Transitional Care Management Liaisons: Improving Patient Engagement and Reducing Readmissions in Medicare HRRP Focus Population Kelsey Brewster; Dana Green, MSW, LGSW, ACM-SW; Deron Campbell, MPH Inova Transitional Services Conclusions
Statement of the Problem • Within the first 30 days following a hospital discharge, patients are most vulnerable to readmission risk. • Approximately 20% of Medicare beneficiaries are rehospitalized within the first 30 days post-discharge1. • For patients who are discharged home, it can be overwhelming to remember post-discharge instructions, identify red flags or new symptoms, manage medications, and organize follow-up appointments, often times, while trying to manage pre-existing conditions.
The data indicates that the TCM liaison program has been successful in improving patient engagement rates. Patients are less likely to decline services after having a face-to-face meeting with a TCM liaison. Additionally, once a rapport is built between a patient and TCM case manager, it is easier to stay in contact and ensure that the case manager is able to follow the patient through the full 30 days following the hospital discharge.
Methods
Background Inova Transitional Care Management (TCM) is a 30-day post-acute telephonic case management program designed to ensure quality transitions of care. The program is made up of RNs, MSWs, and a clinical manager, who serve an average of 4,500 patients per year. TCM case managers provide disease-specific patient education, advanced care planning, medication reconciliation, and psychosocial assessment. They connect patients with primary care and specialist follow-up, and ensure that patients and caregivers are well-informed about red flags, warning signs and symptoms indicative of a worsening condition, and how to respond to problems that arise. The TCM case managers provide services to patients with the largest readmission risk according to the Medicare Hospital Readmissions Reduction Program (HRRP)2. See Table 1 for eligibility requirements. Eligibility Requirements Payer: Medicare Part A or Part A/B Age: 65+ Hospital Admission Type: Inpatient Discharged from Inova Facility Index Admission Diagnosis: CHF COPD AMI PNA Hospital Discharge Disposition Type: Discharged Home to Self Care Discharged Home with Home Health
Figure 2. Example resources provided to COPD patients at TCM Liaison encounter
Assignments for TCM Liaisons • Screen daily admissions report to identify eligible patients and add to “watch list” • Monitor ongoing list daily to identify needs, evolving discharge plans and appropriate time for outreach • Maintain and monitor an ongoing red flag list for patients who are high-risk, previously readmitted, or have been unable to contact • Conduct patient outreach meetings in hospital prior to discharge to include explanation of TCM program and verification of demographics • Serve as part of inpatient readmission reduction efforts in multidisciplinary rounds, apparent cause analysis case reviews, readmission reduction committee meetings, and team huddles
The main barrier that continues to challenge the TCM case managers and liaisons is Northern Virginia’s large population served by Inova. As the case managers expand their workload to higher volumes, it is critical to ensure high level quality of care with the resources allocated to the team.
• Coordinate and complete handoff to designated TCM case manager or liaison for ongoing management through TCM (Liaisons take on a smaller caseload than office-based CMs.) • Partner with inpatient case management and Inova Home Health liaisons for high-level patient care coordination
The next steps are to cement the liaison role into the hospital culture by continuing to be involved in discussions around readmission prevention.
Table 2. Assignments for TCM Liaisons
Results Future Application Patient engagement improved in the 12 month period following liaison implementation at each hospital. This is demonstrated by the TCM program discharge dispositions.
Inova Transitional Care Management (TCM) has developed a liaison role to close the gaps that lead to patient decompensation and preventable hospital readmissions. Although barriers to effective readmission reduction are multi-faceted, the TCM liaisons focus on patient engagement in order to reduce readmission risk.
• Completion* of TCM program increased by 27% • Patients who were unable to contact** decreased by 23% • Patients who declined services decreased by 60%
Objectives
•
Figure 3. TCM program discharge dispositions before and after liaison program implementation (all participating units)
Discharge Hospital
To prepare patients for TCM program content and coordinate handoff to a designated TCM case manager To ensure patient safety by providing tools for self-management
•
To unify inpatient and outpatient processes
•
To participate in development and implementation of readmission prevention strategies
Readmission O/E
•
To increase the effectiveness of efforts to support TCM’s mission/vision by increasing patient engagement and closing gaps that could lead to patient decompensation and readmission
• Eligible patients are identified when a patient is admitted to the hospital with one of the focus diagnoses, rather than at the time of discharge • Patients are flagged early so inpatient case managers can start Medicare focus protocol • Evolution of care plan begins earlier • Patients are more prepared to begin TCM case management program • TCM involvement in the hospitals has helped inpatient teams more fully understand the continuum of care, making them more willing to partner with outpatient groups
Teach-Back COPD
Table 1. Eligibility Requirements for TCM Enrollment
•
The TCM liaison program was just one component of a system-wide coordinated effort of multiple interventions to reduce readmission rates. Although causation cannot be owned by the TCM liaison program, there are several factors that continue to contribute to the success of the system’s readmission reduction efforts.
12 months prior to 12 months after liaison implementation liaison implementation
Inova Fair Oaks
0.98
0.66
Inova Alexandria
1.13
0.95
Inova Loudoun
1.01
0.69
Inova Mount Vernon
1.09
0.93
% Difference
30.3% reduction in O/E
Table 3. Readmission O/E per hospital cohort for 12 months before and after TCM Liaison implementation
Additionally, 30-day readmissions were reduced, indicating that patients were able to stay safe at home during the most vulnerable post-discharge period. • Readmission O/E was reduced by 30% in the 12 month period following liaison implementation at each hospital. *Program completion only includes patients who have completed all TCM program content, avoided readmission, and/or were engaged for the full 30 days. **A patient is considered unable to contact if the case manager attempts to contact patient or caretaker at least 3 times, at different times of day and 3 different days of the week. Category not show is participation, which includes patients who were managed for fewer than 30 days.
The most significant impact of the TCM Liaison program is also the most difficult to quantify. The bridging of inpatient and outpatient worlds created a paradigm shift. In order to reduce readmissions, all entities across the continuum of care must be part of the conversation. This was done by pulling in representatives from the outpatient setting into multidisciplinary rounds, apparent cause analysis case reviews, readmission reduction committee meetings, and inpatient team huddles. These key concepts can be adapted to a wide range of health systems, whether or not there are resources available for a dedicated team.
References 1.
Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine. 2009;360(14):1418–1428. 2. Centers for Medicare and Medicaid Services. Readmissions Reduction Program (HRRP). Available at: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acute inpatientpps/readmissions-reduction-program.html. Accessed October 9, 2018.
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