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 Naphtali.edge@emoryhealthcare.orgCynthia Burke, Atlanta Regional Commission cburke2@atlantaregional.com

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