A New Era For Coordinated Care

With the Centers for Medicare and Medicaid Services now reducing payments to hospitals with high readmission rates, providers are scrambling to find ways to reduce their numbers. One potential panacea is care coordination.

This kind of comprehensive, in-depth care is being piloted around the country and the cut to the pocket book has placed hospitals at the helm of the change.

The Affordable Care Act established the Hospital Readmissions Reduction Program, allowing CMS to reduce Medicare payments to hospitals with high readmission rates.

The CMS looked at three areas: acute myocardial infarction, heart failure and pneumonia. Hospitals with high numbers of patients who return within 30 days of discharge (compared to the national average) are losing up to 1% of Medicare funding this fiscal year. The total penalties are expected to be $280 million assessed to more than 2,200 hospitals nationwide.

Under the ACA, the penalty will increase to up to 2% in 2014 and 3% in 2015. Other conditions, such as cardiac bypass surgery and other procedures in 2015.

“I think hospitals, with the new penalties, are feeling the financial impact the most,” said Janelle Shearer, a program manager at Stratis Health. “Payment penalties are a driver for them.”

Stratis is a nonprofit organization based in Bloomington, Minn. that was contracted by CMS to spend three years focusing on improving care for Medicare beneficiaries in the state. One of its charges was to reduce hospital readmissions.

Stratis is working with hospitals and other partners like nursing homes and primary care providers using evidence-based models of support. What the organization found was a handful of areas that can make a big impact on readmissions. These include the discharge process, medication management, patient and family engagement, communication with other providers and transition care support. 

In-house, Stratis is working with hospitals to ensure that the discharge process is sufficient. Providers, Shearer said, need to make sure the medication list is understandable to a patient and they know the goals of their care at home.

Stratis is also helping hospitals with process mapping – teaching an organization to look at its business, find out where there are gaps and create a process for improvement. When they find their weak points, whether it’s discharge or transitional care, they have training to help improve. 

“In the past, a patient was discharged and you were done with them basically,” Sherer said. “And now we are working past that. I think hospitals are realizing they can’t do it alone – they have to work with primary care providers or public health or nursing homes.”

This is exactly what Mercy Health, a system of providers located in Northwest Ohio and Southeast Michigan found during a recent pilot program to reduce admissions.

Mercy’s program worked with four nurse care coordinators embedded in primary care offices. It worked with 310 patients over a year’s time. Hospital admissions were decreased by 51%, emergency room visits went down by 37% and hospital readmissions dropped more than 35%.  

The goal was to provide in-depth care for high risk patients, said Lynne McCabe, director of the community care coordination programs for Mercy’s parent organization, Catholic Health Partners.

Mercy focused on a list of people that included patients with COPD, heart failure and diabetes who had difficulty meeting physician orders or repeat hospital visits over the past nine months. They also included people who live at home and didn’t have support, were illiterate or had a history of falls or wounds.

The care provided was in-depth; most patients stayed in the program for at least six months, McCabe said.

Mercy would start with follow-up calls after patients were discharged. If those didn’t seem to be working or people were calling in a lot, they would go to their homes. While there, they would perform anything from medication reconciliation to running a family meeting to find resources for a patient.

When Mercy employees went into people’s homes, they found issues such as a patient who was taking 23 pills and would just dump them all in a basket and take a handful at a time – she would just try to take ones that looked different with each dose. They found one woman who was on blood thinners and had a broken, sharp fixed bannister that might have caused a cut. They also helped find homes for a patient’s pets so they could go to assisted living.

“This was face-to-face with frequency of follow ups and home visits and really seeing what needs are there,” McCabe said. “We used behavioral health or social workers and it was about having someone delving in and doing research and using out-of-the-box resources.”

The program was such a success that Mercy is now serving 13 practices with the goal of having 30 coordinators by the end of 2013. They would also like to expand to create a care coordination team that could include a dietician and pharmacist.

The program was initiated with a $500,000 grant, but McCabe said Mercy didn’t use all of that money. Mercy is funding the program now and she said the organization expects to see a return as they meet quality metrics and see reduced admissions.