Abstract
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Based on AtlantiCare's size, the financial risk and impact to the system as a result of the Readmission Reduction Program is significant with $3.3 million at risk annually.
In 2015, CMS estimated the cost of readmissions nationally to be approximately $26 billion. CMS notes $17 billion of this total to be in the form of potentially avoidable readmissions. Approximately 75% of avoidable readmissions happen because of failures in care transitions.
Transitions, however and whenever they occur, are points of vulnerability and failure. The most critical moment in a relay race is when one runner hands the baton to the next and the same applies to the health care continuum. Poorly executed care transitions also can result in additional health care spending related to adverse outcomes. 1 Moreover, patients with complex care needs frequently require care in multiple care settings and are particularly vulnerable to poorly executed care transitions during which lost or missing information can pose significant threats. 2
As a result of these clinical and financial penalties, care transitions are increasingly becoming a point of focus in health care. In addition to readmission penalties there are a growing number of regulations from CMS—from meaningful use requirements to national quality standards—that are compelling health care organizations to improve collaboration and communication in transitions of care. Despite the focus on care transition improvement, multiple challenges are hampering health care organizations' best efforts. AtlantiCare Transitions Program was developed to identify and remedy those challenges.
A care transition is the movement of a patient from one care setting to another. 3 It could be a straightforward transition between units within the same hospital or a more complex transition from the hospital to an external care setting. 2
One of the problems in the management of care transitions is lack of standardization—across the industry, across systems, and sometimes even across a single department. 4 AtlantiCare has identified a critical need for comprehensive care transitions as today's health care landscape shifts away from fee-for-service delivery toward value-based reimbursement models.
Goal 3 of the CMS Quality Strategy—Promote Effective Communication and Coordination of Care—addresses the need to focus on effective care transitions to improve the quality and safety of care delivered and reduce costs. AtlantiCare's strategy to approach readmission reduction is focused on improving care transitions through innovative approaches that connect individuals with the resources that meet their unique needs and by using methods and tools to enhance communication among providers in all care settings. In 2012, AtlantiCare established a team to address this opportunity, led by the Senior Vice President of Quality and Performance Excellence and the Medical Director of Care Transitions.
An initial inventory was taken of current work focused on care transitions. This revealed many worthwhile efforts, but these were not always in alignment or involving collaboration across care settings. Patient and caregiver focus groups provided insights on barriers and enablers from their perspectives. Key strengths were identified: an existing effective infrastructure with key leaders, as well as several best practices in place, such as the BOOST (Better Outcomes by Optimizing Safe Transitions) program.
Four focus areas were identified based on the aforementioned analysis: 1. Risk stratification of patients and optimizing workflows based on the risk 2. Post-acute transitions 3. Optimizing medication reconciliation 4. Standardizing care coordination
The AtlantiCare risk stratification tool was developed based on a tool initially developed by Geisinger Health System Transitions of Care Workgroup in 2007. In 2013, Geisinger modified the tool based on research. AlantiCare's Care Transitions work group developed an AtlantiCare risk stratification tool by further modifying the ProvenHealth transitions tool developed by Geisinger. The tool scores patients for the risk of readmission using 8 variables and also helps to identify modifiable factors.
All AtlantiCare ACO patients who were admitted to the hospital were risk scored at the time of discharge by care managers. Based on the score, care managers formulated a care plan for these patients. Guidelines for the interventions based on the score were identified. Interventions such as frequency of phone calls, enrollment in the Tablet Program (deployment of devices to aid with patient self-management of heart failure and other chronic conditions), and the timing of primary care follow-up were all determined by the risk of the patient.
Utilization of standardized templates by the care management team along with twice weekly transition huddles have provided the team an opportunity to anticipate patient needs and prepare for services patients might benefit from. Over time, routine huddles have contributed to an interdependent team culture, improved relationships, and the delivery of safe and reliable patient care.
Using the screening tool, a risk score was calculated for a total of 4421 unique hospital admissions from August 2015 to September 2016: 11.6% (n = 513) had a readmission within 30 days of discharge. Patients were divided into 4 categories based on risk score. High and very high risk of a readmission was determined by a cut point of ≥18–22 and ≥22 on the risk score, respectively. A total of 730 (16.5%) patients met the criteria for high risk and 1065 (24%) patients were very high risk. Out of the high-risk and very high-risk patients 111/730 (15.2%) and 284/1065 (26.7%) were readmitted, respectively. The prevalence of 30-day readmission was 3.2% and 8.4% among the low-risk and medium-risk groups, respectively.
Timing of receiving the intervention (follow-up phone call, primary care physician [PCP] visit) is critical. The tool has helped to prioritize workflow for all providers, including access for PCPs and care managers. The overall readmission rate has been declining steadily since the initiation of the program. The biggest impact has been on the high-risk category, with scores between 18 and 22. The readmission rate for this subgroup of the population trended down from 26.7% to 13.1% during the last 1 year. With the current interventions there has not been significant impact in the very high-risk subgroup who scored >22. We expect to use other interventions such as a home visiting physician program and virtual visits as possible strategies to decrease readmissions for this subgroup in the future. There also is a need to increase our advance care planning strategies for this population.
On further drilling into the data, we noticed that most of very high-risk patients are being discharged to the post-acute facilities. A drive to improve quality across the continuum was what triggered Atlanticare to develop a preferred post-acute network of skilled nursing facilities (SNFs). AtlantiCare determined that just 20% of this area's SNFs were required to serve in their preferred SNF network. These SNFs were identified through a Request for Information that examined data on facilities' historical outcomes (CMS Star rating, hospitalization rates), care processes, structure, and AtlantiCare care and case managers' perceptions of the value of individual SNFs. In addition, preferred SNFs must meet certain requirements to maintain the relationship, including assignment of a dedicated facility nurse to serve as the lead for AtlantiCare patient transitions and quality assurance, and an advanced practical nurse who is available during the workday for more timely hands-on primary care. Additional enhancement to primary care services is required through use of virtual telemedicine after-hours physician services. Finally, preferred SNFs have a monthly face-to-face meeting with the AtlantiCare Post-Acute Service Medical Director to review all unplanned hospital and emergency room transitions to identify further opportunities for care improvement.
To improve overall quality of patient care and to focus on the prevention of avoidable hospital readmissions, the following initiatives were started with preferred SNFs.
• Collaboration for protocol utilization in patients with congestive heart failure and chronic obstructive pulmonary disease.
• Care coordination of patient being discharged from facilities for the next 30 days.
Learning from this program includes an appreciation that the tool has helped to prioritize access to PCPs in addition to helping care managers' workflow, thereby helping to achieve the “right care for right patient in the right setting.” And although the readmission rate continues to decline within AtlantiCare, the trend is also decreasing nationally and there remains opportunity for further improvement.
Next steps for AtlantiCare include: • Alignment of post-discharge transitions work across the system • Optimizing medication reconciliation across the continuum • Standardizing the discharge process
Further, as hospitals align with SNFs, PCP practices, and other types of medical groups through developing Integrated Practice Units and participating in shared-risk partnerships such as value-based payment and ACOs, there is growing pressure for excellence in transitioning patients across the entire continuum of care. Continued focus is required as initiatives are refined and further best practices emerge.
Footnotes
Author Disclosure Statement
Aside from their employment, Drs. Degapudi and Stefanacci, and Ms. Cooke declared that there are no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors received no external financial support for this article.