Collaborative Case Management - Issue 76 - A peer-reviewed journal from ACMA

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A Peer-Reviewed Journal for Case Management and Transitions of Care Professionals I S S U E



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Shared Care Alerts I N


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Shared Care Alerts: Reducing Avoidable Utilization and Improving Care Coordination and Outcomes Across the Continuum of Care Pamela Garvin BSN, RN; Sarah Greenwood BSN, RN; Cynthia Gingrich MSIM, PMP, CPHIMS; Emily Schneider LCSW-C; Cynthia Seen BSN, RN; Elizabeth Tingo MSN, RN, CMC


Grand Rounds: Why Your Payer Medical Director Should Be Your Best Friend Stephen Crouch, MD


COVID-19 Lessons: The Time is Now to Improve Healthcare Efficiencies Online Ordering for Medical Transports Can Streamline Communication, Response Times


Two Studies, One Result: Free Talking Prescription Labels Improve Medication Safety & Independence By Jenna Reed


Reuniting Families Around the Globe Amid a Global Pandemic By Julie Huber • Edited by Craig Poliner • MedEscort International Inc. • Allentown, PA


Hartford HealthCare Center for Healthy Aging – An Innovative Care Strategy for Older Adults Wendy Martinson, MSN, RN; Penny Ross, MPH; Marc Levesque, MS; Nancy Becker, MA; CMC, Jessica Dakin, BSN, CDP; Michelle Lavoie, BA; Joseph Zuzel, M.S. Ed; Maley Hunt, MHA, LNHA


Housing First to Improve Overall Health Outcomes Abigail Arens, MSW, LCSW; Rachel L. Smith, MBA; Elizabeth Valvo, LCSW, ACM-SW

“Case Management in health care delivery systems is a collaborative practice including patients, caregivers, nurses, social workers, physicians, payers, support staff, other practitioners and the community. The Case Management process facilitates communication and care coordination along a continuum through effective transitional care management. Recognizing the patient’s right to selfdetermination, the significance of the social determinants of health and the complexities of care, the goals of Case Management include the achievement of optimal health, access to services, and appropriate utilization of resources.” ACMA Standards of Practice and Scope of Services, 2020

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A Peer-Reviewed Journal for Case Management and Transitions of Care Professionals ISSUE








I S S U E :

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PUBLISHER L. Greg Cunningham, MHA CEO ACMA • Little Rock, AR

EDITOR Jon Vickers ACMA • Little Rock, AR

EDITORIAL BOARD Joan Brueggeman, RN, BSN, ACM-RN Director of Care Coordination and Utilization Management Services Gundersen Health System | La Crosse, WI Todd McClure Cook, MSW, MBA, EdD, FABQAURP, FABC, CHCQM, ACM-SW Vice President, Integrated Care Management Sharp HealthCare | San Diego, CA Diane DiFiore, DNP, MHSA, RN, NEA-BC Beaumont Health Director, Care Management Development and Education Beaumont Service Center | Southfield, MI Scott Ferguson, MSW, LCSW, ACM Director of Care Transitions and Population Health Mount Sinai St. Luke’s Hospital | New York, NY Dani Hackner, MD, MBA Pulmonary / Critical Care Medicine Chief Clinical Officer & Goodspeed Chair for Quality and Safety Southcoast Hospitals Group Southeastern Massachusetts – Fall River, New Bedford, Wareham Brenda Luther, PhD, RN Associate Professor NEPQR Program Liaison Specialty Track Director, Care Management University of Utah College of Nursing Salt Lake City, UT Ariana Peters Patnode, DO, FACOI, FHM Consultant, Hospital Internal Medicine; Physician Advisor Mayo Clinic | Phoenix, AZ Jessica Snoots, LMSW, ACM-SW Care Transitions Social Worker Frederick Health | Frederick, MD Article Submission Guidelines: Article proposals may be submitted to in one of the following formats: completed article/manuscript, article abstract or article proposal. Submissions should include three learning objectives for your proposed article; outcomes information as applicable to the model/program/intervention described in the article; author(s) bio information: name, contact information, organization, position, education/credentials; and statistical data and outcomes (including p-values) whenever applicable. All article submissions are reviewed and published at the approval of the Editorial Board. Collaborative Case Management is a peer-reviewed journal published quarterly by the American Case Management Association (ACMA) 40 Rahling Circle, Little Rock, AR 72223 Telephone: 501-907-ACMA (2262). Subscription is a benefit of membership in ACMA. Memberships are available at $135 per year. Student membership is open to individuals enrolled in a full-time academic program at $60 per year. More detail about membership categories is available at the ACMA website, or by calling 501-907-2262. Photocopying: No part of this publication may be reproduced in any form or incorporated into any information retrieval system without the written permission of the copyright owner. For reprint permission, please contact ACMA, 40 Rahling Circle, Little Rock, AR 72223. The statements and opinions contained in the articles of Collaborative Case Management are solely those of the individual authors and contributors and not of the American Case Management Association. The Publisher and Editor disclaim responsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements. Copyright © 2020. American Case Management Association. All rights reserved.



Shared Care Alerts: Reducing Avoidable Utilization and Improving Care Coordination and Outcomes Across the Continuum of Care Authors: Pamela Garvin BSN, RN; Sarah Greenwood BSN, RN; Cynthia Gingrich MSIM, PMP, CPHIMS; Emily Schneider LCSW-C; Cynthia Seen BSN, RN; Elizabeth Tingo MSN, RN, CMC

LEARNING OBJECTIVES 1. Discuss the program and project description. 2. Identify how shared Care Alerts can help patients and health care providers. 3. Share the outcomes of shared Care Alerts.

BACKGROUND In 2015, The Maryland Health Services and Cost Review Commission (HSCRC) released a Request for Proposal (RFP) and associated Regional Partnership Transformation Planning grant, focused on bringing hospitals and community partners together to reduce

avoidable utilization, expand care coordination and support services and improve outcomes for patients who were high utilizers (HU) of hospital and ED services. The University of Maryland Baltimore Washington Medical Center (UM BWMC) and Anne Arundel Medical Center (AAMC) joined together to form the Bay Area Transformation Partnership (BATP) along with several community organizations. The grant was used to study cross-organizational, multidisciplinary gaps in data and communications, and to develop solutions. The partnership also received a subsequent four-year ‘Transformation Implementation’ grant to implement the tools and services identified through the planning grant.




In 2015, UM BWMC ED developed the Care Alert concept for their HU patients, with ED physicians writing and maintaining content in their electronic health record (EPIC). They measured a 65% reduction in intra-hospital and ED visits and costs for patients with three or more bedded stays in 12 months prior to receiving a Care Alert/Care Plan. BATP used that success as a foundation for the request to HSCRC for further study and development of Care Alerts with an all-hospital focus. With the BATP, UM BWMC expanded and formalized the guidelines on content, extended utility to include all care team members within and outside hospital walls, and designed the real-time sharing of alerts with and via The Chesapeake Regional Information System for our Patients (CRISP), Maryland’s health information exchange.

The primary purpose of Shared Care Alerts is to have a single location for all care team members to communicate the most important medical or nonmedical information they each uniquely have about a patient to assist with improving care. This demonstrates care coordination to patients and their families, enables efficient care and service alignment, and promotes support and care in the appropriate, least expensive care setting.

The concept and

practical application of


During the Transformation Planning grant process, the hospitals identified that pivotal with hundreds of care decisions are continually made by clinicians providers through large encountering patients in high acuity settings. When the workgroup meetings complex patient and clinician are new to one another and and ‘in the field’ use vital information is unavailable, or indiscernibly lost in a was ongoing for UM ROLE OF COLLABORATION haystack of non-prioritized AND LEADERSHIP “data”, the clinician’s default BWMC ED, during the care decision is often to test, The Regional Partnership admit, and treat more, not less, work included several crossplanning phase. in an attempt to “cover all the organizational teams, strong bases”. This approach is often leadership, project wasteful and dissatisfying to management and systems patients and clinicians alike integration teams. UM BWMC and creates the potential for patient harm. Notably, and AAMC clinical leadership came together to Care Alerts were developed because clinicians became develop formal structures, content guidelines, user frustrated with portals and “data dumps” as they tried interface and workflow requirements. The concept to find useful information when assessing and treating and practical application of Care Alerts was vetted complex patients that are new to them and are with hundreds of providers through large workgroup presenting for care in high acuity settings. Clinicians meetings and ‘in the field’ use was ongoing for UM and community care team members require an easy, BWMC ED, during the planning phase. Inpatient, ED rapid and reliable mechanism of accessing and and ambulatory providers were included, and their sharing “need to know right now” information on feedback was incorporated throughout the complex patients, without having to search for it. requirements phase.

Care Alerts was vetted



Care Alerts provide ED providers and others with rapidly consumable information regarding each complex patient’s usual clinical presentation, medical needs and support structure so that care decisions can be tailored to the individual. Care Alerts are readily visible within EPIC at the point of care at both hospitals, are shared with and via CRISP and viewable within the CRISP Query Portal by any authorized clinician in the state. Goals of the project include: • Enhance patient and staff safety, prevent clinical errors and avoid unnecessary testing. • Reduce ED visits, potentially avoidable utilization (PAU) including 30-day readmissions and visits associated with the Agency for Healthcare Research and Quality (AHRQ) Prevention Quality Indicators (PQI). • Provide actionable information to crossorganizational, multi-disciplinary teams at the point of care/within their daily workflows. • Improve patient and care team satisfaction by communicating with one another about patient’s most important medical and non-medical needs. PROCESS The high-level work plan included extensive work with clinical leadership, ambulatory, ED and hospital clinicians to develop content guidelines, and partnering with a joint technical team consisting of hospital, EPIC and CRISP analysts, systems integration engineers, and project management, who developed the user interface functionality and sharing of Care Alerts across health systems. The team also provides support and maintenance of the interfaces and content. BATP clinical leadership met with providers and community partners across the care continuum, to develop content guidelines. The resulting guiding principles were to write Care Alerts to be succinct, meaningful, durable, appropriate, respectful and actionable. Clinical leadership also provided guidance on business requirements and documentation was developed to include the scope of work and user


interface requirements. User interface design was a key factor to ensure that end-users could readily see Care Alerts in their day-to-day workflows. The cross-organizational technical team was formed and examined which location within the medical record it would be feasible to record a cross-encounter free-text note. Reports were then generated to examine existing content and clean-up thereof. Training and tip sheets were developed and ongoing monitoring to ensure that appropriate content was entered in this very powerful Care Alert location, which would be shared across the hospitals and community partners who participate with CRISP. Patients who may benefit from a Care Alert can be identified by many different mechanisms including regular monitoring of hospital census, readmission reports and staff referrals. Due to the importance of keeping the content within guidelines and maintaining the alerts, entry and maintenance of Care Alerts is a centrally controlled process at each hospital. The primary staff includes two (2) full-time UM BWMC Care Alert authors (one registered nurse for Medical Care Alerts, one clinical social worker for Behavioral Health-related Care Alerts), and one (1) Readmissions Clinical Analyst at AAMC. These Care Alert staff work with and train additional staff and community partners on how to contribute to Care Alerts. When available, authors seek input from primary care providers, specialists and other team members and stakeholders to incorporate into the alerts. The Care Alert authors work with multidisciplinary clinical leadership teams (ED provider, PCP, pharmacist, behavioral health specialists, etc.) who review and approve more complex, ‘extended’ Care Alerts. The alerts can be placed and updated at any time, regardless of where the patient is along the care continuum. Since Care Alerts are free-text entries, there was a significant amount of work to develop and monitor content based on guidelines and templates, develop and implement initial and ongoing training, monitor and improve quality, and maintain the alerts to keep them relevant and up-to-date. The hospital Care Alert



teams have operational processes in place to ensure that alerts have appropriate, durable, actionable, respectful and useful information with contributions by all members of a patient’s care team either through the centralized process or supervised direct entry. A roll-out plan for education and training of clinicians and Care Alert authors was developed and implemented early in 2016. The visibility, accessibility and accountability of care team members for complex patients is enhanced by this tool. PATIENT AND FAMILY INTEGRATION In FY2017, a Joint Patient and Family Advisory Council (PFAC) was formed, comprised of experts from both hospitals. BATP did an in-depth review of Care Alert content with PFAC and gathered their feedback on what information is most helpful to improve care, care coordination and with a focus on what is most important to patients and families. Authors of Care Alerts, including dedicated resources from care management at the hospitals, community care managers, transitional nurse navigators (who focus on specific chronic condition assistance), speak with patients, families/caregivers



to determine what their goals are, including medical and non-medical and related supports/services that are needed to ensure they receive the best care possible in the least cost setting. The most up-todate contact information for both the patient and their designated representative is included in the Care Alert. SOLUTION Shared Care Alerts are cross-organizational entries in each hospital’s EPIC system that document and share via CRISP succinct, critical information on HU patients, in the context of care, such that patient safety is enhanced, and admissions, duplicate testing and unnecessary and potentially harmful interventions may be avoided. Care Alerts contain both members of a patient’s care team as well as any programs they are involved in so that everyone who can see the alert understands what may already be in place for this patient. In addition, the information includes their contact information, including how to reach out to them quickly, usually via secure texting which has been implemented across the partnership. Because Care Alerts complemented existing workflows and improved the care experience for both patients and clinicians, the feature was rapidly adopted and promoted in the medical community.




An extended Care Alert with summarized information using the UM BWMC template. Key Health Concerns: CHF, Restrictive Cardiomyopathy, Pulmonary Hypertension Key Issues: •

8 ED visits to UM BWMC from September 2018-July 2019 all requiring IP admission

Frequent visits to other area EDs during that time as well

Typically presents with shortness of breath

Jolly Good Home Health administers home IV Lasix and monitors labs weekly

Oxygen dependent, requiring 2 Liters o2 at baseline

Limited functional capacity- wife assists with all ADL’s and manages patient’s medication

Suggested Interventions •

Educate on chronic disease management

Palliative consult to discuss goals of care

Referral to pulmonary hypertension

Care management consult to review active services

Refer to CHF Transitional Nurse Navigator- Ph: 410-787-4000

Refer to The Get Well Program or Senior Triage team for community case management

Coordinate care with PCP at time of discharge with follow up within 3 days after discharge

Psychosocial Supports & Concerns •

Lives with wife Janice- Ph: 410-555-1111, who is primary care giver

Financial stressors on disability

Lacks transportation

Professionals Involved in Patient’s Care: •

PCP- Dr. Smith- Ph: 410-555-1234

Cardiologist- Dr. Johnson- Ph: 410-555-0101

Home Infusion with Jolly Good Home Health Care- Ph: 410-555-0125

Reviewed by BWMC Care Plan Committee: 8/12/19 NOTE: “This care plan was developed in order to help improve compliance with treatment and promote better outcomes of care. All patients presenting to the Emergency Department receive a screening medical examination and have their emergency medical condition, if present, stabilized. All care is rendered with respect for patient privacy and dignity. No part of this care plan is intended to interfere with the clinical decision making of the treating physician.”





A brief Care Alert using the UMMS template. Key Health Concerns: CHF, Diabetes, Chronic Pain, Depression Key Issues: •

4 ED visits to UM BWMC between February-July 2019; 2 followed by IP admissions

Typically presents to ED for chest pain and/or SOB

Current smoker

Actions for Consideration •

Limit controlled substances

Counsel on smoking cessation

Refer to Transitional Care Center

Refer to CHF Transitional Nurse Navigator

Barriers to Care •

Social Situation & Supports: Lives alone; limited social supports

Access to Care: Financial stressors; difficulty affording prescriptions; lacks transportation

Challenges: Multiple comorbidities

Behaviors: History of medication and diet non-adherence

Professionals Involved in Patient’s Care •

Dr. Spencer (PCP) - Ph: 410-555-1234

Pain Management- Ph: 410-555-0100

Enrollment Notes •

Referred to Get Well Program in April 2019, but unable to be engaged


A brief, program-level Care Alert from AAMC. This information will help you care for Mr. Billy Brown, a patient working with the Queen Anne’s County Mobile Integrated Healthcare program as part of his discharge plan from the hospital to keep him well in the community. This patient is motivated to work with PT and get back to regular evening walks with his wife. Should any questions arise on this patient’s plan of care, please reach out to Susan Smith, Community Paramedic at 555-555-5555.




The sharing of Care Alerts involved extensive integration work between the hospitals, CRISP and EPIC, to extract the Care Alert content from the Continuity of Care Document (CCD) and place it in a Care Alert registry at CRISP, which enabled sharing of such throughout the state. Care Alerts from all participating hospitals and organizations are displayed in the same location within the medical record at the BATP hospitals. For example, if a patient has four Care Alerts from various organizations, they are displayed together, separated by the name of the organization, followed by their alert information. This is extremely powerful, as not only are hospitals able to share important information, but they can review and communicate with others who are managing the patient and reach out if there is stale or inaccurate information. (See Figure 1)

MEASURABLE OUTCOMES The target population for Care Alerts is primarily higher utilizers of hospital and ED services (three or more bedded stays within the last 12 months at any hospital, with bedded stays including visits as inpatient or observation > 23 hours). Patient utilization can be viewed in both EPIC and CRISP to determine patients appropriate for these alerts without going through each chart. Since these patients already have a pattern of utilization and associated higher costs, utilizing the CRISP Pre/Post Report is able to look equidistant before and after a Care Alert is written for each patient and the resulting difference in total charges, average charge per patient, average charge per visit and average number of visits. These reports are run for each fiscal year, as well as a cumulative report that considers all active Care Alerts within the associated



√ √

CARE TEAM: Hospital ED, Primary Care Providers, Specialists, Community Care Managers, Payers





Request for all care alerts Return care alerts from all hospitals

Patient arrives, and is registered in the ED, Inpatient, or clinic setting

√ √

Statewide Care Alerts viewable within workflows




hospital systems. The pattern of the change in charges for these complex patients is significant for patients who have Care Alerts, regardless of the time period for which reports are run. This intervention shows the highest ROI of all in the BATP portfolio, noting that both hospitals have implemented a ‘quality first’ approach to writing and maintaining the content of the alerts. Here is an example of the decreased total cost of care for the patients who received Care Alerts in FY20: FIGURE 2

Outcomes Shared Care Alerts, FY20* Total Cost of Care change in charges and visits 3-months before and after applying Care Alerts.* w Total Charges (-$11.3M) w Total Visits (-13.4) per 10 members w Average per patient charges (-$10,185)


ED providers to feel comfortable making decisions about admitting versus sending the patient home, based on their judgement as well as their knowledge of the extent of the care and monitoring being done

for the patient.

w Average per visit charges (-$2,415) *Data source: Maryland all-hospital, June 2020 casemix data

Patients receiving Care Alerts written July 1, 2019 through March 31, 2020. AAMC showed similar results (1,192 patients, (-$11.29M) change in total charges, (-$6,625) average charge per patient, (-$2,207) average charge per visit, (-6.6) visits per 10 members Beyond the numbers, how does it help patients? Patient admitted in the ICU at a nearby hospital. The intensivist saw the Care Alert in CRISP, reached out to the Transitional Nurse Navigator noted in the care alert to coordinate care and reschedule the patient appointment at the high-risk discharge clinic. The care alerts are shared with CRISP and with over 100 outside participating entities. Care Alerts have enabled a new COVID-19 ‘Remote Patient


It has allowed

Monitoring’ program and care team members to be identified and their contact information made readily available so that outside organizations know the level of monitoring and attention the patient is being given through this program. It has allowed ED providers to feel comfortable making decisions about admitting versus sending the patient home, based on their judgement as well as their knowledge of the extent of the care and monitoring being done for the patient. SUSTAINABILITY Within the context of the grant work, sustainability is defined as showing an ROI that is equal to or greater than 1.0, meaning the revenue generated by providing the intervention meets or exceeds the costs of providing the intervention. CRISP does not have all-payer claims data, but they



do have all-payer charges from all Maryland hospitals, and a report that allows users to upload and measure the change in charges and utilization for patients for whom Care Alerts have been written.

management leadership, and a leading-edge health information exchange who spent the time to describe their challenges and orchestrate a solution.

The ROI, using a calculation provided by HSCRC as part of the grant, considers the total change in charges by taking 50% of the change in charges (considering variable savings), subtracting the cost of the intervention (the cost of writing and maintaining Care Alerts) and dividing by the cost of the intervention. The ROI for Shared Care Alerts was 35.71 for nine months of FY20, demonstrating a highly sustainable, effective intervention.


INNOVATION This solution was driven by clinician desire to have a single location for actionable information provided by any/all care team members, including PCPs, Specialists, ED providers, community care managers, hospital (and soon Payer) care managers and other post-acute care providers. The innovation was ultimately achieved by the hospitals, CRISP and EPIC coming together to develop a solution using industry standards for data sharing developed by the Office of the National Coordinator and the Health Level 7 standards workgroup. The power of Shared Care Alerts, coupled with other tools and mechanisms for efficient outreach across settings of care, is a tremendous care coordination capability enabled by dedicated leadership. This was enabled by an advanced technical team, quality-focused care

Since Care Alerts are written for and contributed to by all care team members who work with a patient, both within and outside of the hospital setting, they are a teaching mechanism; a culmination of the most important elements each care team member knows about the patient, either directly from the patient or through their work with them. Care Team members are encouraged to provide updates and suggestions for Care Alerts at any point during and at the end of their working relationship with the patient. Each care team member has unique interactions and experiences with the patient that is important for understanding the whole picture. This picture assists care teams and patients by providing continuous communication about patient needs, home environment factors, normal presentation and treatment considerations, social and economic considerations. Having the big picture in a concise location gives all care teams an opportunity to make the most of their limited time with the patients/ families, demonstrates that they communicate with one another and that they are listening and communicating key factors, many of which enhance safety. Hospitals can avoid unnecessary or duplicate testing and avoidable admissions because there are known safe, effective alternatives.




GRAND ROUNDS Why Your Payer Medical Director Should Be Your Best Friend Stephen Crouch, MD

LEARNING OBJECTIVES: 1. Identify ways that providers and payers can collaborate to improve efficiencies in workflows. 2. Identify potential barriers to productive provider–payer interactions. 3. Provide actual examples of solutions a large health system employed to improve relationships with payers.

In 2014, Advocate Health Care -- now Advocate Aurora Health -- created a new position for the organization: Medical Director of Care Management. After being hired into the position, I was tasked with reaching out to our payer partners and requesting an introductory meeting with their medical directors. In addition, I wanted to explain my role to our payer partners because it was new for our organization. I asked our contracting department to


provide the contact information for the medical directors of the largest volume commercial plans and for the medical directors of the Medicaid managed care organizations (MCO), which were new to our state. Lastly, I also wanted to learn more about each medical director and develop an open line of communication moving forward. Unexpectedly, we met resistance from some of the payers as they were initially reluctant to provide the contact information. We received responses such as “Why does he want to talk to us?” and “What is he trying to accomplish?” After overcoming the initial hesitation from our payers, the introductory meetings were scheduled to take place in person rather than over the phone. The face to face interaction was beneficial in establishing a connection and building rapport. In addition, these in-person interactions allowed for introduction to other members on our respective



teams. When we met at the plan’s office, I was able to meet the nursing leadership who oversaw the utilization management and approval processes. If we met on my turf, the medical directors were introduced to my dyad nursing partners who led our utilization management and care management departments. As a result, regular meetings were scheduled to discuss workflows and address barriers each side was experiencing. These meetings led to resolution of issues that had been present for some time. Initially, the meetings were held monthly as we worked through the items that needed to be addressed, and as time went on, we were able to stretch out the meetings to a quarterly schedule. Contacts were established allowing either side to reach out to the appropriate person and quickly resolve minor issues that would arise. Most of the issues involved delays in obtaining approval for postacute services from the plan.

large project, we certainly encountered a few unexpected issues. Rather than moving all sites to the centralized location at the same time, we opted for a staged approach. Every two weeks we relocated staff from two or three hospital sites to the new central location. With the disruption to the utilization management staff’s daily routine and the need for them to adjust to the new environment and standard work, we fell behind and found it difficult to meet the timeframes for submission of clinical information to some of our payers. As a result, we received more technical denials than we experienced prior to the centralization. Based on the relationship we had developed, we reached out to our payer partners and asked for understanding of our workflow issues. Through collaborative discussion, the payers allowed our system to set up a schedule that was acceptable to their team and allowed our team to submit the necessary clinicals outside of the standard payer timeline. The payers recognized our commitment to improving, and the graces granted to our system strengthened our friendship.

I also wanted to

learn more about each medical

director and develop an open line of


A year after we established these relationships, our health system made the decision that the utilization management staff, registered nurses and assistants, were to be moved out of the hospital sites to a central location. The decision to centralize this work had two main goals: to decrease the variation of the review process and to develop standard work. These two changes were intended to increase the efficiency of our staff and provide an opportunity for the nurses to work independently and utilize their unique skills. In preparation for the move, we met with our payer partners, informed them of our plan and discussed any anticipated issues. We made sure they had the correct points of contact in case they identified any issues that were not anticipated by our team. As with any

moving forward.

A few years later, I assumed the responsibility for reviewing cases from one of our acute care hospitals when a peer-to-peer discussion was offered by the plan. Based on the successful relationship with our commercial payers, I was hopeful I could develop similar relationships with the predominant Medicaid managed care organization for this facility. After having an unpleasant peer-topeer discussion with one of their medical directors, I reached out to the senior medical director of the MCO. The outcome of our discussion was to move forward with a better understanding of how each reviews a case to determine medical necessity,




maintain an open line of communication, and assign a dedicated medical director for any issues and peer-to-peer discussion on our patients from that one facility. The dedicated medical director was accessible by email, phone or text, which made completing the peer-to-peer discussions efficient and removed the administrative task of aligning our schedules. We formed a collegial friendship and quickly identified an opportunity for improvement: incomplete submission of clinical records. Based on this information, a reconsideration process was developed. When the MCO determined a patient was not meeting necessity based on the initial clinical records submitted, we were afforded the opportunity to submit additional clinical information which was reviewed by the medical director before proceeding to a peer-to-peer discussion.

advisor role by hiring additional system physician advisors. The additional staffing has been used to review peer-to-peer offerings from all payers for all Illinois hospitals within our system. If a peer-to-peer discussion is needed, a system physician advisor completes the discussion rather than relying on the busy medical staff physician.

As a result of our

positive experience, our system decided to invest in the

expansion of the

system physician

advisor role by hiring additional system

During the first year of this working relationship, the volume of peer-to-peer discussions decreased. This decrease occurred for two reasons: (1) my decision not to pursue every peer-to-peer offered and (2) the medical director’s awareness of my discussion style and thoughts on what constitutes medical necessity when the case does not meet a specific medical care guideline. As a result, the medical director began to overturn the initial decision to deny based on lack of medical necessity and averting a phone call to discuss the case. As a result of our positive experience, our system decided to invest in the expansion of the system physician

physician advisors.


A final example illustrates how the relationship we cultivated with one payer partner persevered over time despite leadership changes. Earlier in the ongoing COVID-19 pandemic, our system was struggling to determine medical necessity for the COVID-19 patients bedded in our hospitals. As a result, we reached out to the senior medical director to discuss their approach to this patient population. We learned that the plan leadership had recently transitioned. The outgoing medical director arranged a meeting with the two new medical directors who were now responsible for our system and explained the importance of the relationship we had established over the years. This laid the groundwork for a seamless transition.

After a brief introductory meeting, both sides began to discuss the current COVID-19 pandemic. We quickly shared our respective approaches to determine medical necessity for this unique patient population and discovered our approaches were similar. In addition, the plan recognized our system’s urgent need to transition our patients to the next level of care after discharge in order to offload our hospitals and



increase bed capacity. Although the plan had previously announced a policy for automatic approval of these requests, we were still encountering barriers. The new medical directors agreed to work with their UM team to resolve the remaining issues. Lastly, we scheduled a follow-up call to discuss readmissions and share programs each side had developed to prevent them. We quickly discovered that there was minimal overlap between our programs, and, in fact, they complemented one another. For example, the plan had a way to provide transportation to post discharge physician appointments and our system had established a process to schedule these appointments; however, we often ran into the problem that the date and time of the follow-up appointment did not align with the availability of the family member who would be driving the patient to the appointment. By utilizing the plan’s transportation program, we were able to ensure the patient kept the appointment and did not rely on the family member for the transportation to the appointment. Over the last six years, we have been able to continue this collaborative process despite turnover at the medical director position within some of the plans. One medical director joined another one of the payers and was quick to initiate the introductory meeting and cadence of meetings with the staff at their new position. These successful relationships are based on active listening, respect, transparency, consistency and responsiveness. From my perspective, the most important takeaways of these friendships are: • Establishing patient-centered processes • Understanding and respecting the payer’s responsibility to their beneficiary and the provider’s responsibility to their patient • Creating an escalation process for concerns when one party is not following the agreed-upon standard work • Learning when to agree to disagree and moving forward • Sharing resources that avoid duplication


Special Insert: Adapting to COVID-19 Across the country, ACMA members are making a difference in the lives of patients and families. The following individuals and organizations were recognized with a donation of support to ACMA. Thank you to everyone who has stepped up, not back, in 2020.

In Honor Of Mark Denno, Orangevale, CA

Christine Babina, Gaylord Hospital Care Management Kris Nelson, Henry Mayo Newhall Case Manager ACMA Dallas-Fort Worth Chapter ACMA Central Texas Chapter

Providence St. Joseph Health St. Johns Medical Center | Holy Cross | Little Company of Mary Medical Center | Mission/Laguna | St. Joseph Burbank | St. Joseph Orange | St. Jude | St. Mary's | Tarzana Cedars Sinai

ACMA National Office Staff All ACMA Members

Saint John Medical Center - Case Management, Home Health and Hospice Teams

Visit the National Case Management Week website to view all honorees


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SETTING THE STANDARD FOR FIXED-WING AIR MEDICAL TRANSPORTS AirMed Adds Aircraft, Services and Easy-to-Use Options to Provide the Highest Level of Care At AirMed, being the leader in fixed-wing air medical transport missions means always improving on our promise to deliver the highest quality care to the world at a moment’s notice. We’ve been busy upgrading our aircraft fleet, the levels of service we provide and even the way you can order an AirMed transport.

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SOME THINGS NEVER CHANGE AirMed continues to provide all-inclusive, bedside-to-bedside service, specialized medical care, highly skilled critical care clinicians and the safest pilots. TO SCHEDULE A TRANSPORT, PLEASE CALL 205.443.4840.



COVID-19 Lessons: The Time is Now to Improve Healthcare Efficiencies

Online Ordering for Medical Transports Can Streamline Communication, Response Times Jeffery McCollom, Senior Vice President Business Development, Global Medical Response Denise Treadwell, President, AirMed International In a year like no other, the healthcare industry has been taxed and tested. The COVID-19 pandemic came and, on one hand, shined a bright light on the courageous, skilled and dedicated women and men on the medical frontlines, risking all to help their communities. Doctors, nurses, EMTs, paramedics, communications operators, flight medical crews and air-transport pilots all have risen to the unprecedented challenges placed before them by an invisible, previously unknown enemy. We take great pride in their efforts. On the other hand, the pandemic exposed critical areas where the industry itself can and must improve. Defining and addressing these issues began almost immediately upon the outset of COVID-19 and will be at the forefront of our efforts in the near- and long-term. But we are an industry accustomed to adaptation, and we will rise to this occasion. The changes we make for the better will not only help in our COVID-19 response, or facing another novel virus, but also in the day-to-day patient care that hospitals, healthcare systems and medical transport companies regularly provide. A MATTER OF TIME One of those critical issues is time: the time it takes to respond to a patient call, the time that clinical staffs have to provide care, and the time to accurately get patients the right level of care for their medical needs. COVID-19 showed us that even the smallest improvements in time management, saving the smallest increments of time, can add up to higher

levels of care. Often, those minutes and seconds saved are the difference between life and death. Global Medical Response (GMR) saw this firsthand. Our ground- and air-transport companies not only serve thousands of communities across the country but were sent to augment the COVID-19 response at hot spots in New York, New Jersey, Texas and California. Here we found that our efforts and those of the hospitals and healthcare systems, often overburdened by incoming patients, could have been improved with better time management through better systems. Small breakdowns in the communication of patient information and hospital capabilities added greatly to the time it took to get patients the care they needed. One solution to address these potential breakdowns and save critical time is a more modern ordering system for medical transports. This would provide accurate information more quickly while freeing clinicians from timeconsuming administrative duties, allowing them to focus on what they do best: patient care. For most hospitals and healthcare systems, the telephone is still the only lifeline to other medical agencies. CHANGING THE PARADIGM It didn’t take a pandemic for GMR to begin thinking about the critical issue of time. In 2011, GMR began developing and rolling out a new Online Ordering System (OLOS), leveraging proprietary software to make it easier and exponentially faster to order medical transports.




This industry-leading system enables healthcare professionals to schedule any level of medical transport at the click of a button. With the facility of this new system, transport scheduling is ten times faster than ordering by phone—saving valuable time while increasing efficiency and hospital throughput. OLOS makes it easy to request and schedule medical transportation whenever it fits into the busy schedule of transfer center users, discharge planners, nurses or other staff at healthcare facilities.

The benefits are immediate and profound: • Accessible from any web browser and imports patient information securely via EHR integration. • Intelligent and can determine the appropriate level of transport based on a few simple questions. • Saves administrative time by creating paperless patient documentation.

COVID-19 showed us that even the smallest improvements in time management, saving the smallest increments of time, can add up to higher levels of care.

• Provides real-time ETAs, as well as transparency of past and future transports to help determine up-to-the-minute bed availability. In fact, visibility into a hospital’s bed availability has become another hot-button issue to stem from the pandemic. Understanding and managing that availability is critical but also time consuming. OLOS provides a fast and easy way to keep on top of bed vacancies through its CleanCue functionality. CleanCue signals hospital staff to clean an empty bed with instant text messages upon patient transport. This improves bed turnover, which is vital during a pandemic but important as well to keep a hospital functioning smoothly and efficiently at any time. This idea of freeing hospitals from cumbersome duties, which are pivotal but also compete for time with


the provision of patient care, is at the core of our philosophy. Ideally, OLOS is merely a jumping-off point where hospitals provide some basic information and we handle all Transportation Network Management from there. This includes arranging any level of transportation (ambulance, wheelchair van, rideshare, taxi, etc.), handling billing, reporting ETAs, ensuring transport crews have sufficient training (like COVID-19 protocols), and, of course, safely delivering patients to healthcare facilities, between facilities or to the patient’s home. A true end-toend program that frees up time for hospitals and caregivers. PILOT PROGRAM RESULTS

By early 2020, just as COVID-19 came to U.S. shores, adopters of this innovative Online Ordering System were reporting increased efficiencies, which means additional time for patient care. Deaconess Health System was one such early adopter. Deaconess serves 26 counties in Indiana, Kentucky and Illinois with nine hospitals and a network of more than 30 care sites. In February, Amy Susott, Chief Innovation Officer for Deaconess, commented on the early results for her health system.

“All Deaconess personnel who are responsible for arranging transport for patients are able to use OLOS. This level of integration is a ‘game-changer’ for patient throughput at Deaconess,” she said. “The system reduces handoffs, increases accuracy for hospital and EMS staff, and reduces hassle and wait times for patients. Additionally, using the right level of transportation will lower costs for both Deaconess and patients, and the standardized documentation reduces billing discrepancies.” GMR has received similar reports from other hospitals now using OLOS. The system not only


eliminates time spent on the phone ordering transportation, but it also streamlines communication between medical transport company and hospital, addressing surges in capacity, allowing all parties to be aware of the need for increased transports and staffing earlier in the process. Addressing patient surge has been one of the key takeaways from the COVID-19 pandemic. GROUND AND AIR COVERAGE OLOS rollouts to partners like Deaconess featured ground transports. But GMR, with both air- and ground transport concerns, has continued to build out the program. Recently, we increased the functionality of OLOS to include requests for non-emergent, fixed-wing air transport quotes through AirMed International. AirMed provides fixed-wing air ambulance transportation for individuals, families, insurance companies, travel-assistance companies and providers of medical care throughout the world. Since 2003, AirMed has completed more than 25,000 missions in all 50 states and more than 150 countries on six continents. AirMed’s all-inclusive, bedside-tobedside service focuses on specialized medical care during the entire transport with highly-trained critical care clinicians and flight crews dedicated to the company’s impeccable safety record. Through OLOS, obtaining quotes for AirMed’s patient services, which includes scheduling transports on commercial airlines as well as via its


own medically-configured fleet, is now as easy as clicking a button. With this system, hospital case managers, travel insurance call centers and health insurance plan administrators can save valuable time while increasing efficiency. SHARING INFORMATION AND EFFICIENCIES Fixed-wing transport online ordering is fulfilled through GMR fixed-wing assets, including AirMed aircraft, and is occasionally outsourced by thirdparty providers with customer approval. But the ground-transport functionality of OLOS is agnostic, meaning it can be used regardless of the ground ambulance provider contracted by a hospital or health system. In other words, we have made it possible for competing ambulance companies to leverage our efficiencies and information resources. In the wake of COVID-19, such acrossthe-board sharing will further decrease response times and patient wait times while freeing more clinicians from administrative duties. GMR will continue to improve its OLOS platform in the coming months and years through increased levels of communication, functionality and depth of information the system can provide. This will be critical to better responding to crises but, more essentially, it will improve healthcare for all Americans at any time of need. To learn more, visit or call 855.267.0911.




Two Studies, One Result: Free Talking Prescription Labels Improve Medication Safety & Independence By Jenna Reed INTRODUCTION The results of a recent study by the American Foundation for the Blind (AFB) underlines an ongoing concern for patients who are visually impaired or blind — the need for accessible prescription labels. As case managers, these simple yet effective labels can improve your patient’s sense of safety and independence while also reducing medication errors. What are accessible prescription labels? These are talking prescription labels. TALKING LABELS & HEALTHCARE In a special study1 related to the impacts of COVID-19 on healthcare featuring individuals who are blind or visually impaired, the AFB discovered one systemic yet preexisting concern related to the labels on the medication bottles — some participants report the labels of their medications are not accessible. While a portion of study participants said this is an issue, others indicate they were successful with requesting ScripTalk talking prescription labels. The study highlights that some pharmacists provide customers with large print or Braille labels on their medications. And a few study participants indicate they were not aware of accessible options for reading medication labels, according to AFB.

In their response to the study findings, AFB officials released the statement: “Healthcare providers should make written information accessible to patients who are visually impaired by providing electronic, Braille and large print options. … Prescription labels and directions need to be available in accessible format to allow the patient independent access. ScripTalk, large print or Braille options that are low cost and can be used to ensure those with visual impairments can independently manage their medications.” Highlighting the vital importance of these accessible labels are the study results. With a response of 1 meaning strongly disagree and 5 meaning strongly agree, 748 individuals who are blind or visually impaired responded to the statement: “I am concerned I am not able to get the pharmacy to request accessible labeling of medications.” The median result was 2.94, meaning individuals are concerned about this topic. Equally important is the results of those who responded to the statement: “I am concerned I am not able to meet with the pharmacist to review medication instructions.” The median response was 2.77 out of 856 who offered feedback on this statement. Again, raising the specter that this is a real issue.



SCRIPTALK STUDY AFB specifically referred to ScripTalk labels in its study results. These talking prescription labels are available for free to patients at thousands of participating pharmacies throughout the U.S. and Canada. ScripTalk is implemented at the pharmacy level. A pharmacist programs a small electronic label with all the prescription information, including drug name, dosage, instructions, warnings, pharmacy information, doctor name, prescription number, date and more. The tag relies on RFID and text-to-speech technology. The pharmacist places the tag on the prescription package and the patient can use a free ScripTalk mobile App or a ScripTalk Station Reader (free on loan for however long the patient needs it) to read all the information out loud. To get a deeper dive and statistical evidence as to how much ScripTalk can help patients who are visually impaired, En-Vision America — the maker of ScripTalk — commissioned an independent study2 to be done with ScripTalk patients. The results show that while 35 percent of ScripTalk users reported experiencing a medication error prior to using ScripTalk, no one experienced a medication error related to mixing up medications or taking the wrong medication/dosage since using ScripTalk. In fact, almost all study participants (98 percent), reported feeling safer taking their mediations since using ScripTalk. Just under two-thirds (62 percent) of those questioned, said they feel safer because they know they are taking the right medication/ dosage. And more than one-third (37 percent) of respondents said they feel safer taking their medications because ScripTalk reads them all of the information they need to ensure they are taking the right medication.


H-E-B, Caremark, Express Scripts, OptumRx and hundreds of independent pharmacies. Case managers can visit www.envisionamerica. com/participating-pharmacies and look up participating pharmacies by ZIP Code to discover the location nearest their patient. To learn more about ScripTalk and sign up for a free collection of brochures and educational materials, as well as a demo prescription bottle to have on hand to show patients and doctors, visit Full information on ScripTalk, as well as information on other available accessible prescription labels, including large print label, dual language translation and Braille are available at ABOUT THE AUTHOR Jenna Reed is a veteran journalist, serving as a writer/editor for almost 20 years working in newspapers as well as with business publications. Several years ago, she expanded on her skills as an editor by transitioning into marketing. Almost two years ago, she relocated from the Washington, D.C., area to the Gulf Coast of Florida. Her passion surrounds educating those in the healthcare industry about how free accessible prescription labels can make a big difference in patient’s lives. Jenna can be reached at and welcomes feedback and questions regarding this article and accessible prescription labels. REFERENCES: 1. American Foundation of the Blind’s Flatten Inaccessibility study covering the topic of healthcare during COVID:


2. ScripTalk Study Report as well as Raw Study Data: scriptalk-study-results

ScripTalk3 is available for FREE at thousands of participating pharmacies throughout the U.S. and Canada, including Walmart, Sam’s Clubs, Costco,

3. How ScripTalk Works:


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Solving the Complex Problem of Unfunded Foreign Patients in American Hospitals for Over 40 Years During unprecedented COVID-19 travel restrictions and medical safety protocols, MedEscort continues to deliver on its unwavering commitment to superior service and patient care. Our knowledge, flexibility, and vast network of global resources allow us to work without interruption, to solve the problem of complex discharges for hospitals throughout the world. Extensive patient & family consultation and education

Worldwide, specialized legal support team

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Reuniting Families Around the Globe Amid a Global Pandemic By Julie Huber • Edited by Craig Poliner • MedEscort International Inc. • Allentown, PA Under an unbelievable amount of COVID-19 global travel restrictions, MedEscort International has continued to provide hospitals and insurance providers with uninterrupted, highly-specialized logistical assets that facilitate the discharge and safe repatriation of unfunded and undocumented patients over the past eight months of the unfathomable, year 2020. MedEscort International is a United States-based business that has been providing resources for over 35 years to hospitals and patients around the world. MedEscort works with domestic and international insurance companies as well as foreign and domestic governments on behalf of hospitals to cover their unfunded international patients. Through the use of their numerous global resources, MedEscort has been able to continue reuniting families around the globe.

Manila in the Philippines. To complete this trip, many resources needed to come together for one patient to return safely to his home country. At that point in time, no one from the United States had been able to navigate the travel bans due to COVID-19 successfully, yet MedEscort knew they could rely on their global network of trusted resources to rise to the challenge. Through that network, they had the confidence and the team they needed to reunite their patient with their family as they have done with many patients even long before Covid-19.

is when “This the case

managers recognized the importance of helping her face these challenges head-on.

MedEscort is the only National network provider of service to Aetna Insurance Company that provides medical transportation both domestically and internationally. They have worked diligently and navigated through the ever-changing regulations placed on air travel due to COVID-19 since the very beginning of the extensive travel bans beginning in March of 2020. THE PHILIPPINES During the height of the shutdown, MedEscort was contacted to help safely return a patient home to

When the patient was admitted to the hospital, amidst the COVID-19 pandemic, she and her family relied heavily on professional case managers to navigate the language barrier and procedures of being in the hospital.

The patient was formerly from Manila and had become ill while in the US. She was admitted to a hospital in the U.S. which presented many challenges for her. Aside from the patient not speaking English or understanding the ever-changing COVID-19 safety protocols, she also did not have access to family or friends to help guide her through her illness due to hospital lockdowns. This is when the case managers recognized the importance of helping her face these challenges head-on. Then, the patient and case managers began to build a strong and trusting relationship.



The case managers contacted MedEscort to begin the process of repatriation for this patient about the time that travel was coming to an abrupt halt around the world. With little hope of a return on the horizon for this patient, MedEscort knew the job ahead was increasingly important. The strained hospital resources due to COVID-19 made conversations with case managers, the patient, and MedEscort challenging. Despite these challenges, MedEscort and the case managers combined their professional efforts with the patient’s family and a continuing care facility in Manila to coordinate a plan to get the patient home to Manila safely and appropriately by following a complex discharge plan. The resources needed to accomplish this goal properly and in compliance with COVID-19 CDC guidelines and AMA guidelines were immense. So, the teams assembled and began the process of pulling out all the stops. Case managers worked directly with MedEscort, the hospital administration, and the patient’s family to build trusting relationships and communicate the plan, ensuring everyone understood every aspect of the journey and that they would be in compliance with all guidelines. The Philippines Authorities were made aware of the repatriation attempt and immediately jumped at the chance to help any way they could to safely return the patient home. Unfortunately, the Philippines was closed to travelers from the U.S. as were many airports along the route from the U.S. to Manila. This presented more challenges, as the patient was weak and unable to travel for an extended time.



MedEscort was prepared and coordinated therapy to begin immediately preparing the patient for the potentially long journey. With the help, compassion and understanding of the Philippine Consulate in New York, Philippine Airlines, the Philippine Health Ministry, the Philippine government and the office of consular affairs; travel to their country from the U.S. was made possible despite challenging COVID-19 restrictions. MedEscort’s work could not be completed without the transitions of care professionals as a greater ally for the patients and the flexibility to work with other resources they may not have worked with before. The appreciation for the work that is done in the hospitals is held in high regard by MedEscort and their team. COVID-19 has presented so many challenges to case managers and they have gone above and beyond in many cases to ensure a successful and full recovery for patients. MedEscort has traveled to Manila before with patients so the resources and relationships they have built over the years were truly a valued asset for this trip. This case would prove to be a huge task and test their dedication to the reunion back home to his family. All of the partners were gracious and accepted the challenge with courage. Working together with so many resources can get overwhelming at times and with so many changes around CDC guidelines, the ability to be flexible was imperative. The travel plans for the return to Manila for this specific patient changed daily due to the demographics of COVID-19 and governmental regulations. Our thanks



and praise to the Philippine Airlines for allowing the team to travel and quarantine in the airport until the return flight to the U.S. as this proved to play a huge part in the repatriation plan. Without the support of Philippine Airlines and the impeccable customer service provided by the Philippine Consulate, the trip could not have been successful. At long last, the patient was home and reunited with his family. This would not have been possible without the case manager’s personal involvement and dedicated effort to help the patient. EGYPT Upon the MedEscort team’s return to the U.S., there was word of the next repatriation and the process began again. This time to Egypt. This next repatriation would be unique in a way that none of our experienced team would expect. Again, due to a language barrier, MedEscort’s research began and the patient was identified and his hometown was contacted. It was discovered that this patient had been missing for 20 years and his family and friends had no idea he was still alive.

worked with the patient to continue to get information and MedEscort continued to put the pieces of the puzzle together. This was an interesting case because once again so many global resources would come together to help someone they originally knew so little about. Like many cases that MedEscort has worked with, this case would prove to have a multitude of layers and details that made it unique. Earning the trust of the patient and his family in Egypt through their global resources was an integral part of his repatriation. MedEscort provides safety and reassurance that each case will be handled ethically, legally and transparently to avoid any misconceptions.

…with the trust and communication that MedEscort has built over the last 35 years, we have found anything is possible.

With hospital administration on board and phenomenal case management, MedEscort was granted access to the patient to do more research into his background and life to help reunite him with his family. With a full understanding of the information provided, MedEscort continued to partner with its global resources once again to develop a successful repatriation plan. This would prove to be a sensitive case. MedEscort wanted to be sure that the patient wanted to go home after being gone for so long and that they would be welcomed home. Case managers

This patient and his family, as well as hospital administration, case managers, and specifically the Egyptian Consulate in New York and Egypt Air along with Med Escort worked together with compassion, dedication and understanding every step of the way to create a working relationship and provide comfort and answers to keep everyone informed and on the same page. After the transport was completed, the patient had been united with his family after 20 long years apart and MedEscort, the U.S. hospital administration, and the case managers remained in contact with the patient and long-term care facility to provide continuing care information for the patient at the new facility.

Communication is key in every single case because each one is different. Each country has is preconceived notions about other countries’ resources and their healthcare systems and is skeptical about working together. But with the trust and communication that MedEscort has built over the last 35 years, we have found anything is possible.




Hartford HealthCare Center for Healthy Aging – An Innovative Care Strategy for Older Adults Wendy Martinson, MSN, RN; Penny Ross, MPH; Marc Levesque, MS; Nancy Becker, MA, CMC; Jessica Dakin, BSN, CDP; Michelle Lavoie, BA; Joseph Zuzel, M.S. Ed; Maley Hunt, MHA, LNHA

LEARNING OBJECTIVES: 1. Review and discuss a new model of care targeting the senior population (Center for Healthy Aging). 2. Identify key disposition referral sources for successful healthcare transitions. 3. Discuss the value of care coordination over the adult’s lifetime vs. episodic care. John is in the Emergency Department after his wife, Mary, found him wandering. She says to the ED staff “I can’t do this anymore!” John had been admitted last month for altered mental status and a urinary tract infection and was transitioned home after evaluation and treatment. While in the ED John’s wife is told there is no medical reason to admit him but they recommend he return home with 24-hour care. Mary is visibly upset because she doesn’t know where to begin and doesn’t


think they can afford to pay for care. This scenario is seen far too frequently varying in complexities based on medical, cognitive and social needs. Historically, the United States has spent more on healthcare than 13 of the highest income countries in the world yet Americans have had poorer clinical outcomes, shorter life expectancies, and more chronic health conditions than these other nations. While the U.S. spends more money on health care costs than other countries it commits comparatively few dollars to social services such as housing assistance, disability benefits, and food security (The Commonwealth Fund, 2015). Recognizing the need to redesign health care delivery, in 2007 the Institute for Healthcare Improvement (IHI) developed the concept of the Triple Aim, providing a framework for “improving the patient experience of care, improving the health of populations, and reducing the per capita cost of health



care “(IHI, 2007). Since its inception, the Triple Aim has been adopted across the country and in countries across the world. Ten years later the John A. Hartford Foundation along with the IHI, the American Hospital Association and the Catholic Health Association of the United States partnered to test new ideas and explore how to create Age Friendly Health Systems using a framework where value is optimized for all – patients, families, caregivers, health care providers, and the overall system (IHI, 2018). These initiatives highlight the absolute need to address the great impact psychosocial and social determinants of health have on cost, outcomes, and satisfaction. Connecticut has consistently been ranked as the wealthiest state in the union yet experiences the same disparate health outcomes that many poorer states face (Connecticut Department of Public Health, n.d.) Over the past decades and prior to the passage of the Affordable Care Act (ACA), the State of Connecticut faced significant economic constraints and reduced or eradicated funding for many community-based services and support available to older adults. The Center for Medicare and Medicaid Innovation was created as a result of the ACA and the State of Connecticut is engaged through the State Innovation Model to create new, sustainable models of care to solve for the concerns of the aging population. In the absence of adequate federal or state programming for older adults, Hartford HealthCare created the Center for Healthy Aging (CHA) as a model of care addressing both the medical and psychosocial needs of older adults. Within the following service lines, Resource Coordinator, Dementia Specialist, Transitional care Nurse and Geriatric Care Manager, the CHA proactively seeks out individuals, caregivers and partner agencies in an effort to find solutions for the patient, organization, and system while aligning strategically with new models of accountable, value-based care. PROGRAM DESCRIPTION The CHA is a creative solution to meeting society’s need to assure informed choice and safe aging in place for all older adults. The program concurrently addresses the need for resources and strategies to support individuals with multi-morbidities while addressing their social determinants of health. The success of the CHA stems from a multi-disciplinary approach built to create a one-stop-shop for information and resources, bringing well trained professionals together to meet all of the client’s needs. The staffing model includes Resource Coordinators, Dementia Specialists, Transitional Care Nurses and Geriatric Care Managers, with specific roles outlined in Table 1.


RESOURCE COORDINATOR • Facilitate care coordination • Provide home, telephone, or office based assessments • Solve for socioeconomic and psychosocial needs • Link seniors and their families to community resources • Work with community agencies to assist with resource allocation • Provide telephone follow-up • Conduct community outreach

TRANSITIONAL CARE NURSE • Conduct in-home assessments with 30 day telephonic follow-up • Assist with care coordination (bridge from between Patient & Family and Healthcare Team) • Educate patient and family/caregiver • Improve self-management skills • Link seniors and their families to community resources • Provide feedback to providers on current living conditions, safety, family support, disease knowledge, and personal health goals • Reduce hospital readmissions • Develop wellness center model for lowincome housing complexes • Facilitate Geriatric Care Management


Support overwhelmed family/caregivers Provide caregiver coaching Educate on the best strategies of care Address safety, wandering, and behavior challenges Link seniors and their families to community resources Provide education to formal and informal caregivers Facilitate care coordination Conduct support groups

GERIATRIC CARE MANAGER • Coordinate care between and/or for the client, family with physicians and other healthcare providers • Monitor chronic disease process and promote whole body wellness • Assistance with medication and attending doctor appointments • Advocate for clients • Screen for, arrange, and monitor home services, including oversight of private caregivers • Refer to appropriate community supports and services including placement if needed




The primary function of the CHA is to provide individuals, families and caregivers with the resources and education to ensure they receive the right care at the right time and in the right place. This means that at the forefront of every interaction are the goals identified by the individuals and their families.

a time interval appropriate to their individual situation. Individuals and their family/caregivers are also encouraged to contact the CHA at any time with questions or concerns. CHA staff may also provide a second full assessment if there has been a change in condition since the last assessment.

The assessment is where the CHA staff first establishes a relationship with the older adult and caregivers. Assessments could occur in an acute care hospital, community setting (older adult’s home, a caregiver’s home, etc.), CHA office, telephonically or virtually. Once the needs and concerns of the older adult are identified the CHA staff can discern the resources and information available to achieve the desired outcomes. Most often these outcomes are centered on safety, but are frequently paired with financial security, socialization, caregiving and improved medical care. At times, the CHA has been viewed as a concierge service linking individuals to anything from a new physician, rehabilitation services, transportation, and private care to snow removal, pet sitting, exercise programs and more. A key feature that sets the CHA apart is the willingness to assist with almost any need.

Integral to the success of the program is the provision of community outreach and education. Through this outreach, the staff raises awareness and is able to identify trends and community needs. CHA staff regularly present at local senior centers, YMCAs, churches, community wellness centers, housing complexes, professional groups and conferences. Prevention and early identification is targeted through screening events that include blood pressure, cholesterol, glucose, HGB A1C and memory.

Another unique feature is that unlike traditional human services programs that address issues based on an episode of care; the CHA is available throughout an adult’s lifespan and not tied to episodic care. Once an older adult or family member contacts the CHA they remain active in the electronic database and are scheduled for follow up communications at

Educational programs created by the CHA Dementia Specialty staff have been so well-received they are now being regularly approached to provide training to skilled nursing facilities, assisted living facilities, private duty agencies, certified nursing assistant certification programs in addition to being offered free to community members at large. A set of unique

Many population health models categorize clients/patients by disease process i.e. heart failure, diabetes or COPD. Individuals connected to the CHA are not placed in the proverbial “diagnosis buckets”. CHA does not use algorithms or decision trees to determine needs or appropriate followup. The client and caregivers actively participate in the discussion and planning of the next steps that work for them.

CHA does not use algorithms or decision trees to determine needs or appropriate follow-up. The client and caregivers actively participate in the discussion and planning of the next steps that work for them.



tools, guides, workshops and training curriculums have been created in an effort to extend educational reach to as many individuals and providers as possible. STAFFING AND TEAM COMPOSITION The first CHA was located in a community setting and debuted in 2004. Over the next nine years growth was slow but in 2014 the CHA was able to significantly expand its reach through the assistance of a grant awarded by the Connecticut Department of Social Services (DSS). The grant was part of the state’s Strategic Rebalancing Act/Money Follows the Person Rebalancing Demonstration to promote community-based services in an effort to reduce long-term care nursing home beds providing autonomy, choice and better quality of life. The grant allowed the CHA to expand from two to 10 staff members and operate three fully functional sites in acute care settings and one satellite location. After completion of the grant, Hartford HealthCare allocated funds to continue the CHA and invest in expansion. To date, the CHA currently operates seven sites in acute care settings, four in community health centers and one in a skilled nursing facility. A unique feature of the CHA staff is the diverse educational and experiential background of the team which broadens the knowledge base available to clients and referral sources. The current team includes individuals with degrees and licensures in Human Development, Gerontology, Social Work, Psychology, Exercise Physiology, Public Health and Nursing. Equally as crucial as education and experience is the selection of staff with the interpersonal and communication skills essential to success: selfmotivation, listening, emotional intelligence, relationship building abilities and public speaking. Vital to providing clients with the most current resources is ensuring the staff possesses the latest information on state and federal programs, grants, and community resources. In addition to monthly presentations from community partners, extensive ongoing training is provided for all staff. Table 2 highlights some of the training provided to staff.


TABLE 2 Motivational Interviewing

Chronic Disease Management


Live Well Facilitators

CHOICES (Connecticut’s program for Health insurance assistance, Outreach, Information and referral, Counseling, Eligibility Screening)

Habilitation Therapy Train the Trainers

Mental Health First Aid

Certified Dementia Practitioners

No Wrong Door Person Centered Counseling

Care Management Certified

Geriatric RN Course

Caregiver Support Group Leaders

Alzheimer Whisperer

OUTCOMES AND SUSTAINABILITY Connecticut consumers have a great deal of options as it pertains to healthcare choice (i.e. healthcare systems, hospitals, providers, homecare agencies, etc.). Social service agencies exist in each town and within other nonprofit organizations. The CHA’s expert staff provides a bridge to understanding and accessing both healthcare and social service services in a no cost, comprehensive, person-centered manner that builds trusted relationships over time and builds allegiance and loyalty to the brand. With the exception of the Geriatric Care Management Program, there is no cost to the client or their insurer. Funding for the CHA is supported by the Hartford HealthCare System. Promoting services and programs offered by Hartford HealthCare provides a downstream of revenue showcasing the return on investment (ROI) to the HHC system. Since 2016, year over year the referrals to the system have increased 246% (Figure 1).The staff document in a Client Resource Management (CRM) database. This allows us to capture new people that reach out to the CHA, as well as, the volume of referrals sent to the system. One of the challenges of our database is capturing the global number of clients we serve; however, we are able to capture our annual new




clients. Some key dashboard metrics include new clients, connections to services (socioeconomic, cognitive and medical services) and the volume of interactions with our clients. The CHA has seen a 133% increase in new contacts from 2016-2019 (see Figure 2). These new contacts are potential consumers for Hartford HealthCare services. FIGURE 1







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Additional responsibilities of the CHA is educational programming on health related topics, long range planning and screenings (blood pressure, cholesterol, memory, glucose, hemoglobin A1C). The goals of these offerings are to keep people well in


the community, increase knowledge, develop better health habits, raise awareness and aid in identification of new or worsening health problems. The educational/screening offerings also help bring new individuals into the system. The events spread the word about the services and programs provided by our large healthcare system. It’s a very grassroots approach to educate and market wellness and healthcare related services. Over the last 4 years (2016-2019) the CHA held 1,733 educational and screening events. These events welcomed 30,817 potential HHC consumers. This strategy is another gateway into the HHC system of care. As we look at the quality/value of the CHA program our Transitional Care Nurse (TCN) service line focuses a great deal of their home visits on medication reconciliation. 92% of their medication reviews have uncovered medication errors/ discrepancies. These issues are addressed and most likely prevent an adverse event or poor outcome. Use of the BOOST (Better Outcomes for Older Adults) readmission risk assessment 82% of patients score high risk for readmission yet the TCN program has a 3.7% readmission rate. The dementia caregiver education series has shown a statistically significant improvement in caregivers understanding dementia symptoms, handling behaviors, effective communication, feeling supported, having a better relationship and keeping their loved one safe and at home. With the rising number of persons diagnosed with dementia and the bulk of needs placed on caregivers, this has an enormous impact on their ability to care for their loved one and help them age safely in place for a longer period of time. Our satisfaction scores continually have 100% of people replying that the CHA is a valuable service. Cost Avoidance can be difficult to quantify, however, the large focus on community outreach involving primary, secondary and tertiary prevention, uncovering medication errors and linking people to community resources highlight our strategies to reduce healthcare costs. Year over year the top 2 and 3 rankings for our referrals are connections to


homecare services and dementia-related services. Five additional service types continually appeared in the referral mix: Health promotion, safety services, access to care, housing options and legal services (Table 3). The downstream effect of system referrals and new patients entering into the system assists with its fiscal health return on investment. Although not as quantifiable, the CHA contributes to maintaining the patients within the system and preventing system leakage as well as meeting the community benefit obligation required of non-profit organizations.


Capturing data for sustainability for the CHA is two-fold: care coordination and financial performance. The CHA, while utilizing a client relations electronic database, lacks the ability to integrate into the system’s personal medical records. As a result, our solution is to upload our detailed assessments into the electronic medical records used by the majority of the healthcare system. Though they aren’t able to see all of our notes the comprehensive assessment is easily available for their viewing and identifies our involvement and contact information.


The current client relations electronic Although the CHA was developed in 2004 with a database requires a great deal of workarounds different focus; it has grown and adapted to the in an effort to capture key financial metrics such as referral conversation TABLE 3 rate as well as the volume 2016 2017 2018 of clients served year over year. As an integrated State/fed programs Health promotion Health promotion healthcare system, Homecare Homecare Homecare including many Dementia Dementia Dementia post-acute care services, there are several billing Health Promotion State/fed programs Safety systems. A couple of Access to services provider etc. Safety State/fed programs these billing platforms Access to services provider etc. Safety Access to services provider etc. have allowed us to capture referrals that Housing SNF Housing led to business, however, Legal/Financial Housing Legal/Financial most do not. Based on Transportation Legal/Financial SNF the financials we were able to secure; year Veterans Community Based Services Community Based Services over year the CHA has downstream revenue of more than its operating needs of the current healthcare climate poising itself margin with recent years more than double. to be a central point of contact for the older adults of Connecticut. However, challenges still remain with CONCLUSION the greatest being reaching people before they are in So how did the CHA help John and Mary? The crisis. It is common for the CHA to be contacted during Resource Coordinator met with Mary in the or after an event that requires immediate help. The Emergency Department and reviewed her continued expansion of community based prevention concerns around caring for John. They talked about strategies, marketing, and partnering with local his functional status and challenges as well as providers is instrumental in bringing to the forefront Mary’s ability to provide care. The assessment advanced planning for issues related to the aging included a review of finances, current supports in process and how to avoid a crisis when possible. place, family dynamics and their current living



situation. Based on this review and the couple’s preferences they were referred to the local adult day center for adding structure to John’s day and to the CHA Dementia Specialist to work with Mary on caregiving strategies. Because John didn’t qualify for home care services under Medicare guidelines a Transitional Care Nurse was referred for a one-time free home assessment to include medication reconciliation, safety and education. A referral was also given to the system homemaker/companion agency for coverage on days John doesn’t attend adult day care. Future planning included review of state subsidized care options, veteran’s benefits based on John’s service and long term care options. Theirs is a classic example of the type of client that reaches out to the CHA. The case highlights the complexity of care and connections to services many older adults and their caregivers are unaware


of and desperately need. Putting in place these resources before a crisis can help prevent visits to the emergency department, hospitalizations and improved quality of life. The CHA is a unique, forward thinking approach to meeting the medical, cognitive and social needs of older Americans. In its fifteenth year of operation, the model is clearly a scalable, sustainable solution that can help meet society’s need to assure informed choice for all older adults. A significant advantage and strength for the CHA model is being part of a fully integrated health delivery system. The deliberate build out of a CHA model proactively targets high risk, frail aging adults, regardless of their social determinants, to positively impact the individual and their family. The CHA extends beyond the medical model to align strategically with new models of accountable, value based care.

REFERENCES Alzheimer’s Association, 2015 Alzheimer’s disease facts and figures. Berwick, D. A., Nolan, T. W., & Whittington, J. (2008, May). The triple aim: Care, health and cost. Health Affairs, 27, 759-769. Connecticut Department of Public Health. (n.d.). Healthy Connecticut 2020 [Assessment]. Retrieved from dph/state_health_planning/shaship/hct2020_state_hlth_assmt_032514.pdf Gwyther, L. P., & Matchar, B. G. (2015-16, Winter). The Duke employee elder care consultation: meeting employees where they are. Journal of the American Society on Aging, 39, 105-108. Massachusetts Executive Office of Elder Affairs. (n.d.). Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011, Apr). The importance of transitional care in achieving health reform. Health Affairs, 30, 746-754. from Ortman, J.M., Velkoff, V.A., Hogan, H. (May 2014) An aging nation: The older population in the United States population estimates and projections. Retrieved from: Press, M., Rajkumar, R., & Conway, P. (2015, Summer). CMS: Innovating to achieve better care, smarter spending, and healthier people. Journal of the American Society on Aging, 39, 73-77. from Tinetti, M. E., Fried, T. R., Boyd, C.B. (June, 20, 2012). Designing health care for the most common chronic condition-Multimorbidity. JAMA, 307, 2493-2494 doi:10.10001/jama.2012.5265 The Commonwealth Fund, U.S. spends more on health care than other high-income nations but has lower life expectancy, worse health. Retrieved from IHI Age friendly Health Systems website. OHS Connecticut State Office of Health Strategy, State Innovation Model,




Housing First to Improve Overall Health Outcomes Abigail Arens, MSW, LCSW; Rachel L. Smith, MBA; Elizabeth Valvo, LCSW, ACM-SW

LEARNING OBJECTIVES: 1. Learn how to build partnerships with social care agencies to fill known gaps in services for patients with the goal of mitigating homelessness. 2. Learn how to adapt the Housing First model to fit within the local landscape in Chicago to support our patients experiencing homelessness. 3. Identify how partnering with supportive housing can reduce the cost of hospital utilization.

In the City of Chicago, approximately 80,384 Chicagoans are homeless (Chicago Coalition for the Homeless) each night. This includes approximately 5,600 people that are living on the street or in a shelter every night. With only 3,000 shelter beds and access to affordable housing nearly non-existent, it is clear that Chicago is experiencing a housing crisis.

At Rush University Medical Center, we believe that access to safe and stable housing is essential to good health. Once a person is stabilized and in a safe space, they can focus on medical needs, mental health treatment and overall well-being. As a health care system, we see patients return to the hospital repeatedly to obtain access to shelter or address health related illnesses that are not being appropriately addressed due to housing barriers. According to the Homeless Point-in-Time Count and Survey from 2017, approximately 5.7% of homeless individuals stated that they planned to go to a hospital or emergency room to have a place to stay that night (2017 Homeless Point-in-Time Count & Survey Report). At Rush, we work with patients with medical and mental health diagnoses they struggle to successfully treat without a stable living environment. Without stable housing, patients often lack access to a refrigerator




for insulin and other medications and electricity for nebulizers/CPAP machines. 44% of persons who are homeless have a disability (2017 Homeless Point-inTime Count & Survey Report). 47% of persons who are homeless reported receiving mental health services (2017 Homeless Point-in-Time Count & Survey Report). Chicago’s public health system is taxed by the sheer number of vulnerably housed individuals. In 2016, Rush was approached by the City of Chicago Department of Public Health Commissioner to join a citywide effort to combat homelessness through potential partnerships between hospitals/health systems and the AIDS Foundation of Chicago (AFC), which began the Better Health Through Housing (BHH) program. That summer, a contingent of stakeholders traveled to Los Angeles to learn more about the Health Through Housing model and bring back best practices in order to implement a similar model in Chicago. This health and hospital/public agency coalition developed into the Housing and Health Workgroup led by Stephen Brown, MSW from University of Illinois Health and Jess Lynch, from the Illinois Public Health Institute.

homeless constitute 10-15% of the total homeless population, they account for 80-90% of public cost and utilization” Housing First programs throughout the country have demonstrated it costs society one-third to a half as much to provide supportive housing rather than allowing citizens to remain homeless. Inpatient and Ambulatory Care Management collaborated to identify patients in need of immediate housing.

As a health care system, we see patients return to the hospital repeatedly to obtain access to shelter or address health related illnesses that are not being appropriately addressed due to housing barriers.

In January of 2018, Rush entered into a contractual partnership with Better Health Through Housing. Aligned with the social, economic and structural determinants of health goals listed in Rush’s Community Health Implementation Plan (CHIP), a small pilot utilizing the Housing First model was initiated to demonstrate the impact of large city agencies and hospital systems on overall health outcomes by addressing housing needs in Chicago. UI Health reports that “Although the chronically



The patient must meet the Housing and Urban Development’s definition of chronically homeless.

The patient must be a frequent utilizer at Rush University Medical Center. This was defined as 3 ED visits within 3 months OR 3 inpatient visits within a year.

• Patient must be single and able to perform all daily activities.

The Housing First model was used for this program, which prioritizes patients’ choices and goals while acknowledging that safe consistent housing contributes to their well-being. Housing is not conditional on sobriety or abstinence, utilizing a harm reduction framework and patient-centered approach which meets patients “where they are”. Patients did not need to agree to attend appointments, begin treatment for medical or mental health needs, or abstain from substance use or alcohol. This program was particularly unique, because the following factors did not disqualify a patient from this program: • Veterans status • No documentation or legal status • Listed on the sex offender registry



• Felony history or history of arson • No income (if a patient has income they will contribute 30% to housing) • Is not sober and is not interested in sobriety • Not engaging in behavioral treatment and/or medication Without the exclusions that could bar patients from housing, we were able to connect patients that are not typically able to or have additional barriers to obtaining housing. This aspect of the program was intriguing to us because we were able to impact patients that might not otherwise have housing options. In order to identify patients that might qualify for the program, we created an abridged version of the Level of Care Utilization System (LOCUS) assessment to determine patients’ readiness for housing. The LOCUS tool, developed by the American Association of Community Psychiatrists’ Health Care Systems Committee Task Force on Level of Care Determinations, assesses individuals for:

From January of 2018 to September of 2019, 20 patients were assessed for the program and seven patients were housed initially. Outreach workers by the BHH program performed an intake process to determine immediate needs and assist them in moving into temporary (bridge) housing. From there, each patient was assigned a housing case manager to assist with the transition to housing. This process included: finding a permanent housing facility/unit that the patient qualified for, and identifying any barrier or need to help the patient become housed. Monthly meetings with the housing case managers from Better Health through Housing were scheduled to communicate updates, share pertinent patient information and assist to facilitate connections to medical and mental health care as needed.

Housing First programs throughout the country have demonstrated it costs society one-third to a half as much to provide supportive housing rather than allowing citizens to remain homeless.

• Level of patient engagement • Severity of chronic medical and mental health conditions • Patient ability to manage medical conditions • Ability to maintain independent living Our inpatient and outpatient teams collaborated to identify patients that may be a good fit for the program. Patients were identified in the emergency room, during hospitalization and at primary care visits. A social worker then met with the patient to complete the abridged LOCUS tool and the housing pilot team reviewed the assessments.

Due to difficulty engaging with the housing team, one patient was dismissed from the pilot. Another patient did not fully participate with the requirement to stay in their unit consistently and voluntarily left the program. By pilot’s end, five patients were successfully housed. Preliminary analysis indicated that the Inpatient and Emergency Department utilization for all five patients declined. By calculating the cost avoidance due to diverting the patients into this pilot we were able to estimate the cost saving. This showed estimated cost savings for these patients’ medical care is approximately $1,104,908.98.

The pilot ended successfully and we are currently in the evaluation phase to determine if we can engage in other housing initiatives in Chicago.


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