American Case Management Association - Transitions of Care Learning Collaborative

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ACMA TRANSITIONS OF CARE LEARNING COLLABORATIVE 2019 / 2020 Leveraging ACMA’s Transitions of Care standards to guide and improve care transitions Findings from a six-health system learning collaborative.


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Authors Marlene Bober, RN, MHA, ACM-RN, is vice president, practice development, American Case Management Association Kathleen Ferket, MSN, APRN-BC, is senior consultant, Transitions of Care and Simulation Programs, American Case Management Association

Acknowledgements ACMA thanks the leaders of the six organizations who participated in the TOC Learning Collaborative. Their commitment to the project, pre- and post-assessment, and utilization of the TOC Standards, especially during the initial COVID-19 pandemic, is a tremendous contribution to improving care transitions. We could not advance and improve safe care transitions for our patients without these committed leaders and their organizations. We also acknowledge and appreciate Pfizer for its continued sponsorship of the TOC Standards and the support provided to conduct this ACMA Learning Collaborative.


Click on the Transitions of Care logo at any point to return to the CONTENTS page

CONTENTS

Click on any section listed below and be taken to that section.

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The TOC Learning Collaborative

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Learning Collaborative Participants

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What the Learning Collaborative Did

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Accomplishments and Next Steps

Case Studies 11

Advocate Aurora Health

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Duke University Health System

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Inova Health System

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Memorial Hermann Health System

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St. Francis Hospital and Medical Center

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Tenet Health

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TOC Self-Assessments and Findings

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Next Steps

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Appendixes Appendix A: COVID-19 and Care Transitions

48 Appendix B: Key Takeaways from TOC Learning Collaborative Webinars

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The TOC Learning Collaborative

THE TOC LEARNING COLLABORATIVE Value-based care has gained traction and more attention is being paid to care transitions, not only to improve patient outcomes but also to reduce costs related to unnecessary readmissions, emergency department (ED) visits, and other expensive services. Nearly 20 percent of hospitalized Medicare patients are readmitted within 30 days of discharge, costing more than $26 billion a year.* To financially incentivize health care organizations to better coordinate care and improve care transitions, the Centers for Medicare and Medicaid Services (CMS) instituted hospital readmission penalties and rolled out value-based payment programs, including the Bundled Payments for Care Improvement (BPCI) program and the Medicare Shared Savings Program (MSSP). From ACMA’s perspective, the heightened attention on care transitions is a very welcomed development. ACMA understands how important care coordination is to a safe and effective care transition; when patients and families are unsupported by a strong discharge plan, it places vulnerable patients at risk for poor outcomes. At the same time, we know that ensuring safe, effective transitions of care for all patients, particularly high-risk patients, is a complicated undertaking. The term transitions of care refers to the movement of patients — between health care locations, providers, or levels of care as their conditions and care needs change — and the set of actions designed to ensure coordination and continuity. In any one particular care transition, a variety of factors can make it more difficult for acute, post-acute, and ambulatory care providers, as well as payers, to collaborate, coordinate care, and exchange critical information about patients. Recognizing these challenges, ACMA developed the Transitions of Care (TOC) standards (see sidebar on page 5). Published in January 2019, the five standards are intended to guide care managers and other health care professionals in identifying and implementing the necessary processes and approaches to ensure smooth transitions. Effective transitional care can prevent medical errors, identify issues for early intervention, avert unnecessary hospitalizations and readmissions, support consumers’ preferences and choices, and avoid duplication of services, thereby improving the quality of care while utilizing resources more effectively.

* Centers for Medicare and Medicaid Services. Community-Based Transitions Program. Updated July 7, 2020. https://innovation.cms.gov/innovation-models/cctp

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ACMA Transitions of Care Standards Standard 1

Standard 2

Standard 3

Standard 4

Standard 5

Identify patients

Complete a

Perform and

Establish a

Communicate

at risk for poor

comprehensive

communicate

dynamic care

essential care

transitions

transition

a medication

management

transition

assessment

reconciliation

plan that

information to

addresses

key stakeholders

all settings

across the

throughout the

continuum of

continuum of

care

care

Visit transitionsofcare.org for details on each standard, consensus measures, and more. To assess the effect that the standards have on care transitions in a real-world environment, ACMA launched the TOC Learning Collaborative, which ran from December 2019 to June 2020. The collaborative had four primary goals: • To test the implementation of ACMA’s TOC standards in real-world health system environments across a variety of U.S. regions. • To identify innovative or effective practices, as well as challenges and barriers, that may impact implementation of the standards. • To ask health care organizations to assess their compliance with the TOC standards, identify and pursue opportunities for improvement, and then reassess compliance to determine progress made. • To share results and lessons learned from the TOC Learning Collaborative to guide broader adoption of ACMA’s TOC standards.


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Since the collaborative was launched in late 2019, the COVID-19 pandemic caused some delays and interruptions to the Learning Collaborative’s schedule. In the first several months of the pandemic, hospitals in certain parts of the country were overwhelmed with COVID-19 patients and the work of the collaborative was re-prioritized due to the national emergency. (See Appendix A for details.) While modifications were made to the timeline, the Learning Collaborative’s goals were achieved, and findings were enhanced by application of the TOC standards at this critical time. This report provides case studies from participating hospitals that highlight specific approaches taken to improve care transitions. It also contains practical real-world implementation advice that can be adapted for use in a variety of different care settings.

LEARNING COLLABORATIVE PARTICIPANTS ACMA acknowledges the care management leaders and staff at the following organizations for the time and energy they put into the Learning Collaborative: •  Advocate Aurora Health, an integrated health system with more than 500 sites of care across Illinois and Wisconsin. •

Duke University Health System, an academic health system based in Raleigh-Durham, N.C.

Inova Health System, a five-hospital system based in Falls Church, Va.

•  Memorial Hermann Health System, a health system with more than 250 care delivery sites, including 14 hospitals, based in Houston. •

St. Francis Hospital and Medical Center, a 617-bed teaching hospital serving Connecticut that is a member of Trinity Health, a 92-hospital health system.

•  Tenet Health, a publicly traded, 65-hospital system with over 510 ambulatory and other facilities across the United States.

We also acknowledge and appreciate our sponsor Pfizer, which supported the development of ACMA’s TOC standards and continues to support the testing of the standards through this Learning Collaborative.


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WHAT THE LEARNING COLLABORATIVE DID To meet the goals set for the Learning Collaborative, we asked participants to engage in four parallel endeavors between December 2019 and June 2020: assessing their organizations’ compliance with the TOC standards, identifying an opportunity for improvement related to the TOC standards, using established or TOC consensus measures to evaluate outcomes, and exchanging best practices and knowledge with other collaborative participants. Each of these endeavors is described below:

Self-Assessments Each of the six participating organizations conducted a pre- and post-assessment at the beginning and end of the Learning Collaborative (in November/December 2019 and July 2020). For each self-assessment, care management leaders and other staff scored their organization’s compliance with each TOC standard on a scale of 1 to 4, with 1 being “not performing” and 4 being “consistently performing.” ACMA analyzed the data from the pre- and post-assessments and then showed all the participating organizations how their performance compared with other Learning Collaborative members on each standard. This benchmarking exercise was intended to help participants identify the standards on which to focus their improvement efforts. This process also allowed us to identify opportunities based on the assessments of all participants. These opportunities include the following: • Advanced care planning documentation was identified as an improvement opportunity across Learning Collaborative participants (TOC Standard 2). • Medication reconciliation was frequently performed across the Learning Collaborative participants (TOC Standard 3). • The electronic health record (EHR) has contributed to the communication of essential care transition information to stakeholders across the continuum of care (TOC Standard 5).

See TOC Self-Assessments and Findings (page 37) for more about the self-assessments.


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Improvement Opportunities Each of the six participating organizations identified goals related to improving care transitions for a particular patient population. All the goals are tied to one or more of the TOC standards. For instance, Advocate Aurora Health’s goal, which relates to TOC standard 4, was to improve longitudinal care management for Medicare BPCI patients diagnosed with sepsis. As originally planned, the organizations were to implement specific actions to achieve their improvement goals over the course of six to seven months (December/January through June 2020) and then measure the results. The case studies (pages 15–36) detail the specific improvement goals and actions taken by each participant. Due to COVID-19, some of the case studies have not yet demonstrated conclusive outcomes. The pandemic required participants to reprioritize staff and resources. As a result, five of the six participants had to delay or modify their improvement plans. One exception was Inova Health System, which implemented improvement plans in January 2020 before COVID-19 hit. Inova’s goal was to ensure that transitions of care calls occurred soon after hospital discharge for MSSP patients. This initiative was in addition to work Inova had already formalized in collaboration with system and community physician partners to identify at-risk populations and reduce readmissions. ACMA acknowledges the Inova team’s efforts, which are described in detail in the case study on page 20. Early results suggest that the specific improvements taken, which included using the state’s health information exchange, are making a difference. All-cause readmissions for Inova’s MSSP patients have been declining.

TOC Consensus Measures and Other Established Metrics In addition to developing the five TOC standards, ACMA endorsed nine TOC consensus measures (five outcome metrics and four process metrics) that hospitals, health systems, and payers can use to measure transition of care process and outcomes. A crosswalk of established measures was also created that shows what measures align with each TOC standard and can be used to assess compliance with each standard.


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In the early stages of the Learning Collaborative, participating organizations were asked to identify the TOC standards they would be focusing on improving, as well as the consensus and established measures they would be using to monitor their progress. Each organization’s case study lists the measures they chose to use, when relevant.

Sharing of Knowledge and Best Practices All participants in the Learning Collaborative were asked about the barriers and challenges they faced in improving care transitions. Three common issues were identified as the most prevalent: • Ensuring longitudinal care management to provide continuity of care across a patient’s entire care experience •

Navigating challenges related to post-acute care transitions

Responding to care management workforce challenges across the continuum

ACMA held three interactive, web-based learning sessions aligned to each of these challenges. During the first half of these events, best practices from the research and the interviews with care management leaders at the six participating organizations were presented. The second half of the events was devoted to open discussion and sharing among the participants. From these interactive sessions, ACMA identified numerous best practices, lessons learned, challenges, and barriers. Appendix B includes key takeaways from all three webinars.


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ACCOMPLISHMENTS AND NEXT STEPS Despite COVID-19-related challenges and setbacks, the Learning Collaborative has successfully engaged care managers. This is evident through: • Validation from collaborative members that the TOC standards provide actionable guidance to improve transitions of care across the continuum. “We used the TOC standards to assess our current processes and infrastructure,” said Inova’s Tonya Kirchmyer, BSN, director of care management, Signature Partners in Health. “The assessment highlighted opportunities that offered substantial benefit to patient transitions with the fewest barriers to implementation.” • 100 percent participation by collaborative members in the webinars and discussions. • Satisfaction survey results indicating that collaborative members were extremely satisfied with the webinars and discussions. • Feedback from members saying that the collaborative helped them develop relationships with other participants and the opportunity to share best practices. These relationships proved particularly helpful in comparing and brainstorming solutions brought on by the COVID-19 pandemic.

ACMA’s Learning Collaborative has succeeded in achieving the established goals. The Learning Collaborative started by enlisting six hospitals and health systems from various parts of the country to test the TOC standards and consensus measures in real-life environments. Next, leading best practices were identified that health care organizations could use to implement the standards and address challenges to improving care transitions. Finally, this white paper begins the process of supporting other health care organizations in adopting ACMA’s TOC standards to achieve the critical mission of improving care transitions. It is ACMA’s hope that the case studies and practical information provided throughout this white paper are helpful and useful in supporting efforts to improve care transitions.

We used the TOC standards to assess our current processes and infrastructure. The assessment highlighted opportunities that offered substantial benefit to patient transitions with the fewest barriers to implementation. Tonya Kirchmyer | BSN, director of care management, Signature Partners in Health


Case Study

Photo: Advocate Aurora Health

Advocate Aurora Health is a large integrated health system with more than 500 sites of care across Illinois and Wisconsin.

Improvement project goal: Improving longitudinal care management for Medicare BPCI patients diagnosed with sepsis. TOC standard(s) addressed: Standard 4 Process/outcome measures: The following established measures, which align with TOC standard 4 (see ACMA’s TOC metric alignment list): • Implementation of practices/processes for care transition that include documentation. (MIPS measure IA_CC_10) • Provide episodic care management, including management across transitions and referrals. (MIPS measure IA_PM_15) • Admission to hospice in less than three days before death. (CMS IQR and OQR 216) Results: Pending.

Advocate Aurora Health* sees longitudinal care management as a critical aspect of its value-based care journey. The large Midwestern health system currently cares for more than 1 million lives under risk-based payment contracts, including Medicare’s BPCI program, which financially rewards or penalizes Advocate Aurora based on the quality and cost of care outside as well as inside the hospital. “To succeed in that space, you have to take a long view, or longitudinal view, of the patient,” said Sherri Aufderheide, DNP-RN, executive director, inpatient care management and utilization management. * Only Illinois-based hospitals and providers in the Advocate Aurora Health system participated in the ACMA Learning Collaborative.

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When Advocate Aurora joined ACMA’s Learning Collaborative, the Midwestern health system already had years of experience working to improve transitions of care, including the establishment of an affiliated post-acute network. The biggest challenge Advocate Aurora faced was the lack of an enterprisewide electronic health record (EHR) that all providers across the continuum could use to share and access patient information. Home health, inpatient care management, affiliated post-acute facilities, and primary care physicians all had different documentation systems, which led to communication gaps. “None of those systems really talked to each other, and there was no easy way for us to see everything that was happening with the patient across the system,” Aufderheide said. For the ACMA Learning Collaborative improvement project, Advocate Aurora decided to begin tackling this communication gap problem. Aufderheide assembled a multidisciplinary team to work on improving care transitions for Medicare BPCI patients diagnosed with sepsis. After the COVID-19 pandemic began, the team continued to meet virtually with the goal of developing a longitudinal care management plan that could be used by care managers across settings to coordinate care for BPCI sepsis patients. The team has been helped in its efforts by a parallel effort to launch an Advocate Aurora systemwide EHR.

Advocate Aurora’s Established Processes and Practices In 2018, Advocate Aurora created a systemwide integrated care management structure. This integrated structure ensured a centralized leadership model. The health system also standardized care management processes to support longitudinal care management. For example, for complex inpatients going home, the inpatient case manager conducts a warm handoff with the outpatient care manager and/or a nurse navigator. A warm handoff is a care transition conducted between two members of the care team in front of the patient and/or family. In another example, inpatients who go to a skilled nursing facility (SNF) in Advocate’s post-acute network are followed by embedded, employed advanced practice nurses (APNs) and physicians at the SNF. The SNF physician and APN work with the patient on discharge plans and hand the patient off to the next level of care (e.g., home health, primary care).


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To help with social service referrals, Advocate uses a digital platform, which has a robust database of local community agencies that can help patients with food insecurity and other social determinants of health, or nonmedical factors that impact health outcomes. The technology app allows for closed loop referrals. When a health care provider refers a patient to a participating food pantry, the food pantry would document in the app that the patient came to the pantry and the provider would be able to monitor this access. Advocate Aurora’s post-acute network currently has more than 35 affiliated SNFs across Illinois. To identify potential SNFs to collaborate with, the health system’s accountable care organization (ACO) determined which facilities Advocate Aurora hospitals refer to the most due to location, quality scores, and other factors. To join the network, SNFs had to agree to a variety of quality-related requirements, including having a licensed, registered nurse (RN) on-site 24/7 and establishing effective discharge planning processes.

Advocate Aurora’s Improvement Charter Care management staff at Advocate Aurora decided to focus on improving longitudinal care management for BPCI patients with sepsis because of the large volume of BPCI patients affected by this diagnosis. In addition, they wanted to build on the work they had already done to improve care coordination for BPCI patients. A multidisciplinary team, with representatives from inpatient, ambulatory, and post-acute, began to tackle the challenge by looking at existing processes and tools used to coordinate care for sepsis patients — from hospitalization through discharge to post-acute and/ or home. The team found a lot of variability in the transition process for sepsis patients, with no consistent protocols or tools used. The effectiveness of handoffs between sites was primarily dependent on the care managers’ communication abilities and approaches. “Some care managers would have specific communications to hand off between places, while others were not as proactive in their communications,” Aufderheide said. “So, it is a person-dependent process. Because we are all currently on different EHRs, it is difficult to make it a system-driven process.” To address the shortcomings in the existing process, the multidisciplinary team developed an interim, paper-based longitudinal care pathway for BPCI sepsis patients to guide care sites in documenting and exchanging needed information during care transitions. This initiative aligns to TOC standards 2 and 4. The longitudinal care pathway is also being used to inform the creation of a soon-to-be-launched longitudinal care record in Advocate Aurora’s EHR.


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Concurrent with the team’s work, Advocate Aurora has been converting hospitals, ambulatory sites, and other providers across the health system to a single EHR, which will allow all care sites to view and document in the same patient record, creating a longitudinal care record that tells a patient’s complete story from hospitalization through discharge to post-acute and/or home. The final phase of the EHR conversion, which involves bringing all Advocate Aurora hospitals in Illinois onto the health system’s common EHR platform, was scheduled to occur before the end of 2020. The multidisciplinary team anticipates the EHR conversion will help the health system improve care coordination and communication across care sites for all patients, including BPCI sepsis patients. In addition, Advocate Aurora has begun using EHR reporting functionalities, as well as a third-party software, to send electronic alerts to care managers when patients transition to different sites of care. This should also help address communication gaps. While the longitudinal care plan has not yet been implemented, Aufderheide believes the Learning Collaborative’s improvement project has helped to improve care coordination for BPCI patients with sepsis. “Just bringing those groups of people together to work on the project has enhanced our communication around care coordination,” Aufderheide said.

Just bringing those groups of people together to work on the project has enhanced our communication around care coordination. Sherri Aufderheide | DNP-RN, executive director, inpatient care management and utilization management


Case Study

Photo: Duke University Health System.

Duke University Health System is an academic health system based in Raleigh-Durham, N.C.

Improvement project goal: Improve transitions of care across the continuum by creating a stronger relationship and consistent handoffs and communication among the inpatient cardio-thoracic surgery team, DukeWELL, Duke Home Care & Hospice, Duke Primary Care, and Duke Private Diagnostic Clinics TOC standard(s) addressed: Standards 1, 2, 3, 4, and 5 Process/outcome measures: Duke selected five TOC consensus metrics as well as other relevant metrics: TOC standard 1: Evidence of completion of health risk assessment (CMS IQR/OQR 262) TOC standard 2: •

Evidence of advance care planning discussion (CMS IQR/OQR 0326)

• Receipt of discharge information (HEDIS TRC) TOC standard 3: • Better understanding of medication adherence as evidenced by fewer incidents of fluid overload •

Identify and manage barriers to medication adherence

TOC standard 4: •

Patient engagement after inpatient discharge (office, home, or telehealth) (HEDIS TRC)

• Evidence of longitudinal care management for patients at high risk for adverse health outcomes or risk (MIPS IA_PM_14) TOC standard 5: •

Receipt of discharge information (HEDIS TRC)

Evidence of bilateral exchange of necessary patient information (MIPS IA_CC_13)

Results: Pending.

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One reason Duke

University Health System is investing time and resources in

developing longitudinal care management capabilities is that care team members want to do the right thing for patients by ensuring safe and effective care transitions. A second reason is a chronic inpatient bed shortage. “Our three hospitals are filled beyond capacity every day,” said Pat Kramer, EdS, ACM-SW, CCM, CSW senior director, case management, utilization management, and clinical documentation improvement. “To address this, we want to do everything we can to have patients treated in their primary care office, as opposed to the emergency room. We want to get care managers involved to make sure that patients have the resources they need to take care of themselves and have home health in place to prevent readmission.” A third reason for prioritizing longitudinal care management is the need to reduce avoidable readmissions, which dovetails into Duke’s Learning Collaborative improvement project. Data supported pulling a multidisciplinary and multi-entity team together to figure out how to address coronary artery bypass grafting (CABG) readmission rates, which were stable but above benchmark. The Duke Heart team drilled into the CABG readmissions data and determined that some of the readmissions may be avoidable. “The data supported getting people to the table to collectively discuss improving CABG care transitions,” said Tara Kinard, MSN, associate chief nursing officer, DukeWELL.

Duke’s Established Processes and Practices Duke has an integrated care management function at the system level. Kramer oversees the inpatient case managers, outpatient clinical social workers, and utilization managers. Duke is also trying to break down silos with a cross-functional, cross-organizational team that is trying to coordinate care management functions across all entities. The team meets a few times a month. To help identify patients with a high risk of readmission, one of the tools that the Duke care team members rely on is the readmission risk score, which is automatically calculated for patients in Duke’s EHR. The inpatient case managers have this score pulled into their patient list and use the score to tailor recommendations for post-discharge referrals. The team will also be assessing patients for social drivers of health, documenting the social history as appropriate, and arranging for supportive services post-discharge.


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All high-risk hospital patients are followed by inpatient case managers while hospitalized. Duke also has ambulatory care managers in the health system’s population health office (DukeWELL), who provide care management and care coordination for patients through their continuum. Currently, attributed patients (e.g., ACO contracts, Medicaid managed care) are eligible for longitudinal care management, and inpatient case managers refer eligible patients when they are being discharged. There are pathways into care management and care coordination for non-attributed patients as well. Duke Health has established a collaborative network of 25 SNFs, which is called the HOPE Collaborative. Duke has an open-door policy. Any SNF can join the collaborative, so long as it agrees to certain requirements, such as sharing quality performance data, having a licensed RN on-site 24/7, and ensuring patients have primary care appointments scheduled at discharge. “We decided to include any SNF that met our basic requirements and then help bring them all up to a higher-level of quality,” Kramer said, referring to the aphorism “a rising tide lifts all boats.” Duke has recently formed a similar collaborative for high-value home care providers. The home care agencies that join the program must also agree to share data on various metrics.

Duke’s Improvement Charter In February 2020, a team with representatives from across the care continuum began meeting to discuss how to improve care transitions for CABG patients. Team members include representatives from inpatient case management, DukeWELL ambulatory care management, home care and hospice, the Heart Center, and primary care.


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The team focused on developing a workflow to improve transitions for CABG patients discharging from Duke University Hospital. Data indicated that readmission rates for this patient population was above benchmark. Subsequent team discussions helped pinpoint potential reasons for the high readmission rate in this patient population. “We saw a huge opportunity to improve communication with transitions [related to] who has the ball with this patient and which ball(s) do they have,” said Kinard. “For example, patients could receive post-discharge phone calls from DukeWELL care management, the Heart Center team, home health, their primary care provider’s office, and their surgeon’s office. We saw the potential in mapping processes, such as postdischarge calls, to ensure smooth transitions and avoid duplication of services to streamline the patient experience, minimize confusion, and improve patient outcomes.” Beginning in March, the team’s work had to be put on hold for three months due to COVID-19. But the team resumed meeting in June and mapped out a streamlined workflow that will help Duke care team members know who will be following up with the patient at key points in the care transition. In addition, education will be provided to patients, so they are aware of the various transition points. A warm handoff of the patient will occur between the inpatient case manager and the outpatient care manager prior to discharge home. The workflow covers other key transition points, including home health, cardiac rehab, and cardiology, so that care team members know who is contacting the patient when and about what. “As care managers, we make sure that patients have their follow-up provider appointments and home health set-up,” said Kinard. “We also screen for social drivers of health and coordinate resources, reinforce the patient’s discharge plan, and develop a patient-centered care plan with goals.” Additionally, the Duke Heart Center will be providing CABG-specific training to Duke’s ambulatory care management and home health teams. “This is so we understand what we should be listening to and looking for when we’re working with these patients, and more quickly be able to identify and communicate potential risks or concerns that could result in a complication,” Kinard said.


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“We expect to see a decrease in avoidable readmissions because we have identified opportunities from the TOC assessment,” Kinard said. “We will implement interventions at key transition points that we predict will address some of the reasons CABG patients have been readmitted, such as fluid overload, surgical site infections, etc. We will be working more seamlessly as a team and monitoring these patients more effectively in the outpatient setting.” These interventions align with TOC standards 4 and 5, which address communication and the importance of a dynamic care plan that can be shared across settings.

We want to do everything we can to have patients treated in their primary care office, as opposed to the emergency room. We want to get care managers involved to make sure that patients have the resources they need to take care of themselves and have home health in place to prevent readmission. Pat Kramer | EdS, ACM-SW, CCM, CSW, senior director


Case Study

Photo: Inova Health System.

Inova Health System is a five-hospital system based in Falls Church, Va., which is near Washington D.C.

Improvement project goal: • Increase transitions of care calls within 48 hours of hospital discharge for patients in Inova’s MSSP ACO. • Improve ability for care managers to perform medication reconciliation. TOC standard(s) addressed: Standard 1 Process/outcome measures: Inova chose five of the established measures that ACMA identified for Standard 1, including one TOC consensus measure: •

Notification of inpatient admission (HEDIS)

All condition readmissions (ACO-8)

All-cause unplanned admissions for patients with diabetes (ACO-36)

All-cause unplanned admissions for patients with heart failure (ACO-37)

All-cause unplanned admissions for patients with multiple chronic conditions (ACO-38)

Results: All-cause readmissions for MSSP patients declined by 1.2 percent between December 2019 and March 2020. During the same time frame, hospital admissions in the MSSP population declined by 8.09 percent for patients with multiple chronic conditions, 13.47 percent for heart failure patients, and 7.06 percent for patients with diabetes.

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Inova Health System is successfully leveraging information technology to help care managers identify and assist at-risk patients during transitions of care. For instance, in late 2019, the five-hospital system joined the State of Virginia’s health information exchange (HIE), which allows Inova providers to access and exchange information about their patients with non-Inova providers across the state. In late 2019, Inova’s ambulatory care management team signed up to receive real-time notifications of their patients’ visits to any provider in Virginia, including hospitals and EDs. By gaining visibility into patients’ utilization, the care management team has been able to reach out to at-risk patients more quickly after a care transition — which was one goal of Inova’s Learning Collaborative improvement project. Early results suggest that Inova’s technology-driven approach is working. Readmissions are declining among patients in Inova’s MSSP ACO, which is called Signature Partners in Health. “Now my team can get a notification in real-time when one of our patients visits the ED or gets admitted to the hospital,” said Tonya Kirchmyer, BSN, director of care management, Signature Partners in Health. “That did not happen previously. Now we are able to engage patients in a timelier manner post-utilization of any acute care utilization.” Joining the HIE, known as Connect Virginia, has also proved critical during the COVID-19 pandemic. The HIE flags patients from across the state who have been diagnosed with COVID-19 and makes it easy to see what patients have positive or pending COVID-19 lab test results, no matter where the patient got the test taken. “This has increased our visibility to patients with COVID or suspected COVID so we can activate services and outreach to that patient for follow-up,” said Pamela Andrews, RN, MSW, MBA, ACM-RN, CMAC, CCM, assistant vice president, Inova Health System.

Inova’s Established Processes and Practices Inova leaders are working on developing a systemwide care management structure. To begin this process, Inova conducted an inventory of all care management programs in the health system, as well as referral sources. Current programs include the following: •

The Signature Partners ACO has a multidisciplinary care management team.

• The health system offers a 30-day post-hospital transitional care program to vulnerable patients. • Several physician offices have care managers to support and assist high-risk patients.


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The goal is to develop an integrated care management structure that replaces the current siloed approach. Inova owns a SNF and home care agency. In addition, Inova’s ACO is contracted with 11 SNFs in the community. Inova has a SNF council that identifies opportunities for Inova-SNF collaborations. Inova also has a unique Inova House Calls program. Older patients who are discharged home can receive primary care at home if they are homebound and cannot get to the primary care practitioner’s office. Inova is in the process of implementing a care coordination software solution that will help support bidirectional communication across acute, post-acute, home health, and primary care to improve transitions of care. The tool communicates updates on patient status and care plans from the post-acute facilities. The platform also provides post-acute quality and resource ratings to support patient choice.

Inova’s Improvement Charter For the Learning Collaborative improvement project, Inova set two goals. The first was for care managers to conduct transition of care calls within 48 hours of discharge. During these calls, care managers review and assess patients’ understanding of their medical conditions, medications, follow-up appointments, etc. Receiving daily notifications from the Virginia HIE of what patients visited EDs or were admitted to hospitals outside the Inova health system has helped Inova care managers achieve this goal, not only for MSSP patients but for all patients attributed to providers that are part of the Signature Partners network. This process aligns with TOC standards 1, 2, and 5. “Prior to getting this data from the HIE, we did not know when patients were utilizing the ED or hospital until after the claims ran, which could be a week,” Kirchmyer said. “Receiving this information on a daily basis enabled us to be effective in calling within 48 hours of discharge to all our patients.” Inova’s second opportunity was to improve the accuracy of medication reconciliation, which aligns with TOC standard 3. When care managers made transition of care calls to discharged patients, they found that the medication list in the EHR did not always correlate to the medications that patients reported taking. However, the care managers, who are nurses, did not have security rights to perform medication reconciliation or make changes to the medication list. Care management leaders worked with IT staff to establish appropriate access for the care managers. Now care managers reconcile medications during discharge calls and transmit a copy of the reconciled medication list to the patient’s primary care provider.


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Inova rolled out both of these improvement strategies months before COVID-19 spread across the country. Medicare ACO data from the first quarter of 2020 (January through March) shows that admissions and readmissions declined among MSSP patients compared to fourth quarter 2019 (see exhibit below). The high-risk MSSP patient population experienced the greatest utilization declines, with admissions among heart failure patients decreasing by 13.47 percent. These improvements are the result of ongoing system initiatives, utilization reduction initiatives of Signature Partners, and the enhancement of available tools to increase care management’s ability to identify high-risk patients and support medication reconciliation. Measure number

Official measure name

Q4-2019

Q1-2020

Performance difference

ACO-8

Risk-standardized, all condition readmission

14.41

13.39

-1.02

ACO-38

Risk-standardized acute admission rates for patients with multiple chronic condition

59.90

51.81

-8.09

ACO-43

Ambulatory-sensitive condition, acute composite

1.97

1.33

-0.64

ACO-35

Skilled nursing facility 30-day, all-cause readmission measure

17.88

16.18

-1.7

ACO-36

Risk-standardized acute admission rates for patients with diabetes

37.86

30.80

-7.06

ACO-37

Risk-standardized acute admission rates for patients with heart failure

83.60

70.30

-13.47

Prior to getting this data from the HIE, we did not know when patients were utilizing the ED or hospital until after the claims ran, which could be delayed by a week. Receiving this information daily enabled us to be effective in calling all of our patients within 48 hours of discharge. Tonya Kirchmyer | BSN, director of care management, Signature Partners in Health


Case Study

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Photo: Memorial Hermann Health System.

A large not-for-profit health systems in Southeast Texas, Memorial Hermann Health System owns and operates 14 hospitals and has joint ventures with three other hospital facilities. The system also has numerous specialty programs and services located throughout the Greater Houston area.

Improvement project goal: Optimize communication and handoffs for ACO patients managed by the acute and ambulatory (or transitional) case management staff. TOC standard(s) addressed: Standards 1, 2, and 4 Process/outcome measures: Results of a pre- and post-test given to staff who received education about handoff communications. Results: Pending.

Like many health care organizations, Memorial

Hermann Health System is

transitioning from fee-for-service to value-based payment arrangements, which financially incentivize organizations to prevent unnecessary admissions and other costly encounters. “Our system CFO talks about a plane with two engines,” said Patricia Velky, BSN, assistant vice president, care coordination. “One is value and the other is fee-for-service. We need both engines to drive the plane. We’re living in value, but we’re surviving because of fee-for-service.”


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To help prepare for the shift to value, Memorial Hermann is investing in longitudinal care management or ensuring continuity of care across multiple care settings. Velky describes these efforts as “evolving.” The Houston-based health system is currently piloting longitudinal care approaches in patient populations assigned to Memorial Hermann’s ACO and Medicare’s BPCI-Advanced program. For the ACMA Learning Collaborative improvement project, Memorial Hermann originally intended to optimize communication and handoffs across the care continuum for ACO patients. Because of the COVID-19 pandemic, the health system had to narrow the project focus to improving handoffs between acute and ambulatory care managers.

Memorial Hermann’s Established Processes and Practices Currently, care management at Memorial Hermann is handled separately on the inpatient and ambulatory side. Inpatient care managers handle discharge planning for hospitalized patients. Then transitional care managers, who are employed by the health system’s Population Health Services Organization, handle ambulatory care management for ACO and BPCI-Advanced patients, working with outpatient physicians and post-acute providers to coordinate care after hospital discharge. Community health workers, social workers, pharmacists, and health coaches work alongside transitional care managers to help patients make healthy changes, access needed services, etc. Velky is charged with creating a transitional care management structure for the health system, which will marry inpatient and ambulatory care management and help keep patients healthy and out of the hospital. “I’m looking to be that bridge between the ambulatory side and the acute side,” she said. Memorial Hermann has an established network of about 40 aligned SNFs. Recently, the health system began working with lower-performing SNFs to help them improve quality scores and other metrics, as well as improve their capability to take on higher-acuity patients. For their part, all collaborating SNFs in Memorial Hermann’s network must agree to share quality data, have a licensed RN on duty 24 hours a day, and meet other requirements.


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Memorial Hermann is redesigning how it handles SNF-to-home transitions. Previously, the health system’s consulting partner placed post-acute representatives at the SNFs in Memorial Herman’s network to help with care transitions for patients in BPCI-Advanced. Soon, Memorial Hermann is transitioning to a different model. The health system has hired post-acute care managers and licensed vocational nurses to round on patients in the aligned network and work with facility staff to ensure that discharges go smoothly and that patients do not readmit to the hospital.

Memorial Hermann’s Improvement Charter When the COVID-19 pandemic reduced the amount of time available to work on the Learning Collaborative improvement project, Memorial Hermann care management staff decided to narrow their focus to two challenges related to optimizing handoffs between acute and transitional (or ambulatory) case management staff: • On the ambulatory side, transitional care management staff did not know how to find needed information about their patients, including discharge plans, in the recently adopted inpatient case management documentation platform. • On the hospital side, inpatient case managers had inconsistent knowledge on how to identify ACO patients in the EHR. The patients were flagged as ACO patients in the EHR’s banner, but staff did not know where to look for that information. Additionally, finding the ambulatory teams’ documentation in the EHR was challenging. This was important because the hospital case managers needed to identify currently managed patients or refer new ACO patients to transitional care managers at discharge.

To address these challenges, Velky asked the transitional care management team to create an educational slide presentation on how to identify an ACO patient in the EHR. At the same time, the acute case management team was asked to develop an educational presentation on the inpatient documentation platform, which explained where transitional care managers could find various forms in the new system. “Our goal was to level set everyone so they would at least know where to look for the information they needed,” Velky said. This goal supports processes outlined in TOC standard 5.


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A pilot of each education session was conducted at one hospital in the Memorial Hermann system. Case managers took short pre- and post-tests before and after watching the educational presentations to gauge whether the presentations taught them how to find needed information. Then the presentations were fine-tuned somewhat based on the results of the pilot. Memorial Hermann is now preparing to roll out the education systemwide. All case managers will be asked to take the pre- and post-tests to determine whether the education successfully met its mission.

Our system CFO talks about a plane with two engines. One is value and the other is fee-for-service. We need both engines to drive the plane. We’re living in value, but we’re surviving because of fee-for-service. Patricia Velky | assistant vice president, care coordination


Case Study

Photo: Trinity Health Of New England.

St. Francis Hospital and Medical Center is a 617-bed teaching hospital serving Connecticut. St. Francis is a member of Trinity Health, a 92-hospital Catholic health system that serves 22 states.

Improvement project goal: Develop a comprehensive care transition model across the continuum with the goal of achieving the best health outcomes for high-risk Medicare fee-for-service patients with congestive heart failure (CHF), chronic obstructive pulmonary disorder (COPD), acute myocardial infarction (AMI), and pneumonia. TOC standard(s) addressed: All five standards. Process/outcome measures: St. Francis chose the following measures, which include a number of established and consensus measures from ACMA’s TOC metric alignment list: TOC standard 1: All-cause readmission rate for CHF, COPD, AMI, and pneumonia diagnoses (ACO-8) TOC standard 2: Transition to the least restrictive next site of care TOC standard 4: •

All-cause readmission rate for CHF, COPD, AMI, and pneumonia diagnoses (ACO-8)

ED utilization

TOC standard 5: •

Timely transfer

Receipt of discharge information (HEDIS)

Patient satisfaction score related to patient understanding of discharge information

Results: Pending.

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When St.

Francis Hospital entered the ACMA Learning Collaborative in late 2019,

leaders envisioned building a collaborative, cross-continuum care management model. One overarching challenge they want to address is the lack of communication across inpatient, outpatient, and post-acute providers. “We tend to work in silos, and we want to make sure that we connect with each setting better,” said Caroline Segovia-Marquez, BSN, director, case management. As a member of Trinity Health, St. Francis Hospital receives some technical and strategic assistance from the national and regional health system offices related to improving care transitions. For example, in the future, St. Francis will be transitioning to the single instance of the EHR used across Trinity Health. The hope is this integrated EHR will allow the entire patient journey across care sites to be documented in one record, giving patients, care managers, providers, and others easy access to the record. For its Learning Collaborative improvement project, St. Francis focused on improving the hospital discharge process for high-risk Medicare fee-for-service patients who had diagnoses of CHF, COPD, AMI, and pneumonia. These are four of the diagnoses that CMS monitors for high readmissions, penalizing hospitals that have high rates.

St. Francis’ Established Processes and Practices Trinity Health has created ministries at the regional level to highlight and support the unique needs of each community; therefore, the centralization of care management is occurring at the regional level. St. Francis is a member of the Trinity Health Of New England region, which actively participates and places a strong focus on improving the value and quality of care across the care continuum. A clinically integrated network (Southern New England Health Care Organization) and ACO (Trinity Health Of New England ACO) bring together Trinity hospitals, physician providers, and other care providers from across the region and the care continuum to pursue joint goals, including care coordination and value-based payment arrangements. Trinity Health Of New England is engaged with various alternative payment models, including BPCI-Advanced.


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Trinity Health owns a local home care agency and a skilled nursing facility. In addition, St. Francis has been working on building collaborative relationships with independent SNFs. This is being driven through the ACO. St. Francis is also looking to start an outpatient palliative care program to provide follow-up care to inpatients who receive palliative care consults at the hospital. St. Francis has a large, employed hospitalist group. About 95 percent of medical patients are attended to by hospitalists. The director of the hospitalist program is very engaged in care transitions and BPCI-Advanced work.

St. Francis’ Improvement Charter In December 2019, St. Francis implemented several actions to achieve its goal of improving discharge planning and care transitions for high-risk Medicare fee-for-service patients with CHF, COPD, AMI, and pneumonia diagnoses: • Creating an identifier in the EHR to make it easy for staff to know when a patient is in the Trinity Health Of New England ACO. “Instead of having to look through spreadsheets or emailing somebody to get this information, patients are clearly identified as members of our ACO, and we can work with our own team outside of the hospital to help with the patient transition,” said Segovia-Marquez. • Using medical history technicians to obtain a patient’s medication history to aid in accurate medication reconciliation. “Getting the medication history is a timeconsuming task for our physicians, so we have pharmacy technicians who work in the ED and are instrumental in getting the history ready for the providers to perform a reconciliation,” said Segovia-Marquez. (TOC Standard 3 alignment) • Conducting daily readmission huddles — with the inpatient care manager, outpatient care management, home care liaison, physician director, and ACO navigator — to identify high-risk patients and develop transition plans. • Identifying and discussing patients at risk of readmission during daily interdisciplinary rounds on the clinical units. Segovia-Marquez and other leaders regularly join the rounds to provide in-person education on readmission risks and how to mitigate those risks before the patient leaves the hospital.


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• Provide secure EHR access to our post-acute partners to ensure that they have the necessary information to continue to care for the patient. (TOC standard 5 alignment) • Educating post-acute partners on the importance of ensuring advance care planning is completed for all patients prior to any hospitalizations. St. Francis emphasizes this during weekly meetings with post-acute partners and provides the facilities with some educational tools and materials on advanced care planning.

St. Francis is also looking to adopt a new health risk assessment tool, which will be built into the EHR, to identify patients who are at risk for poor transitions. This aligns with TOC standard 1. “Our current tool does not look at social determinants of health, which we want to incorporate because those [non-medical risk factors] play a big part in transition failures.” When St. Francis goes live on the new EHR, the hospital will gain access to a health risk assessment tool that the health system has adopted, which assesses social determinants of health among other risk factors. While St. Francis was able to identify improvement opportunities from the preassessment, the timing and challenges of the COVID-19 pandemic delayed implementation. Thus, results are yet to be determined. “In Connecticut, we got hit hard,” Segovia-Marquez said. “At one point, we were about 60 percent COVID patients and had three ICUs running. We were just in survival mode at that time.”

We tend to work in silos, and we want to make sure that we connect with each setting better. Caroline Segovia-Marquez | BSN, director, case management, transfer center, and bed control


Case Study

Photo: Tenet Health.

Tenet Health is a publicly traded, 65-hospital system with over 510 outpatient centers and additional sites of care across the United States.

Improvement project goal: • Original goal: Reduce avoidable readmissions at Tenet hospitals with high readmission penalties for a patient population. • Revised goals due to the COVID-19 pandemic: Ensure advance care documents are current and ensure information transferred (such as COVID-19 test results) have acknowledgement of receipt by the post-acute provider. TOC standard(s) addressed: •

For original goal: Standard 1

For revised goals: Standards 2 and 5

Process/outcome measures: • For original goal: High readmission risk identification and monthly avoidable readmissions discharged to SNF (TOC consensus measure) •

For revised goals: N/A

Results: Pending.

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Looking back on the darkest days of the COVID-19 pandemic, when many Tenet

Health

hospitals were filled with very sick, infected patients, Manisha Youngblood, BSN, director, continuing care, saw how important cross-continuum communication was for safe and effective transitions of care. “That was a lesson learned,” she said. “While it is important to establish early on the post-acute care collaborative communication structure, the pandemic amplified the importance of tight communication as we collectively navigated public health emergency updates.” Like other organizations in the Learning Collaborative, Tenet Health faced a care transitions quagmire in the early months of the pandemic. Many post-acute providers, particularly SNFs, were not accepting patients discharged from hospitals due to a lack of personal protective equipment, limited facility space for isolating or quarantining patients, and fears of COVID-19 spreading among staff and residents. One advantage of working at a large health system like Tenet Health is the opportunity to compare how different organizations in the health system address a challenge. Based on what she saw during the early months of COVID-19, Youngblood found that Tenet hospitals that had the most open, transparent communication with post-acute providers were more successful than others at meeting post-acute admission criteria, which helped to solve care transition delays. “When communication was really transparent and everyone stated their concerns and obstacles, it created a sense of collaboration and an intention to work together,” Youngblood said. For its Learning Collaborative improvement project, Tenet Health was originally going to focus on reducing avoidable readmissions. However, due to the pandemic, the readmissions project was put on hold. Instead, Tenet Health rolled out two improvements systemwide aimed at improving the exchange of information about patients between sending and receiving providers, including advance care directives and COVID-19 test results.

Tenet’s Established Processes and Practices Systemwide, Tenet is participating in five ACOs, all of which are in various value-based payment programs, including MSSP and BPCI. Tenet Health ACO partners with a convener, or consultant, to help with functions related to value-based care and payment. In addition to providing data analytics, the convener handles care management for patients who are discharged to post-acute settings.


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Care management responsibilities for ACO patients are divided among inpatient, ACO, and post-acute care managers. The care management governance structure at Tenet Health helps ensure that care managers are on the same page. In terms of workflow, the inpatient care manager conducts the initial discharge assessment. If the patient is being discharged home, the inpatient care manager arranges a warm handoff to the ACO care manager. (A warm handoff is a care transition conducted between two members of the care team in front of the patient and/or family.) When the patient is being discharged to a SNF, the warm handoff is to the convener’s transition care coordinator. Tenet owns various parts of the post-acute continuum in different markets. In addition, Tenet has continuing care networks of post-acute providers across the system. The members of these networks vary from hospital to hospital but can include all types of post-acute providers, including home care, SNFs, and long-term acute care hospitals. Post-acute providers are invited to participate in Tenet’s continuing care networks based on quality and utilization data. Once in the network, the provider must share quality data and meet other requirements. Tenet has also started approaching post-acute providers with lower quality scores and offering to support their efforts to improve those scores so that the providers can improve patient care and potentially qualify to join Tenet’s continuing care network.

Tenet’s Improvement Charter The advent of COVID-19 created urgency across Tenet Health to improve the exchange of information between the sending and receiving providers.


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One specific goal was to ensure that patients being transferred to Tenet hospitals from SNFs in Tenet’s continuing care network had up-to-date advance directives in place before being transferred. To achieve this, inpatient nurses at Tenet hospitals would ensure the advance directives were complete when they assessed the patients on admission. “We made sure that those nursing homes understood that they should have a clear policy of gathering the advance directives of these patients,” Youngblood said. “It was one less thing these patients and their families needed to be concerned with. In the event a patient had to be admitted into our hospital, those advance directives could be transmitted straight over to us from the nursing home.” The second goal was to ensure that essential information about the patient, including COVID-19 test results, were conveyed when being transferred from Tenet hospitals to the next level of care, such as home care or SNF. “We wanted to make sure that they [the receiving providers] receive the dates and times when a patient tested positive for COVID-19, became negative, the type of test used, and other details. That way staff would know how to triage the patients. For instance, should a nursing home put the patient in an isolation room when they were transferred?” Another crucial detail that needed to be conveyed was whether a patient had pending COVID-19 test results. “It was really important that those results were transferred to the accepting post-acute care provider immediately when they became available,” Youngblood said. This supports TOC standards 4 and 5. Tenet uses a care coordination software to exchange patient information with postacute providers in the health system’s continuing care network, which aligns with TOC standard 5. “It has given us great synergy in terms of keeping each other updated on the details about the patient,” Youngblood said. “It also helps our hospitals understand what services the post-acute providers are able to provide and what types of patients they are able to take. For instance, it helps us know whether a provider is able to take all COVID-19 patients or only returning patients with COVID.” Soon, Tenet Health hopes to return to its original care transitions-related improvement goal: Reducing readmissions in Tenet hospitals with high rates of readmissions.


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We made sure that those nursing homes understood that they should have a clear policy of gathering the advance directives of these patients. It was one less thing these patients and their families needed to be concerned with. In the event a patient had to be admitted into our hospital, those advance directives could be transmitted straight over to us from the nursing home. Manisha Youngblood | BSN, director, continuing care, Tenet Health


TOC Self-Assessments and Findings

TOC SELF-ASSESSMENTS AND FINDINGS One key goal of ACMA’s Learning Collaborative was to test implementation of the TOC standards in real-world health systems to obtain a baseline understanding of which standards might be more challenging for hospitals and health systems to implement than others. Another goal was to determine if participation in the Learning Collaborative, which included opportunities for sharing best practices among members, might help to reduce any of the challenges identified. Despite the disruptions brought on by the COVID-19 pandemic, the Learning Collaborative participants were able to successfully use the TOC standards as a guide to improve care transition processes in their organizations. The TOC self-assessments served as a starting point for organizations to assess and measure their performance against the TOC standards and use the standards to guide and improve practice.

The Pre- and Post-Assessment Process ACMA asked the six participating organizations to complete pre- and post-assessments at the beginning (December 2019) and end (June 2020) of the Learning Collaborative. The organizations were asked to rate their hospital or health system on how well the organization met each element of every standard, using a four-point scale: 1 = Not performing 2 = Inconsistently performing 3 = Frequently performing 4 = Consistently performing

At the outset of the Learning Collaborative, to facilitate performance comparison, blinded pre-assessment data from the six participating organizations was shared across all Learning Collaborative members. ACMA leadership also met individually with all six organizations to review their data, as well as how they ranked against the comparative group. This process allowed the participants to identify opportunities for improvement.

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Data Collection Process It was considered beyond the scope of the Learning Collaborative to conduct in-depth, objective studies of each organization’s approach to care transitions, and ACMA acknowledges that the data collection approach used for the self-assessments relied on the subjective judgments of the participants. Additionally, ACMA was not prescriptive about the preassessment methodology, and data collection methods varied across participating organizations. Some participants assessed each hospital independently, and some participants assessed the health system as a whole. Additionally, some participants only involved longitudinal care members in the assessment process, while others involved a committee of members from across the organization. Moving forward, a more standardized approach to data collection is recommended to improve reliability.

Key Findings Significant improvements in participants’ scores on the post-assessments compared to the pre-assessments were not expected. The seven months between the assessments did not allow time to institute major improvements, and much of the available time for improvement efforts was impacted by COVID-19, which required hospital staff to focus on the emergency. Despite this, participating organizations used the pre-assessment findings to institute and refine processes or practices to address gaps and opportunities uncovered through the pre-assessments. This led the participating organizations to improve scores across all five standards on the post-assessment (see figures 1–6, pages 39–41).

Other findings from the pre- and post-assessments include the following: • Effective medication reconciliation processes appear to be hardwired at the participating organizations based on their assessments of TOC standard 3 (see figure 4). • Organizations with robust and interoperable EHRs appear to perform better on communicating essential information across the continuum, as required under TOC standards 4 and 5 (see figures 5 and 6). • Advance care planning, including assessing patient needs (TOC standard 2) and sharing advance care planning documents across care sites (TOC standard 4), remains an improvement opportunity for all Learning Collaborative participants. • Learning Collaborative participants participating in value-based payment programs, including the MSSP and BPCI, scored higher across all TOC standards.


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In a follow-up interview at the end of the Learning Collaborative, all participants wholeheartedly agreed that the TOC standards accomplish their goal of providing guidance to health care organizations as they work to improve transitions of care across the continuum.

Figure 1 Overall Standards 1–5 | Pre- and Post-Assessment 4.0 3.5

3.5

3.6

3.4

Score 1–4*

2.5

3.3

3.2

3.0

3.0

2.8

2.6

3.4

2.6

2.5

2.8 2.5

2.0 1.5 1.0

Notes: Organization B did not complete the post-assessment. The comparison group refers to the average score of the cohort of the six participants; it is the aggregate composite comparing all of the organizations to each other.

0.5 0 A

B

C

D

E

F

Comparison group

Organization

Five of the six Learning Collaborative participating organizations reported improvements on all five TOC standards between the pre-assessment (in December 2019) and the postassessment (in June 2020). The sixth participant did not complete a post-assessment.

Figure 2 Standard 1 | Identify Patients at Risk for Poor Transitions | Pre- and Post-Assessment 4.0

3.7

3.6 3.5

Score 1–4*

3.0

3.7

3.6

3.3 3.0

2.8

2.7

2.5

2.7

2.5

2.4

2.3 2.1

2.0 1.5 1.0 0.5 0 A

B

C

D

E

F

Comparison group

Organization

Of the Learning Collaborative members that completed post-assessments, all reported improvements on TOC standard 1, which addresses identifying patients at risk for poor transitions using a validated assessment tool. * Scoring key 1 = Not performing 2 = Inconsistently performing 3 = Frequently performing 4 = Consistently performing

Pre-assessment score

Post-assessment score

Notes: Organization B did not complete the post-assessment. The comparison group refers to the average score of the cohort of the six participants; it is the aggregate composite comparing all of the organizations to each other.


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Figure 3 Standard 2 | Complete a Comprehensive Transition Assessment | Pre- and Post-Assessment 4.5 4.0

4.0

3.7

4.0

3.9

3.7

3.5

3.5

Score 1–4*

2.5

3.0

3.0

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3.2

2.6

3.0

2.6

2.3

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Notes: Organization B did not complete the post-assessment. The comparison group refers to the average score of the cohort of the six participants; it is the aggregate composite comparing all of the organizations to each other.

1.0 0.5 0 A

B

C

D

E

F

Comparison group

Organization

TOC standard 2, which addresses completing a comprehensive transition assessment, remains an opportunity for improvement for using a validated assessment tool, noted in both pre- and post-acute settings.

Figure 4 Standard 3 | Perform Medication Reconciliation | Pre- and Post-Assessment 4.5 4.0

4.0 3.5

3.3

3.2

3.0 Score 1–4*

3.8

3.7

3.5 3.2

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2.7

2.5 2.0 1.5 1.0 0.5 0 A

B

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Comparison group

Organization

The medication reconciliation process appears hardwired in Learning Collaborative participating hospitals and health systems.

* Scoring key 1 = Not performing 2 = Inconsistently performing 3 = Frequently performing 4 = Consistently performing

Pre-assessment score

Post-assessment score

Notes: Organization B did not complete the post assessment. Organization C did not complete the preassessment for Standard 3. The comparison group refers to the average score of the cohort of the six participants; it is the aggregate composite comparing all of the organizations to each other.


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Figure 5 Standard 4 | Establish Care Plan Across the Continuum | Pre- and Post-Assessment 4.0 3.6

3.5

3.3

3.2 2.9

Score 1–4*

3.0 2.5

2.9

3.3

3.1

3.0

2.6

2.5

2.6

2.7

2.2

2.0 1.5 1.0

Notes: Organization B did not complete the post-assessment. The comparison group refers to the average score of the cohort of the six participants; it is the aggregate composite comparing all of the organizations to each other.

0.5 0 A

B

C

D

E

F

Comparison group

Organization

Organizations in the Learning Collaborative that had robust and interoperable EHRs performed better on TOC standard 4, which looks at establishing a care plan that addresses bidirectional communication across all care settings.

Figure 6 Standard 5 | Communicate Essential Care Information Across Continuum of Care | Pre- and Post-Assessment 4.0

3.8

3.5

3.6 3.3

3.2

Score 1–4*

3.0 2.5

3.0

2.8 2.6

2.4

2.6

2.4

2.2

2.0

2.0 1.5

1.4

1.0

Notes: Organization B did not complete the post-assessment. The comparison group refers to the average score of the cohort of the six participants; it is the aggregate composite of comparing all of the organizations to each other.

0.5 0 A

B

C

D

E

F

Comparison group

Organization

Organizations in the Learning Collaborative that had robust and interoperable EHRs performed better on TOC standard 5, which looks at communicating essential care information across the continuum of care.

* Scoring key 1 = Not performing 2 = Inconsistently performing 3 = Frequently performing 4 = Consistently performing

Pre-assessment score

Post-assessment score


Next Steps

NEXT STEPS The TOC standards represent the most recent addition to ACMA’s established care transition resources. ACMA has advanced transitional care competencies through both the ACM certification exam, which ensures clinical competency, and the Advanced Care Transitions Simulation (ACTS), which leverages unique patient scenario simulations to further enhance critical thinking, assessment, communication, planning, and collaboration capabilities.

Organizations committed to improving care transitions should consider using the ACMA TOC standards and associated tools available at transitionsofcare.org. These materials can be incorporated into a comprehensive process to enhance the quality of care transitions.

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Appendixes

APPENDIX A: COVID-19 AND CARE TRANSITIONS For case managers across the country, the COVID-19 pandemic has tested their abilities to coordinate care and ensure that patients safely and effectively transition between care settings. However, at the same time, the pandemic has forced many to be creative about addressing challenges brought on by COVID-19. During this time, major organizations quickly adjusted key processes that, under normal circumstances, would have taken years to modify. Some of the changes being made by the six TOC Learning Collaborative participants, such as the shift to telehealth care coordination visits, are proving beneficial to patients and/or care management staff and may permanently change the way teams collaborate and serve patients. Of note is the importance of having advance care planning documentation completed for patients transitioning from post-acute facilities with a COVID-19 diagnosis. For those organizations with well-developed relationships, communication and collaboration during COVID-19 are proving highly effective.

TOC Challenges During the Pandemic In the first several months of the pandemic, hospitals in certain parts of the country were overwhelmed with COVID patients and ICUs were full. At the time of this writing (mid-January 2021), many hospitals are dealing with a winter surge of COVID-19 cases. In response to COVID-19, CMS announced numerous waivers of Medicare regulations to ease the burden on hospitals and other providers. One example is the telemedicine waiver, which provides Medicare beneficiaries with coverage for needed telehealth appointments, including post-discharge follow-up visits. CMS also encouraged state Medicaid agencies to reimburse providers for telehealth visits during the pandemic, and many commercial insurers followed suit. Another example of a Medicare waiver related to care transitions is the exemption of the three-day mandatory inpatient stay for patients prior to being discharged to a SNF.

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While the CMS waivers have been helpful in managing transitions, the six TOC Learning Collaborative participants highlighted several challenges that they have faced during the pandemic, including the following:

Adjusting to a decrease in the number of care management staff available to help patients with transitions. For instance, at Inova, RN staffing decreased by 50 percent on the health system’s ACO care management team; these RNs were reassigned to assist with COVID-19 triage and other priorities.

Quickly preparing for remote work and telephonic/telehealth care management. For instance, at Duke Health, inpatient and ambulatory care managers were largely deployed to telework, beginning in March/April. By October, most of the inpatient case managers had returned to the hospital to meet with inpatients face-to-face. However, available office space is a problem; social distancing requirements have limited the total space available in hospitals for staff to work. Ambulatory care managers at Duke continue to work remotely and are preparing to begin virtual meetings with patients using video-conferencing technology.

Addressing post-acute discharge challenges. Like many other TOC Collaborative participants, Advocate Aurora found that many SNFs were closed to admissions or had very strict admission protocols during the early months of the pandemic. “As the sickness became more widespread, skilled nursing facilities would be locked down and they would not take any patients, including safe returns for patients who had lived there as long-term care patients,” said Sherri Aufderheide, DNP-RN, executive director inpatient case management and utilization management. The lack of available personal protective equipment for post-acute staff was one driver behind closed admissions at SNFs. Another was the lack of available space in SNFs to isolate infectious and potentially infectious patients.

Absorbing revenue losses. At hospitals and health systems across the country, elective surgeries and routine care appointments were canceled or postponed, which resulted in significant revenue losses. Some TOC Collaborative participants reported that their hospitals and health systems had to furlough members of the care management team to address revenue losses.


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TOC Opportunities The rapid response of Learning Collaborative members, as well as other health care organizations across the country, to the challenges brought on by COVID-19 has been impressive. Learning Collaborative members shared several actions they have taken that have helped patients through this pandemic, including some changes that promise to continue after the pandemic ends.

The wide-scale adoption of telehealth and other virtual approaches to care. Providers across the country have rapidly replaced face-to-face visits with telehealth visits to reduce the spread of COVID-19. The Department of Health and Human Services found a nearly 50 percent increase in primary care telehealth during the peak of the pandemic.* Learning Collaborative members have also adopted telehealth approaches to conduct case management visits. “It was proven during the COVID-19 crisis that utilization of telehealth is an effective and efficient way to communicate with patients,” said Caroline Segovia-Marquez, BSN, director, case management, transfer center, and bed control, St. Francis Hospital and Medical Center. “Patients are more engaged as we are ‘meeting them where they are.’ Some patients are challenged with technology but [the visits] can be coordinated with their family members and/or the home care nurse.”

The adaptation to telework and working from home. At Advocate Aurora, care management team members who do not provide bedside care have been deployed to work from home, which has required the adoption of virtual meetings. At first, this impacted the team’s ability to work together, but care management staff quickly adjusted. Now Aufderheide believes the use of virtual meetings is increasing collaboration. “We identified that we could get a lot more done in less time with a bigger group of people, and that’s a win for us from the standpoint of collaboration. Specifically, we have increased our teamwork across the care continuum because now the inpatient and ambulatory care managers can all meet. We are all now in the same virtual stratosphere together.” Duke’s Pat Kramer, EdS, CCM, CSW, senior director, believes the telework experiences during COVID-19 may help advance the case for developing limited work-from-home options for care managers after the pandemic, which may help improve employee satisfaction. “We’re exploring work-from-home options in a very limited capacity as the COVID response showed a work-from-home rotation can be effective for some tasks and improves staff morale,” she said.

* U.S. Department of Health and Human Services. “Press Release: HHS Issues New Report Highlighting Trends in Medicare Beneficiary Telehealth Utilization amid COVID-19.” July 28, 2020. https://www.hhs.gov/about/news/2020/07/28/hhs-issues-new-report-highlightingdramatic-trends-in-medicare-beneficiary-telehealth-utilization-amid-covid-19.html


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Increased attention on ensuring safe, effective home discharges. Because many SNFs have been limiting admissions during the pandemic, hospitals are having to discharge more patients home, including higher-acuity patients who would typically be transferred to a SNF. To address this issue, Advocate Aurora focused on increasing supportive care programs, such as more frequent home nursing visits, for patients who are discharged home. The health system also expanded its remote monitoring capabilities so that advance practice providers in the hospital can virtually check important vital signs of homebound patients daily. Advocate Aurora case managers are also approaching patient assessments with increased diligence to ensure they identify all the possible needs a patient has, including social determinants of health, or non-medical risk factors such as food insecurity and lack of housing. As described in Advocate Aurora’s case study (page 11), Advocate Aurora uses a digital software application to help with social service referrals. During the COVID-19 pandemic, case managers are taking extra steps to help patients get needed medications and medical supplies (e.g., thermometers). The increase in patients being discharged home is also causing case managers to evaluate whether a discharged patient has a primary care provider in place, and if not, provide information and support to coordinate a smooth transition to an ambulatory provider, according to Patricia Velky, BSN, assistant vice president, care coordination, at Memorial Hermann.

An increase in integration and collaboration between acute and post-acute care. At Inova, the occurrence of COVID fueled initiatives to integrate care management functions across the health system. “Daily discussion meetings on transitions and new workflows developed to make communication more effective,” said Tonya Kirchmyer, BSN, director of care management, Signature Partners in Health. “This has led to more proactive patient transitions as communication improved across teams.” As described in the Tenet Health case study (page 32), the pandemic has led the health system to work more actively with affiliated SNFs in the organization’s continuing care network. “The pandemic required our hospital director of care management to lead more collaborative calls with our continuing care network since we all had to quickly adapt to changing state and CDC guidance,” said Manisha Youngblood, BSN, director, continuing care. “The COVID crisis further matured the established relationship with our network of post-acute care providers. Both sides better understand that transparent communication and collaboration is necessary, regardless of a pandemic.”


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An increased focus on advance care planning. At St. Francis Hospital and Medical Center, the heightened numbers of very sick patients during the COVID-19 crisis has helped reinforce the importance of having advance care planning discussions and ensuring that there is documentation of these discussions. “We saw a lot of patients come through our hospital doors who didn’t have these documents in place or even have a decision maker identified,” said Segovia-Marquez. “So, when we are faced with an emergency, if we are going to full code, we have to make decisions that the patient may not want. Without that discussion or without that proper documentation, it puts a lot of strain on our providers.” St. Francis clinicians believe advance care planning discussions need to happen prior to a patient walking in the door of our hospital. To help ensure this occurs, the hospital’s ACO is providing education and support to SNF and primary care partners on completing these discussions and ensuring proper documentation of the patient’s wishes.


Appendixes

APPENDIX B: KEY TAKEAWAYS FROM TOC LEARNING COLLABORATIVE WEBINARS The TOC Learning Collaborative held three interactive webinars in early 2020 on topics identified as important to collaborative members: longitudinal care management, postacute challenges, and care management workforce challenges. Below are key takeaways from the webinars, which shared best practices from the research and from collaborative participants.

Longitudinal Care Management Currently, most efforts to manage care transitions are episodic in nature, meaning they mainly focus on transitioning patients from one care setting to another. With the TOC standards, ACMA is hoping to move the industry beyond episodic care management toward true longitudinal care management. ACMA has developed the following working definition of longitudinal care management:

A strategy to ensure the understanding of care delivered in multiple settings and foster relationships across the system of care.

Longitudinal care management is still a sought-after goal among Learning Collaborative participants, although some are farther along than others. Key success factors for longitudinal care management include: • An integrated or centralized care management structure or team that oversees the cross-continuum relationships and capabilities for the health system. (See the Advocate, Duke, and Tenet Health case studies for examples.)

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• Data analytics that help to identify patients at risk for poor transitions and to determine the best level of care

— For instance, Tenet Health has a unique tool that predicts a patient’s readmission risk. The tool was created by Tenet data scientists. It pulls clinical, administrative, and social determinants of health (non-medical risk factors) data from the EHR and admission-discharge-transfer (ADT) feed. In addition to giving each patient a readmission risk score, the tool provides care managers with the likely next level of care based on an analysis of matched characteristics to other similar discharges.

• Other population health capabilities, including clinical integration across providers, specialized programs or resources for complex patients (e.g., in-home or telehealth visits, health coaching, disease management), and technical assistance with valuebased payment arrangements.

— Some collaborative participants are using conveners, or consultants, that help health care organizations succeed under value-based payment arrangements, such as BPCI and MSSP. The conveners supply various technical support, including data analytics and patient navigation. The convener typically takes a percentage of any financial gains the health care organization experiences under the contract.

• A longitudinal patient record that incorporates information about the care received from all care sites (TOC standard 4).

— So far, no collaborative members have created a longitudinal care health record, although some are preparing to do so. For example, Trinity Health plans to adopt a new longitudinal care plan module.

— A related success factor is information exchange, or the ability for all providers involved in a patient’s care (both employed and affiliated) to access and add to the patient record. Success with this goal varies among collaborative members, depending on the level of EHR integration and other factors.


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• Social determinants of health assessments and referrals to ensure patients obtain needed supports to help with non-medical risk factors, such as food insecurity.

— Some members are using social service referral databases and platforms (e.g., a social determinant of health referral module, state-based referral databases) to help identify appropriate community organizations to refer patients to and track whether patients accessed these services.

Navigating Post-Acute Challenges As described in the six case studies, most collaborative members have established networks of affiliated SNFs and home care agencies to help ensure safe, effective care transitions. Some health systems are collaborating only with post-acute providers that meet certain performance criteria, such as quality scores and patient volumes. Others are taking a more inclusive approach and working with all providers willing to commit to taking steps toward improving care coordination and quality scores, while also reducing readmissions, unnecessary lengths of stay, and other costs. One question to consider when setting up a post-acute network is how many providers to include. Memorial Hermann’s experience is instructive. The health system’s SNF network went from 80 SNFs down to 18 and has now risen to about 40. Through this process, Memorial Hermann learned a key lesson: Volumes matter in terms of getting SNFs to commit. “When we were as big as 80, we couldn’t get volumes to the SNF facilities to where they really felt any ties back to our health system,” said Matthew Harbison, MD, vice president, care management and hospital medicine. “If it is a couple of patients a day, it doesn’t really impact them from an operations standpoint. We’re trying to get to the right size where we can drive enough volume to really be a significant portion of their success.” Another consideration when developing post-acute networks is whether to involve hospital full-time employees or affiliated physicians directly in post-acute care. At Advocate Aurora, inpatients discharged to a SNF in Advocate’s network are followed by advanced practice nurses and physicians employed by Advocate Aurora who visit the SNF and monitor the care patients receive.


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The ability to easily exchange key patient information with post-acute providers is another critical success factor. For instance, Duke requires SNFs in its HOPE Collaborative to connect to a Duke portal for affiliated providers. This connection allows SNF staff to easily access a patient’s discharge summary and other key information. Duke is also using a digital tool that pulls ADT data and sends automatic electronic notifications to Duke’s population health office (DukeWELL) as well as some primary and specialty clinics whenever a patient is discharged from an affiliated SNF. Care managers then follow up with high-risk patients at home. The need for warm handoffs to post-acute providers was also stressed by many Learning Collaborative members. A warm handoff is a care transition conducted between two members of the care team in front of the patient and/or family. For instance, the hospitalist program at St. Francis supports physician-to-physician handoffs for high-risk patients, by having the hospitalists call the patient’s PCP after that patient is discharged to home or to home health.

Care Management Workforce Challenges Collaborative participants discussed several strategies for addressing current workforce challenges, which range from an increased demand for care managers to high turnover rates. • Grow the number of available case managers by generating interest in the profession and providing a pathway to employment.

— ACMA’s Illinois chapter held educational events at local nursing schools to get new nurses interested in case management. ACMA encourages other ACMA chapters to consider similar events, whether virtually or socially distanced. Videos in ACMA’s Advanced Care Transitions Simulation (ACTS) program can be used to attract and educate promising, future care managers.

— Tenet Health has a collaboration with Samuel Merritt University in California, which offers a master’s in case management program. Tenet’s hospitals in California host clinical rotations for hands-on learning opportunities.


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Use non-licensed care coordination personnel to support care managers.

— Several collaborative members are using community health workers, including Duke, Advocate, Trinity Health, and Memorial Hermann. For instance, at Duke, community health workers support care managers through resource coordination. In addition, a team of resource associates engage in patient activation by reaching out to patients to help close gaps in care, such as missed diabetic eye exams, mammograms, and annual wellness visits through awareness, education, and appointment coordination. Another team supports transitions of care from hospital to SNF by assisting inpatient case managers with the administrative steps of SNF referrals.

— Tenet Health uses care management assistants, which go by the title “discharge planners,” to help with care coordination. The health system hires people with health care experience for these roles, such as nursing assistants or emergency medical technicians.

Understand how to justify new positions.

— Collaborative members demonstrate the need for additional care management staff by showing recent census increases and pointing to Medicare conditions of participation around the number of inpatient care managers. The TOC standards self-assessment tool, which can help identify gaps in best practice, may also be leveraged to justify staffing models. Other important data that can be used in overall care management ROI calculations include decreases in lengths of stay, declining readmissions rates achieved by the care management team, as well as lower denial rates when utilization review is handled by care management.

— Last year, Tenet conducted an analysis of case management cost centers. Linda Van Allen, BSN, vice president, case management and continuing care, and her team compared current staffing levels and staff mix at every hospital against national benchmarks from the ACMA National Hospital Case Management Survey. While they found some staffing level gaps, they mostly uncovered skill mix issues. For example, at one hospital, they presented a business case to the CFO that showed that the hospital could better support patient care transitions more efficiently without negatively impacting performance metrics. “… [the] hospital … was very heavy on nurse case managers, and they didn’t have enough support staff or social workers,” Van Allen said. “We demonstrated if you align staffing to the expected staffing mix, you can pay for a social worker and part of a support staff FTE.”


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• Explore the use of telehealth and similar technologies, both with patients and other providers. This goes beyond telephonic case management to incorporate new technologies, including virtual visits and remote monitoring.

— Trinity Heath’s Home Care Connect™ virtual home care program has enrolled more than 30,000 patients with CHF and other conditions. Patients receive a tablet as well as wireless medical equipment, including a scale, pulse oximeter, and blood pressure cuff. Every day, patients follow prompts on the tablet to report vitals and answer condition-specific questions. The patient’s home care nurse receives all this information electronically and reaches out to the patient as needed. The virtual care program has helped Trinity reduce its home health readmission rate from 13 percent in 2017 when the program launched to 8 percent in September 2019.

— At Duke, physician specialists are available to conduct e-consults with clinicians at some of the SNFs in Duke’s HOPE Collaborative. This makes it easier to follow up on complex patients after they are discharged to the nursing home and ensure they are receiving appropriate care.

Developing the pipeline of future care management leaders

— At Inova, they are working on integrating their inpatient and outpatient care management teams. As part of that effort, they recognized the opportunity to develop a career ladder for case managers who may be interested in some day pursuing a manager or leadership position. Many hospitals and health systems do not have large leadership layers in case management. Inova created a career ladder that includes a Level 1 case manager and a Level 2 case manager. This creates an accessible promotion opportunity so that promising young leaders are not disenchanted by a lack of opportunity for growth.

Making efforts to retain current care management staff

— According to Learning Collaborative participants, several factors affect staff satisfaction, including compensation, work-life balance, opportunities to pursue meaningful work, strong onboarding processes, and opportunities to obtain certifications and continuing education.


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© January, 2021 by American Case Management Association, Little Rock, AR All rights reserved. No part of this publication may be reproduced in any fashion or by any means without written permission from ACMA.