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Transcript of Naphtali Edge, Emory University Hospital Midtown [email protected] Cynthia Burke,...
Care Coordination and Transition
A hospital’s journey to partner with a community-based organization (CBO) to improve care across the continuum
Naphtali Edge, Emory University Hospital Midtown [email protected] Burke, Atlanta Regional Commission [email protected]
THE PERFECT STORM
• 1 in 5 MEDICARE PATIENTS READMIT WITHIN 30 DAYS
• AFFORDABLE CARE ACT
• HEALTHCARE PARADIGM SHIFT
• MEDICARE PENALTIES
CMS Community-based Care Transitions Program
• Empowering the patient
• Patient-centered goals
• Tools that focus on the patient
• Medication reconciliation
• Discharge plan of care
• Making f/u appointments
• Recognizing red flags
• Using a personal health record
End of Contract Year June 2012-January 2013
• 1 full time coach
• Average 90 patients enrolled/quarter
• Participant readmission rate – 17.4
(2010 baseline 23.6)
February 2013-January 2014
Goals:
• Increase footprint and enrollment
• Maintain low readmission rates
• Continue to target high risk participants
Quality Improvement Measure For Program Growth
September, 2013
PLAN
DO
STUDY
ACT
1. Outcome Measure - readmission rate
2. Process Measure - referral rate
3. Balancing Measure - eligibility rate
CMS Metrics to Monitor
PLAN
Integrate direct referral process
Increase program introduction at bedside
Add staff with proven track record in mental health
and substance abuse counseling/therapy
Offer inpatient intervention for those outside catchment area
DO
• Redefine data warehouse census report. Secondary screen by RN case managers
• Q2-3 2013 2 new coaches were hired with expertise working with patients with
underlying mental health, depression, and substance abuse
• Recruit and hire an additional coach Q4 2014.
• Develop in-hospital schedule for all CCTP community coaches providing inpatient
interventions augmenting community interventions to meet weekly caseloads.
STUDY
• Percentage of eligible referrals meeting CCTP criteria increased Q4 2013 to Q2 2014 by 8% (53%-57%)
• Percent of bedside consults for those eligible increased Q3 2013 to Q2 2014 by 43% (40%-57%). During the same timeframe, there was a significant decrease in decline rates of -79% (38%-8%) and increase in enrollment (HV) rates by 111% (36%-76%) of those eligible to participate.
• During timeframe Dec 2013 through July, 2014, there were 692 referrals, 618 eligible, and 186 were enrolled.
MISSED OPPORTUNITY: 432 patients discharged before intervention
ACT
18.8% 19.6% 14.6% 20.0% 7.7% 4.9% 6.3% 2.7%Q3
2012Q4
2012Q1
2013Q2
2013Q3
2013Q4
2013Q1
2014Q2
2014
0
50
100
150
200
250
300
350
8092 96
70 65
185
237
332
15 18 14 145 9 15 9
Sum of Enrolled Sum of Readm
INCREASED ENROLLMENTS/FOOTPRINT
IS automated referral designImproved efficiency by reducing the amount of time to screen patients Secondary screening by existing CT clinicians facilitating high risk stratification for “the right” referrals.
80% increase in potential footprint
4% pre-direct referral, prior to Q4 201320% post-direct referral, quarter 2013 and beyond
ACT
SUSTAINED REDUCTIONS IN READMISSIONS
Barriers • Limitations within Data Warehouse• Staffing capacity to enroll all patients,
especially those outside catchment area• Lack of engagement by hospital staff
• Ongoing refinement of referral process• Maximize inpatient interventions• Build staff capacity to enroll all eligible patients• Sustain engagement of patients post DC
• Improve visibility of service within hospital• Educate staff• Share collective impact across
Solutions
THE FUTURE OF OUR PARTNERSHIP• Year 3 and 4 renewal
• Continue to monitor program growth in relation to demand
• Expanding reach into short term sub-acute rehab
• Program stratification
• Scheduler to maximize deployment of community coaches
• hospital based coach to increase bedsides and improve program visibility within
hospital, improving acceptance rates and collaboration for collective impact