Chronic Care Management: A Unique Way to Reduce Readmissions Lisa Hogan RN, BSN; Chronic Care Management Team Leader Introduction The chronic care management program began October 2016 as a way to help a population of patients who needed assistance in managing their chronic conditions and medications. These patients do not meet the criteria for health care and/or are not ready for hospice services. Patients in this group need follow up, education, and ongoing monitoring. Prior to this program, these patients had nowhere to go for long-term assistance. The CCMP team at FMH has grown from 1 full-time RN to 2 full-time RNs, 1 full-time LPN, and 1 part-time CNA. Each member of the team calls patients, makes home visits, educates on disease processes, and performs medication management. During home visits for medication management, medication lists are gathered and sent to the appropriate provider to verify the medications and alert the practice that CCMP is involved with their patients. Stop light tools and hospital-approved education handouts are used to reinforce teaching and educate on specific disease processes during home visits as well as on weekly phone calls. Services are currently provided at no cost to participating patients.
Data / Results As of February 2019, 335 patients have been or are currently enrolled in CCMP through Frederick Memorial Hospital (FMH). Health Quality Innovators analyzed data from September 2015 through November 2018 on 129 patients who had been enrolled in CCMP for at least 6 months. CMS claims were compared with this group of patients to include 6 months prior to starting CCMP and 6 months after entering the program. Results showed a 47.7% reduction in overall hospital utilization and a 58.6% reduction in hospital utilization costs.
Analysts from FMH studied data from May 2018 through November 2018 on 138 patients who had been enrolled in CCMP for at least 6 months. CMS claims were compared with this group of patients to include claims submitted 6 months prior to enrolling in CCMP and then 6 months after entering the program. Results showed an 84% reduction in 30 day readmissions and a 52% reduction in ER visits. This, in turn, resulted in a 64% reduction in hospital costs for Medicare Part A to show a savings of $2.1 million. The improvement in readmissions and ER visits also resulted in a 26% reduction in hospital costs for Medicare Part B to show a $175,000 savings for Medicare Part B. During weekly calls, patients have expressed great satisfaction with the use of the monitoring and the personal touch that CCMP offers to them. Patients have demonstrated increased compliance with medications, monitoring vitals, and keeping follow up appointments.
Objectives
Reduce hospital readmissions Reduce cost for the healthcare system Reduce ED utilization Increase patient satisfaction Increase patient engagement in their own care
FMH CCMP Cost Impact: 6 Months Pre-CCMP Start Date v 6 Months Post-CCMP Start (N=138 patients, Timeframe: May 2018–Nov 2018) Part A
Part B
–64%
–26%
Total (Parts A & B)
Methods Patients in the Chronic Care Management Program are referred to us in several ways including Home Health Care, MD offices, community agencies, and Case Managers from our hospital. Each patient is assessed by a member of our team to identify their specific needs. Most of the patients in the program are set up with our telemonitoring system to assist in monitoring their weight and vital signs. All patients are called at least weekly or more often, if needed. Home visits are made for education and teaching. Patients are assessed for medication management needs and set up with a plan to ensure compliance and understanding of medications.
–57%
Conclusion Patients enrolled in CCMP have improved outcomes with readmissions and ER visits. They demonstrate increased independence and compliance with self-care. CCMP is able to demonstrate significant savings to the hospital system which makes the ROI well worth the effort. CCMP has shown that with technology and a personal touch from the CCMP clinicians, patients feel more secure and capable in caring for themselves and their chronic diseases. This innovative program can serve as an example to other hospital systems to aid in reducing readmissions, reducing ER visits, and improving patient satisfaction and involvement in their own care.