Erlanger s Care Transitions. Working Together. UT Resident Orientation June 26, 2015

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1 Erlanger s Care Transitions Working Together UT Resident Orientation June 26, 2015

2 WHAT IS CARE TRANSITIONS?

3 What is Care Transitions? A program that has been formed to meet and exceed CMS changes from The Affordable Care Act.

4 Purpose of Care Transitions WHAT IS THE PURPOSE OF CARE TRANSITIONS? WHICH INSURANCES DOES IT INCLUDE?

5 Purpose: CMS Guidelines To decrease the overall readmission rates for the Medicare Fee for Service (A&B population). Medicare Railroad excluded Medicare C excluded

6 Purpose: CMS Guidelines Hospitals will be fined for Readmissions within 30 days for: Congestive Heart Failure Heart Attacks Pneumonia 2016 = COPD and Joint Replacements Discharges versus Readmissions (Explain)

7 Hospital Fines from CMS HOW DO THE FINES WORK?

8 How does this work? FINES 2011 = Jul 1, 2008 Jun 30, 2011 = 1% 2012 = Jul 1, 2009 Jun 30, 2012 = 2% 2013 = Jul 1, 2010 Jun 30, 2013 = 3% 2016 = Jul 1, 2013 Jun 30, 2016 = 3% Allowed so many readmissions per 3 year Once exceed then pay % of total cost

9 Erlanger s Care Transitions Program The Call Center Erlanger s Care Transitions Team

10 WHO QUALIFIES FOR THE CARE TRANSITIONS PROGRAM AT ERLANGER?

11 Qualifications Has to have Medicare Fee for Service (A&B) Has to have one of the six diagnoses: Congestive Heart Failure (CHF primary or secondary), Heart Attack, Pneumonia, Chronic Obstructive Pulmonary Disease (COPD primary or secondary), Total Hip Replacement, Total Knee Replacement Readmit within 30 days of discharge from hospital (no matter what the diagnosis)

12 Call Center CHF, Pneumonia, Heart attack, COPD, Total Hips/Total Knees 3 Calls 1 st = Within 48 hours after discharge 2 nd = Within 10 days after 1 st call 3 rd and final = Within 10 days after 2 nd call If patient goes to SNF or Rehab will call weekly until discharged home. Doesn t matter where patient lives!

13 Erlanger s Care Transitions Team Interviews/assesses each Medicare A&B readmission to see why they came back and what we can do to prevent another readmit Make recommendations to MDs and CMs Educates patient and family on disease and disease management and lack of understanding Encourages patient to claim disorder and become independent with care of disease. Encourages the use of Erlanger s entities (HHC, DME, Pharmacy = Continuity of Care). Calls patient weekly for 30 days (home/snf/rehab)

14 Does Care Transitions Work? Year All AMI CHF COPD PNU is through April of 2015

15 4 Main Reasons for Readmissions Did not get prescriptions filled or understand how to take prescriptions. Did not have a follow up PCP appointment or able to keep appointment. Did not understand discharge orders or given a copy of the discharge orders. Discharged to early

16 Solving Prescription s Problem Erlanger pharmacy = visits each care transition patient who is being discharged home Can determine if any scripts need pre-authorization (helps delay of taking med) Helps determine if can get it cheaper (antibiotic) Identifies med programs that can assist Educate patient on meds Assist in determining if any meds interact with each other. (Saving Lives or potential problems) MD can write an order for Erlanger Pharmacy referral Erlanger delivers medications to Hamilton County residents, SNFs, Rehabs

17 Solving PCP issue Case Management = assisting with PCP Clerk s to make follow-up appointments Less than 23% of patients have a PCP appointment before discharge See doctor in 2 4 weeks after discharge is not a PCP appointment! Care Transitions Clinic on Fridays (for Erlanger patients who do not have a PCP or can t get in for a couple of weeks. Must have insurance.) Number to make appointment is SNFs/Rehabs to make appointments before patient is discharged and if no PCP help them find one.

18 Solving Discharge Instruction Problem Call Center goes over discharge orders again on first call/visit. Erlanger patient s able to send them a copy of their orders if needed. Need to get copy of the discharge orders from facility (SNFs/Rehabs) sent to fax and make to ATTN: Paul Smith

19 Solving the Discharge to Early problem Care Transitions Manager follows up with every Medicare A&B readmit. Reviews chart fully and reviews information sent from SNFs and Rehabs as well as chart from last visit. Care Transitions Manager follows that patient for 30 days personally with calls and communications.

20 Home versus Home with HHC About 62% of patients go home without HHC and this has gotten better because about 6 months ago it was around 84% went home without HHC. What can qualify a patient for HHC? Nursing and PT can stand alone, all other areas need to have Nursing or PT ordered with it. Education of disease, Education of meds orders need to say Disease Management and Medication Management. If patient is having difficulty with specific things then be specific when ordering. (i.e. Dietary Management needs understanding of CHF diet and fluid restriction) Anyone with COPD or CHF should have a home med monitor. Order needs to say Home Med Tele Monitoring.

21 Keeping patients from being readmitted for 30 days What about patients that don t go home after discharge? Rehab SNFs How can care transitions assist you?

22 Rehabs/SNFs Communicate with Care Transitions staff (admission/discharge). Involve the Care Transitions Manager if family or patient is not progressing or if need an advocate. Encourage the use of Erlanger s HHC, DME, and Pharmacy Make sure patient has meds, copy of discharge orders, and follow-up appointments made before discharging from your facility Partnering with Erlanger to help decrease readmissions

23 Paul Smith s Contact Information Office number: Fax number: address: QUOTE: You can dream, create, design and build the most wonderful place in the world, but it requires people to make the dream a reality. -Walt Disney

24 QUESTIONS

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