to learn why they came back from which systems can be improved to meet the demand of the patients in the community.

The Transition Coach functions as a facilitator of interdisciplinary collaboration across the care transition, coaching the older patient and caregiver to assert a more central role in their care. The focus of this model is to coordinate these setting-specific practitioners during the transition, expanding the purview of the traditional team. The older patient, caregiver, and Transition Coach work together to maximize the involvement of interdisciplinary expertise. This ensures that the appropriate professionals are involved, the correct issues are addressed, and that the care plan and treatment goals are understood. The patient and Transition Coach review the content area of the four pillars during each contact with the Transition Coach, but the specific focus varies by patient and by visit. Because the Transition Coach tailors the content from the Four Pillars to the needs and priorities of the patient during each intervention contact point, the patient’s readiness, and ability to increase his/her involvement within the Four Pillars will dictate the most appropriate timing to focus on specific content.

NPs are tasked with care coordination of the ambulatory care sensitive patient population. Mary Naylor writing in American Journal of Nursing noted the following.

APN inclusion in transitional care—since 1989, a multidisciplinary team based at the University of Pennsylvania has been testing and refining an innovative model of transitional care delivered by APNs. Patients offered this care are high-risk, cognitively intact older adults with a variety of medical and surgical conditions who are transitioning from hospital to home.

In collaboration with each older adult, family caregiver, physician, and other health team members and guided by evidence-based protocols, the APN assumes primary responsibility for optimizing each patient’s health during hospitalization and for designing the plan for follow-up care. The same nurse implements this plan after discharge by providing traditional visiting nurse services, making home visits and being available seven days a week by telephone.

Three randomized, controlled trials funded by the National Institutes of Health (NIH) consistently demonstrated that this model of care improves older adults’ satisfaction, reduces rehospitalizations, and decreases health care costs.

The most recently reported trial of a protocol directed by APNs is designed to address the health problems and risks common among older adults during an acute episode of heart failure. When compared with the control group, members of the intervention group have improved physical function, quality of life, and satisfaction with care. People in the intervention group had fewer rehospitalizations during the year after discharge, resulting in a mean savings in total health care costs of $5,000 per patient.[3]

In a randomized control trial designed to test the validity of an ANP driven transitional care model, Naylor, et al demonstrated increased time between hospital discharges to readmission or death, reduced total number of rehospitalizations, and decreased healthcare costs. At 52 weeks the intervention group had fewer readmissions (104 vs. 162) lower total mean cost ($7,636 vs. $12,481) with the greatest reduction in index and comorbidity-related rehospitalizations occurring in the first 3 months of the intervention[4]

Older patients with chronic illness often require care from a variety of practitioners in multiple settings. For example, in each month, an individual with chronic illness may receive care from his or her primary care physician or a specialist in the ambulatory care setting. That same person may then receive care from a hospitalist physician and nursing team during an inpatient admission, a different physician and nursing team during a brief stay in a skilled nursing facility (SNF), and finally, from a visiting nurse in the home. Yet during times when they are most vulnerable and their informal caregivers are often overwhelmed, systems of care fail patients by not ensuring that: (1) the critical elements of the care plan developed in one setting are transferred to the next; and (2) the essential steps that need to take place before and after transfer are executed. By default, facilitation of successful care transitions becomes the responsibility of patients and their caregivers, who often do not possess the necessary health care self-management skills or confidence to assume this role.

Core Concepts of Transitional Care Management (TCM)

1. A comprehensive assessment of an individ­ual’s health goals and preferences, physical, emotional, cognitive, and functional capaci­ties and needs, and social and environmental considerations.

2. Implementation of an evidence-based plan of transitional care.

3. Care that is initiated at hospital admission, but extends beyond discharge through home and telephone visits.

4. Mechanisms to gather and appropriately share information across sites of care; engagement of patients and family caregivers in planning and executing the plan of care; and

5. Coordinated services during and following the hospitalization by a health care professional with special preparation in the care of chroni­cally ill people, often a master’s-prepared nurse.

The goal of improving care transitions across these multiple sites can be achieved through a patient-centered interdisciplinary team model that is comprised of five components:

1) A patient-centered record that consists of the essential care elements for facilitating productive interdisciplinary communication during the care transition

2) A structured checklist of critical activities designed to empower patients to enlist interdisciplinary collaboration throughout the transition

3) Nurse Transition Coach facilitated patient activation and self-management sessions designed to help patients and their caregivers understand and apply the first two elements, and assert their role in managing transitions

4) Nurse Transition Coach follow-up visit(s) in the home with accompanying phone calls designed to sustain the first three components and provide continuity across the transition.

5) An ANP for providing timely medical intervention in working with the PCP to adjust treatment including medication administration in the home to prevent re-hospitalization and to extend to a medical centered model.

The Transitional Care Team members function as facilitators of interdisciplinary collaboration and care continuity across care settings, coaching the older patient and caregiver/s to play an active and informed role in care plan execution. The Transitional Care Team members first interact with patients upon hospital admission to ensure a smooth transition to post-acute care with the goal of returning to home. The team’s role is not to be a service broker or care manager, but rather, to provide information and support for the patient in identifying concerns and problems and building relationships with practitioners. While the ANP’s role is to intervene when appropriate to provide medical treatment and changes to the treatment plan in conjunction with the patient’s primary care physician.

To be effective in administering a transitional care program use of a dedicated model that focus on four pillars per Eric Coleman a pioneer in transitions of care and standard model used by an overwhelming number of facilities.

The following is a list of the tools and support for each of the four pillars that the transitional care team would focus on:

1. Medication self-management:

• Tools include an up-to-date Medication List, having reconciled the pre and post hospital regimens, to be clarified by the patient with the Primary Care Practitioner.

• Support includes education based on patient’s needs, review of new medications, side effects, adverse drug reactions, and guidance in developing a patient-oriented medication management system.

2. Use of a patient-centered record:

• Tools include a patient-specific Personal Health Record (PHR) prepared by the patient or Transition Coach, but managed by the patient/caregiver, to facilitate cross-site communication and ensure continuity of care across different practitioners and settings.

• Support includes teaching the patient how to manage the PHR, its components, how to update the data, and the value of taking it everywhere.

3. Primary Care and Specialist follow-up:

• Tools include use of the PHR as a guide for preparation of an effective and productive follow-up visit with the Primary Care Practitioner or Specialist.

• Support includes discussion involving the patient’s concerns, topics to be discussed with physician, future health care plan, and health maintenance issues.

4. Knowledge of Red Flags:

• Tools include information sheets explaining self-management of chronic illnesses (causes, signs, symptoms and care), and medication information sheets explaining the purpose, use, warning signs, side effects, and storage tips for each medication.

• Support includes explanations of above and education based on the patient’s diagnoses, history, level of understanding, and ability to assimilate the information.

Hospital Process and Content

A priority goal of the hospital visit is to relate the four pillars to patient needs and priorities. All patient contact is based on the four pillars: Medication self-management, the Personal Health Record, the Primary Care Physician or Specialist follow-up, and review of Red Flags.

1) Medication Management:

· Reinforce importance of knowing each medication: why, when and how to take what is prescribed. The pharm techs gather a medication history in the emergency room for all Medicare Beneficiary providing a basis for a better medication reconciliation process at discharge. The pharmacists provide the medication reconciliation prior to discharge and identify patients that would benefit from a medication to bed program and have physicians provide prescriptions to fill in-house prior to discharge so patients can receive medications and be educated prior to going home.

Encourage patient to ask the nurses and/or discharge planners to review the list of medications one by one, to write down any extra instructions or details, and to ask questions such as:

o “What is this medication for?”

o “How often do I need to take it?”

o “For how long?”

o “Will this interact with any of the medications I’m taking at home?”

· Introduce new medications

· Review status of pre-hospital medications (determine whether necessary to continue to take, adjust dosage, or discontinue)

· Review Side Effects/Adverse Drug Reactions (ADRs)

· Reiterate importance of adherence to a regimen

· Identify possible problems with refilling prescriptions (e.g. transportation, cost, etc.)

2) Personal Health Record (PHR)

· Use the PHR (especially the Discharge Checklist section) to guide the conversation in the hospital.

· Explain the PHR has information about the patient and her/his health care that every health care practitioner needs to know.

· Work with patients in developing and writing down (on the PHR) patient-specific questions to ask hospital doctors, nurses and discharge planners such as “What is my plan?” and “Where am I going?”

· Encourage patient to:

o Bring the PHR everywhere, (doctor visits, Emergency Department, vacation, etc.) and share it with all practitioners (e.g., therapy, PCP, Specialists, home health care nurses).

o Use the PHR as a mechanism for getting important questions answered.

3) PCP or Specialist follow-up:

· Enlist patient’s involvement in scheduling an appointment with the PCP or Specialist as soon as possible after discharge:

o to discuss the reasons that brought the patient to the hospital in the first place

o to discuss any new medications or old medications that have been added, discontinued, or dosages changed

o to discuss any change in health status or adverse events since hospital discharge

o to discuss the patient’s future health care and maintenance plan (e.g., how the patient can be proactive in preventing a recurrence of the problem)

o to refer the patient to additional services or specialty care as needed

· Assist in empowering patient to maintain collaborative partnership with PCP and/or Specialist.

4) Red Flags:

· Alert patient to disease-specific warning signs and symptoms

· Instruct patient how to access health care system, including nights and weekends: “Call your Dr.’s office immediately if any of the following occur: fever, bleeding, confusion, uncontrollable pain, increased tiredness.”

TCM programs that include such an expanded team can meet many needs for patients and their caregivers including the necessary education for chronic conditions as well as addressing the many SDOH issues that lead to readmissions. This author has used this program at different types of healthcare facilities including safety net academic level 1 trauma hospital with rates dropping from 21.5% to 15.8% over a 3-year period and was able to maintain that rate ongoing. While there is an investment in personnel the outcomes will pay for the investments in terms of the value-based program decrease in penalty from the HRRP and increase in Star rating and improvements in Medicare payments under the VBP. Included in the TCM at the academic program was a BCPI program that had many of the same diagnosis as the HRRP chronic conditions that saw cost reduction and improvement in health over the 90-day period with increase in revenue in the millions of dollars. The same program also treated Sepsis patients with reduction of readmissions from over 30% to just over 16% in 2 years while decreasing mortality at the same time with the NP being the primary driver of the care for those patients under the TCM program. That data was provided by HSAG (Health Services Advisory Group) a contracted company by Medicare that is intended to work with hospitals and healthcare facilities to improve the outcomes for patients. They are an external quality review organization.

Any facility of healthcare entity seriously wanting to bend the curve on readmissions and quality outcomes should consider a true TCM team not just a TCM nurse or social worker.

[1] Social Network as predictor of Hospital Readmission and Mortality Among Older Patients with Heart Failure, FERNANDO RODRI´GUEZ-ARTALEJO, MD, PhD, Journal of Cardiac Failure Vol. 12 No. 8 2006 [2] Cavillo-King et al.: Social Factor Impacton Readmission or Mortality, Journal of Internal Medicine 28(2); 269-82, 2012 [3] Transitional Care: Moving patients from one care setting to another. Mary Naylor, PhD, RN, FAAN and Stacen A. Keating, PhD, RN, Am J Nurs. 2008 September ; 108(9 Suppl): 58–63 [4] Transitional Care of Older Adults Hospitalized with Heart Failure: A Randomized, Controlled Trial, Mary D. Naylor, PhD, Dorothy A. Brooten, PhD, Roberta L. Campbell, PhD, Greg Maislin, MS, MA, Kathleen M. McCauley, PhD, and J. Sanford Schwartz, MD, JAGS 52:675–684, 2004 r 2004 by the American Geriatrics Society