Engaging patients in proactive self care is relatively easy when they are “captive” within the hospital. The challenge is convincing them to follow care plans once they are discharged to return home or to other care settings, in practice reducing preventable hospital readmissions. Meritage ACO built an external network of providers and an internal care management team that adopted a new hybrid model of care combining: care transitions coaching, complex care management and care coordination. The care transitions program resulted in remarkable 30-day readmission rates of 10.2 percent compared to the national average of 17.5 percent.
Since 2012, the Centers for Medicare and Medicaid Services (CMS) has placed aggressive focus (and financial incentives) on reducing 30-day all-cause hospital readmissions. Yet the hard reality is no matter what providers do to improve care, the X-factor is the patient. If patients (and/or their families) choose not to become engaged in improving their own health by not following the care plans developed specifically for their needs, they are likely to be readmitted within 30 days for the same condition.
Meritage Accountable Care Organization (ACO) of Novato, California, sought to address this challenge in 2013 when it launched a new program aimed at improving collaboration between care settings and providers in order to raise patient engagement levels. As the first healthcare organization in the North Bay to be designated a Medicare Shared Savings Program ACO, Meritage ACO had a financial as well as ethical incentive to work with other providers to help reduce readmissions.
Leading the initiative was Meritage ACO’s Andrea Kmetz, R.N., Director of Care Management and Quality Assurance. Kmetz worked with Meritage ACO leaders to build an external network of hospitals, skilled nursing facilities (SNFs) and hospice services along with an internal care management team consisting of physicians, MSN care managers and care coordinators. The concept was to follow its highest-risk patients through their journey throughout the healthcare system in order strengthen its transition gaps, maintain patient engagement and improve outcomes.
To accomplish its goal of engaging patients more effectively, Kmetz and her team developed a hybrid care management model consisting of three elements:
• Care transitions coaching. Nurse care managers visit patients at the bedside before they are discharged to explain the process, provide education, answer questions, assess the patient’s willingness to engage in their own care needs and plan for their transition needs. Visiting patients before discharge has proven more effective than attempting to convey this information as patients and their families are planning to leave.
• Care management. This approach involves the use of several tools and techniques, including a modified version of the Coleman Care Transitions Intervention that includes one bedside visit in the hospital, one SNF or home visit and three follow-up phone calls; use of a Patient Activation Management Tool to assess patient willingness and ability to care for themselves; Motivational Interviewing to help patients understand the value of making lifestyle changes; Brief Action Planning that enables patients to set their own care goals; and the Teach Back Method to ensure patients understand instructions.
• Care coordination. This effort’s goal calls for eliminating the duplication of care that often occurs when patients move between settings.
To ensure collaboration between providers, Meritage ACO created a mobile care navigation network to enable patient-centered communications between providers and settings via secure texting.
n the nearly two years since the program was launched, it has produced outstanding results. To give a little context, according to CMS, despite recent improvements overall the national average 30-day readmission rate for Medicare fee-for-service beneficiaries is 17.5 percent. Statistics from the Medicare Payment Advisory Commission show that roughly 75 percent of readmissions are preventable. These high rates not only cost billions of dollars each year, they also result in harm that could have been prevented, not to mention the needless disruption to the lives of patients and their families.
Meritage ACO’s application of skilled nurse care management that engages patients (and their families) at the hospital, in skilled nursing facilities and in their homes, combined with the use of patient-centered mobile technology designed to ease communication between providers and care settings has resulted in a readmission rate of 10.2 percent for its highest-risk patients – less than half the national average. This improvement has placed the organization just shy of the 90th percentile for chronic heart failure, asthma/COPD and all-cause readmission avoidance.
Skilled nurse care management also has made a difference in the context of end-of-life discussions. Informally, patients reported finding it difficult to initiate such discussions with their physicians. They felt their physicians were too busy and that 15-minute appointments were too short. An end-of-life discussion is highly personal and typically requires a lengthier conversation. As nurse care managers have taken on that task, patients have expressed gratitude that a care team member is willing to discuss this sensitive topic. The required sensitive conversation helps ensure the dignity we all hope for as we reach the end of our journeys.