4 strategies to improve care transitions

The mission to improve Grand Rapids, Mich.-based Spectrum Health's care transitions started with a dog.

After his family dog Dutch, was hit by a car, Jay LaBine, MD, Associate CMO of Spectrum Health, took him to the local animal hospital. Before the dog was released, the veterinarian sat down with Dr. LaBine for forty-five minutes giving in-depth instructions on how to care for Dutch at home. Later that day, Dr. LaBine went to his hospital to conduct rounds.

"I literally discharged seven people in 30 minutes," he said. "I thought to myself, 'We've got a problem. We need to address these issues in a more robust, systematic way.'"

Dr. LaBine discovered the unsettling reality that a veterinarian took more time with a pet owner to explain the care expectations for a recovering dog than a physician might spend with a human patient preparing for discharge. This realization led to his partnership with Clay Richards, CEO of naviHealth, a Cardinal Health company, to better manage the care transitions at Spectrum Health. Mr. Richards and Dr. LaBine discussed the importance of effective care transitions and shared strategies to improve this process during a panel discussion at the Becker's Hospital Review 5th Annual CEO + CFO Roundtable on Nov. 9 in Chicago.

The need for strong care transitions
According to the Medicare Payment Advisory Commission, 43 percent of Medicare patients leaving the hospital today will enter some type of post-acute care, which results in a tremendous amount of spend, said Richards. He estimates the healthcare industry spends more than $100 billion on post-acute care annually.

"Post-acute care is the wild wild West of healthcare," said Mr. Richards, since practice patterns in the industry vary greatly by region. He cited a 2013 study commissioned by the Institute of Medicine that found variation in post-acute care spending accounts for 73 percent of variation in total Medicare spending.

This unbridled utilization and extreme variance in post-acute care is coupled with a very challenging demographic, according to Mr. Richards. By 2025, the population aged 65 and over is projected to grow by 41 percent, citing research from the U.S. Census Bureau. This aging population will place increasing demand on the care transition system already burdened with extreme variance and unsustainably high costs.

Mr. Richards also discussed the lack of technology resources available to provide critical information for effective care transitions decision-making that are prevalent elsewhere.

"If I want to find a bagel shop half a mile from here, I can go on Yelp, find ten different bagel shops and learn everything about them and the user experience," he said. "Contrast that to four years ago when I was starting naviHealth and my grandmother was being discharged from the hospital. When my family asked where to send her, the hospital gave us a single, printed sheet of paper with addresses and phone numbers. That is not an informed patient choice."

“With increasing spend, tremendous variance and minimal application of modern day conveniences or data to support the decision-making process, it's not surprising to see an explosion of cost in the realm of care transitions,” said Mr. Richards.

How to improve care transitions
naviHealth was founded in 2011 to work directly with both payers and health systems to manage post-acute care transitions to lower costs and achieve better patient outcomes and satisfaction.

With a growing focus on the evolving post-acute space, Mr. Richards envisions a healthcare industry where care transitions lower readmission rates, reduce unnecessary utilization and use data to drive better network decision-making, while improving the patient's overall healthcare experience.

Here are four strategies Mr. Richards and Dr. LaBine identified to improve care transitions and achieve this vision.

1. Focus on the care model, not the business model
Before partnering with naviHealth, Dr. LaBine said nurses at Spectrum Health would try to connect with hospital discharge planners and nursing home staff in charge of managing a patient's stay through utilization management techniques. During communications with the nursing home, nurses discovered these facilities often kept patients at the facility for longer than medically necessary, recognizing the financial benefits associated with a prolonged stay.

"Nurses kept coming up to me saying, 'this patient really wants to go home but the care facility won't let him,'" said Dr. LaBine. "The system was driven more by the business model than the care model. That was one of the first things I identified as a tremendous opportunity to improve upon."

2. Understand a patient's functional status
To improve the first care transition from hospital to post-acute care, clinicians and hospital staff must fully assess the condition of the patient, considering their activities of daily living, cognition and ability to walk, among other factors.

"Diagnosis does not drive the variance in post-acute care," said Mr. Richards. "Our data revealed understanding a patient's functional status as the big driver."

Understanding and assessing a patient's individual functional status in the hospital allows clinicians and hospital staff to better predict not only where a patient needs to go for post-acute care, but also the length of stay, therapy requirements and estimated discharge date.

3. Conduct more "warm" handoffs
When looking at data for Spectrum Health, Dr. LaBine identified a 35 percent medication error rate between hospitals and skilled nursing facilities.

"In one case, there was a 65-year-old stroke patient who was discharged from the acute care hospital to the skilled nursing facility," he said. "He had dysphasia and a peg tube in, yet there was an order for a general diet."

To fix this disconnect between care management in the hospital versus skilled nursing facilities, Spectrum Health instituted more warm care management handoffs to improve communication. In these warm handoffs, primary care providers meet face-to-face with a staff member from the post-acute care facility to talk about the care transition process and review all care orders for the patient, immediately making corrections and adjustments where necessary, discussed Dr. LaBine.

4. Complete proactive discharge planning
In typical care transition processes, discharge planning starts two days before a patient leaves the post-acute care facility, typically between day 20 to day 22, shared Mr. Richards. Through naviHealth's care transition system, a discharge plan is made as soon as the patient is admitted to the post-acute facility. This proactive discharge planning identifies the exact number of days the patient should stay at the facility to achieve the desired functional goals — valuable information for both payers and the patient's caregiver or family.

Proactive discharge planning also aids patients' transition from the skilled nursing facility to their homes by highlighting any non-clinical needs patients might have — like feeding or bathing — giving families plenty of time to figure out how to meet those needs, whether themselves or through a home care service.

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