- For the thousands of patients released from their 23 acute care hospitals a year, Mercy Health ensures that each patient receives the highest value care. But there is only so much providers can do within the walls of their health system to extend that high-value care through care transitions during the post-acute care period.
Effective care transitions are key to not only improving Mercy Health’s patient outcomes and preventing avoidable hospital readmissions, but achieving success in the health system’s many risk-based care contracts, such as its Medicare Shared Savings Program accountable care organization and bundled payment models.
Providers in risk-based care contracts are on the line for the quality and costs of care even after patients are discharged from the hospitals. Failing to track the patient throughout the care continuum and even into the home can result in hospital readmissions and other expensive, avoidable encounters.
To boost risk-based model success and patient outcomes, the health system created a care transition workflow that uses care transition coordinators to follow patients from the hospital to post-acute care facilities to home, explained Ron Drees, Mercy Health’s Director of Post-Acute Services.
“One of the keys for us in providing post-acute follow up for patients is identifying patients that our care transition coordinators will follow from the time they’re an inpatient at a Mercy Health facility through any additional care they will need beyond,” he said. “We identify those patients based on readmission risk rates. In Mercy Health’s hospital settings, those care transition coordinators will interact with those patients and let them know we’re following their care – whether that’s in the home or skilled nursing environment.”
The care transition model’s success depends on extensive information sharing and communication with post-acute care facilities.
However, Mercy Health owns just five skilled nursing facilities in three different regions, Drees stated. As the largest health system in Ohio, Mercy Health needs a robust network of post-acute care providers to manage hundreds of thousands of discharges each year.
In response, the health system created a preferred network of skilled nursing facilities, known as the Coordinated Care Network. Mercy Health also discharges patients to facilities outside of their network that have inclusive care collaboration agreements with the health system.
While the network of skilled nursing facilities outside of Mercy Health may provide high-value care, limited information sharing between the hospitals and post-acute care facilities threatened Mercy Health’s performance in risk-based contracts.
“One of the gaps we identified through our process is that the skilled nursing facilities are very busy taking care of their patients, and don’t always connect back with us when the patient is actually discharged to go home,” he said. “As such, we make weekly calls to the skilled nursing facilities to follow up, get an update on how the patients are doing, and their anticipated discharge date. But there are always surprises. People get better sooner than they think before that next week’s call resulting in being discharged earlier.”
In some cases, Mercy Health had to wait for claims data to track their discharges through various care transitions. By the time claims data reaches a provider organization, many patients at risk for hospital readmissions and other adverse events have already experienced those outcomes.
The health system needed to be able to track their discharges in real-time to prevent costly, avoidable healthcare encounters that would also harm the system’s risk-based quality and cost performance.
Drees partnered with PatientPing to implement a platform that allows hospitals to connect with other post-acute care providers using the service, even if the facilities are not part of the health system.
“What PatientPing allows Mercy Health is to get real-time notification of the discharge from the skilled nursing facility directly, so that we can have our care transition coordinators contact those patients once they’re discharged,” Drees elaborated. “As such, we can interact with that patient much quicker than if they were released three days before our next weekly call. A lot of the things that we do are more beneficial if you can do so within the first 24 hours of discharge.”
For example, medication reconciliation within the first few hours of discharge can ensure patients in risk-based care contracts acquire the proper medications and adhere to follow-up care instructions.
“That’s probably the number one issue we find, patients did not obtain all of their medications when they went home,” he said. “It allows Mercy Health care transition coordinators to be able to interact with family members, or make transportation arrangements so they can get to the pharmacy and get their medications. It potentially reduces that risk of re-hospitalization or a trip to the ED [emergency department].”
The transition coordinators could also work with patients shortly after being home to schedule their follow-up appointments.
“Depending on the severity of their illness, we usually try to do that at three, seven, or fourteen days,” he stated. “Once again, that helps with clinical flow, to get that notification early and make sure we can arrange for the patient to see their physician in an appropriate time frame.”
Real-time care coordination notifications also supported Mercy Health transition patients from their physician offices to their homes.
“When a patient is not an inpatient and starting with home health services directly from a physician office or from the community, we can also get an alert for that, which is another benefit of the platform as that patient may also be on the risk list for us to follow up with,” he said. “It allows us to see whether the patient is having some signs and symptoms that may lead to an admission to the hospital. Our Mercy Health care transition team can then step in at that point to interact with them.”
Those quicker interactions during or shortly after care transitions have a positive impact on value-based reimbursement and risk-based care performance, Drees added. First, real-time care coordination notifications boost patient satisfaction, which can result in high performance scores under risk-based contracts and help hospitals and health systems improve net margins by 50 percent, according to a 2016 Accenture study.
“We talked about the speed of the notification. When we look at patient satisfaction, if Mercy Health care transition team can contact a patient within the first 24 hours of going home, then they are more satisfied with the care they’re getting because patients know we’re on top of their care and concerned. And that plays a key role in patient satisfaction, which is always a top priority for Mercy Health,” he said.
Effective communication between the hospitals and post-acute care facilities also brings down costs of care.
“That quicker interaction helps to reduce the cost of care,” he said. “Every Monday, we have a care transition coordinator call at which time we review things that happened during the weekend. Medication reconciliation is one of the big concerns discussed. Ensuring proper medication is administered in a timely manner can have an impact on readmissions.”
Real-time care coordination and communication, rather than waiting on claims data and weekly calls, is the key to optimizing care transitions and succeeding under risk-based contracts, Drees emphasized.
“When we look at value-based reimbursement, allowing those interactions to occur in real time can help avoid some of those costs associated with med reconciliation and not following up with the physician.”