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Approach improves communication, coordination among clinicians

By JULIE MINDA

The trend line is clear: To be successful under reform, health care providers will need to coordinate patients' care in a way that improves the patients' outcomes while also reducing the chances that they'll relapse and need avoidable, expensive follow-up hospitalization.

A new care coordination model that Catholic Health Initiatives is piloting in three of its regions promises to help the system to achieve these ends. The Accountable Care Readiness Project in Denver; Lexington, Ky.; and Lincoln, Neb., creates a formal structure for improving coordination among clinicians, supporting patients as they move from one care site to another and helping patients better manage their chronic health conditions.

The approach provides "a continuity of care physicians never had before for their patients," said F. Rose Rexroat, manager of community services and virtual care for Saint Joseph Hospital in Lexington.

CHI representatives will describe the program and its outcomes at "The Accountable Care Readiness Project: Coordinating Care for Patients with Chronic Disease," an Innovation Forum session at the Catholic Health Assembly, June 3-5 in Philadelphia.

A graying population
Kimberly Leugers is vice president of strategy and implementation for the Englewood, Colo.-based health system and part of the team that developed and then helped roll out the initiative to the pilot sites. She said the model takes a population health approach to the care of seniors with coronary artery disease, chronic obstructive pulmonary disease, congestive heart failure and pneumonia. It systematically supports Medicare patients and their clinicians in better managing their treatment, particularly after discharge from the hospital, so that they do not quickly relapse.

Since the pilot was launched in the fall of 2010, about 300 patients in Denver, Lexington and Lincoln have participated in some aspect of the program.

"To deliver this type of accountable care, you have to be able to have very specific care management protocols, including a way to manage patient transitions and coordinate care across the continuum," Leugers said.

CHI's model combines three elements of proven effectiveness:

• A "transition coach" meets with patients prior to hospital discharge, following up with home visits and phone calls for four weeks post-hospitalization. These coaches — usually nurses and usually with a caseload of about two dozen patients — educate patients about medication use and treatments and help ensure they quickly schedule and keep appointments with their respective primary care physicians.
• Nurses stationed in the offices of primary care physicians serve as "health coaches," helping Medicare patients manage chronic conditions, stay on track with their health goals and change their behaviors, as needed. Health coaches may staff one or more physician offices. This program element also places a facilitator — normally a nurse — in physician offices temporarily, to help the practice make structural changes that improve patient outcomes. One task of the facilitator is to put in place a disease registry system, software that identifies evidence-based protocols for various diagnoses.
• A social worker in each market specializing in geriatric case management helps frail elderly patients and their home caregivers to access the support they need from community agencies and programs to avoid nursing home placement and hospital readmission. The transition and heath coaches and primary care physicians can make referrals to this care manager at any time.

Leugers said CHI's Institute for Research and Innovation, which helped launch the project, uses grants to pay half the expenses of implementing the program, and the local CHI network pays half out of its discretionary expense funds.

A period of change
CHI selected the Denver, Lexington and Lincoln regions as pilot markets based on their having large populations of senior adults, the prevalence of the targeted primary diagnoses, the capacity to implement an electronic disease registry, the level of interest and commitment by senior leaders and physicians and the potential for involving private and Medicare payers in the program in the future, among other criteria.

The rollout played out slightly differently in each market since the dynamics are different in each. In Colorado, the pilot involved physicians affiliated through a contract relationship, with some of the hospitals within Centura Health, a subsystem CHI cosponsors with Adventist Health System. In Lincoln, the physicians are employed by CHI through an organization called The Physician Network. The physicians who participated in Lexington's pilot are from an independent multispecialty group called the Lexington Clinic.

Dr. Barry Hoover, chief medical officer for The Physician Network, helped manage the Lincoln rollout. He said it was challenging to set up the infrastructure for intense care coordination, including getting the essential buy-in from physicians and their office staffs. "The physicians had understandable concerns that the process could interrupt their work flow, slow things down and perhaps even come between them and the patients.

"That hesitation resolved as the physicians learned that the team could off-load some of the care and educational and social work involved with care of these patients," Hoover said. He added that it helped also to reassure physicians that they were not losing control of patient care and to educate them about how the model can improve care and outcomes.

Patients, too, had to adjust to the change, Leugers said, since they "were not used to having folks manage them this deliberately."

Lexington's Rexroat affirmed, "Many patients commented they had never had anyone interested in what occurred after discharge."

Lincoln's Hoover added, "There was often some confusion regarding who all these people were that were getting involved in (patient) care. It helped when the care team members explained their roles …"

In the end, Hoover said, "Many patients appreciated all the extra attention they received. Family members also tended to appreciate the help and attention."

Leugers said preliminary evidence indicates that patient outcomes have improved and readmissions have decreased. And so, CHI plans to invite its other markets to put in place the infrastructure of the Accountable Care Readiness Project. CHI also plans to expand beyond the hospital and physician office environment and apply its approach to coordination with skilled nursing facilities, area agencies on aging, home health practices and other care venues.

Paving the way for the future
Leugers noted that none of the three pilots are official "Accountable Care Organizations" — none have applied for demonstration status from the Centers for Medicare and Medicaid Services, none comply with the parameters established by CMS for ACOs, nor do they plan to do so in the near future. But she said regardless of whether health care facilities plan to become an official CMS ACO in the future, they'll need to have some type of model in place to better coordinate care and manage patient transitions.

"It's a new way of organizing and operating our services and delivering care," Leugers said. She noted this is a way of "facilitating smart, meaningful change to position us for this dramatically different environment."

Rexroat and Hoover noted their markets had not been coordinating post-discharge transitions intensively prior to participating in the pilot, and Hoover said the change was needed under reform. "We are in the 'middle game' of moving from a volume-based, fee-for-service environment to a value-based environment. It is our responsibility to make this upfront investment in change and quality … so we can be successful in the new world of health care."

Copyright © 2012 by the Catholic Health Association of the United States
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