IssueBrief. Case managers strengthen health care s weakest link: Improving care transitions

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1 IssueBrief VOLUME 4, ISSUE 3 Case managers strengthen health care s weakest link: Improving care transitions Don t dare call them handoffs. Guiding patients to the care they need, when they need it, lies at the heart of case management and is critical in the new approaches to care. The current emphasis on coordinated care has heightened awareness of the need for smoother transitions, while calling attention to the lack thereof. Likewise, it has become clear care transitions are neither medical events nor handoffs. Rather, they are part of a process that should be but rarely is seamless. Instead, transition points are the weakest links in the chain of care, leading to inefficiency, fragmentation and poor outcomes. 1 Reasons abound; perhaps the most significant are lack of communication, accountability and coordination. Nationally, there is a lot of discussion about improving transitions of care, but putting the talk into action is proving difficult. We see many collaborative models of care developing and many of those are pilots and "Professional case managers ensure timely communication with the patient and with the team, which can make a significant difference in the progress of a patient s recovery." Kathryn M. Kathy Serbin, BSN, MS, CCM, Commission Chair 1 Fisher ES, et al. Creating Value: Better Care Coordination. Better to Best: Value-Driving Elements of the Patient Centered Medical Home and Accountable Care Organizations; PCPCC, March 2011.

2 demonstration projects. But we are struggling with broad assimilation of consistency nationally, said Cheri Lattimer, RN, BSN, executive director of both the Case Management Society of America (CMSA) and National Transitions of Care Coalition (NTOCC). After talking to patients, it doesn t take long to see that much remains to be done. The evidence demonstrates improving transitions can advance the Triple Aim: 2 Improve the health of the population; enhance the patient experience of care; and reduce, or at least control, the per capita cost of care. 3, 4, 5 Yet patients continue to experience a fragmented system in which their transitions of care are less than positive. What does it take to move beyond lip service? Four experts shared their views: Lattimer; Commission Executive Director Patrice Sminkey, CMSA President Nancy Skinner, RN-BC, CCM; and Commission Chair Kathryn M. Kathy Serbin, BSN, MS, CCM. There was general agreement among the four about what is needed to improve care 2 Developed by the Institute for Healthcare Improvement ( org/offerings/initiatives/tripleaim/pages/ default.aspx). 3 Improving Care Transitions brief, Health Affairs, Sept. 13, Naylor M, et al. "The Importance Of Transitional Care In Achieving Health Reform." Health Affairs, 30, no.4 (2011): The NTOCC's TOC Compendium, a collection of resources, including white papers, journal articles, and website links, related to transitions of care. transitions and that professional case managers play a central role. Communicate Ensuring clear communication with the patient, within the care team and across locations may be the most important element of a successful transition, and professional case managers are ideally positioned to meet that challenge. They ensure timely communication with the patient and with the team, which can make a significant difference in the progress of a patient s recovery, Serbin said. It follows, then, that the lack of communication is one of the greatest challenges. Lack of communication within the health care system can lead to inefficient transfers, frustrated patients and families, decreased quality of patient care and suboptimal health outcomes, she said. Poor communication including failure to transfer affects myriad other aspects of care; notably, medication management, Lattimer said. In fact, medication errors during transitions of care occur about one-third of the time. 6 To improve transitions of care, providers must first improve communication during transitions between and among providers, patients and caregivers. A good analogy is 6 Gleason KM, McDaniel MR, Feinglass, J, et al. Results of the Medications at Transitions and Clinical Handoffs (MATCH) Study: An analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med 2010; 25: "After talking to patients, it doesn t take long to see that much remains to be done. Cheri Lattimer, RN, BSN, executive director of the Case Management Society of America and National Transitions of Care Coalition technology. The health IT industry is moving toward interoperability, which allows different EHR systems to talk to each other. Today, however, what s needed is not just EHR interoperability, but real-life interoperability between and among providers and facilities across the continuum of care, Lattimer explained. We move very quickly in health care today, and there is little time to assimilate. If we can communicate clearly regarding what the patients know, what they still need to help them achieve goals, what gaps remain; and develop strategies to close those gaps, we will be much more successful than in the past, Skinner said. And that, she added, is something at which case managers excel. Create accountability Successful communication demands accountability and clear understanding of roles. Accountability comes in many forms. Part of it is identifying who is responsible for transitions at each point and establishing points To 2

3 of accountability for sending and receiving care, particularly for hospitalists, specialists, primary care physicians and nursing home providers, said Lattimer. (See table below.) Team members need to know what they are responsible for when they receive a communication. For instance, sending an to the entire team is useless unless the team members know what they need to do in response how they need to act on the. Think of it in terms of passing the baton in a relay race. Both runners must have a hand on the baton before it can be passed on for the next leg of the race. Such accountability is the first item in NTOCC s Key Elements of the Framework for Measuring Transitions of Care: Patients should have an accountable provider or a team of providers during all points of transition. The provider(s) would provide patient-centered care and serve as central coordinator(s) across all settings, and with other providers. This care coordination hub has to have the capacity to send and receive when patients are transitioning between care sites. While the primary care patientcentered medical home incorporates such a hub, other practitioners can take this role as well. More broadly, accountability involves aligning incentives with desired outcomes. New Clarifying the Transition of Care Interaction between the Sender and Receiver SENDER RECEIVER Who What To Whom When Verify/Clarify Act Upon Accountable provider Tests Consultations Medication reconciliation Transition/ discharge summary Assessments Patient education My Medicine List Accountable provider and patient Send the timely for appropriate intervention with patient Sender verifies is received by intended recipients Sender clarifies for recipient Sender will document transaction Sender will resend if not received by intended recipient Who What To Whom When Verify/Clarify Act Upon Accountable provider Tests Consultations Medication reconciliation Transition/ discharge summary Assessments Patient education My Medicine List Accountable provider and patient Received the timely for appropriate intervention with patient Receiver acknowledges having documents and asks any questions for clarification of received Receiver uses the and takes actions as indicated Receiver ensures continuity of plan of care/ services How is this Documented Document data source: Paper medical record Electronic health record Checklist How is this Documented Document data source: Paper medical record Electronic health record Checklist source: NTOCC Clarifying the Transition of Care Interaction between the Sender and Receiver 3

4 reimbursement codes for transitions of care which CMSA and NTOCC helped develop are creating incentives (see sidebar below). Medical homes and accountable care models also provide incentives for coordinating care. And hospitals now face penalties for excessive readmissions. Regardless of one s view of the Affordable Care Act, it has advanced accountability through penalties and reimbursement incentives, Skinner observed. As we move forward, providers see there is not only a benefit in doing the right thing in effecting appropriate transition, there s also a financial benefit to making sure the patient is engaged, empowered and educated. Lattimer concurred. We ve all wanted to do the right thing. We are extremely pleased the CMS has recognized the need to support transitions of care and care coordination. We also know we need to go further in addressing the financial support for coordination: achieving the right thing for the right patient at the right time. New codes, new opportunities We don t work around them. We collaborate with them to develop a transitional care path that meets that patient s specific needs. Nancy Skinner, RN-BC, CCM, CMSA president Put a hub in place The professional case manager is the hub for patient care: He or she engages with the team, the patient, the family and others beyond the team. The case manager understands when to bring in other team members. We are seeing in our trend studies that professional case managers and board-certified case managers in particular are suited to take the lead in this area. They are decision makers and managers, said Sminkey. In an increasingly complex and fragmented health care system, the professional case manager Recently, Medicare began accepting newly created CPT codes (99495 and 99496) for care coordination to reimburse for the management of patients who have recently been discharged. The CPT codes cover services provided when a patient's condition requires moderate- (99495) or high-complexity (99496) medical decisionmaking as the patient is transitioning from inpatient hospital care to home or another community setting. Physicians, physician assistants and advanced practice nurses can all use these codes, and the contact can be by phone, electronically or in person. Such services provided by case managers are generally covered. links patients and families with appropriate providers and resources across the care settings. The case manager also links the various providers and resources with the patient. Professional case managers are uniquely positioned to coordinate care and improve transitions, to serve as the hub to which all parties are connected. Sminkey likened the case manager to an air traffic controller, who directs the traffic so the plane arrives at the desired destination. The air traffic controller doesn t pilot the plane or determine the destination. He or she has a specific role on a larger team. Case managers need to see themselves the same way. Professional case managers, like air traffic controllers, can t do everything by themselves. They focus on what they do well and fully engage their team to obtain the best outcome. A fully integrated team means a fully engaged team. Skinner offered a similar analogy: a GPS. The GPS doesn t tell you where the GPS wants to go; you select the destination and the GPS guides you to where you want to go. Likewise, the professional case manager helps the patient get where he or she wants to be to reach toward the goal that patient and their support system wish to achieve. Patient advocacy means keeping the patient at the forefront As the hub, the traffic controller or the GPS, the case manager always takes a person-centered approach. 4

5 Patient and family are at the center of all activity, said Skinner. We don t work around them. We collaborate with them to develop a transitional care path that meets that patient s specific needs. Patient engagement and education are essential. Looking the patient in the eye, touching her, communicating in a way he understands e.g., adjusting for hearing problems, literacy, cultural barriers, etc. is at the heart of what the case manager does, she noted. Along those same lines, Sminkey added, it s important to remember the case manager is working with an individual and his or her family not a case. That s what distinguishes professional case management from utilization review. We don t talk about cases. We talk about people. Utilization review is not case management, she said. Case management has always been about patient-centered care, no matter what the practice setting. We must never forget this: We are patient advocates, regardless of the changes going on in the industry, Sminkey said. For similar reasons, she takes particular exception to the term handoff. It s never a handoff, she said. It s just bringing in another team member. Handoff not only dehumanizes the patient, but it misses the fact: Transitions are part of a process; they are not discrete medical events, but part of patients continuum of care, whether acute or chronic, wellness or end of life. Skinner made this point forcefully. Too often, she said, a transition of care is viewed as the discharge rather than as the process that begins with the first interaction between provider and patient. We look at transitions as the event of leaving, she noted, not as the process of working toward active patient participation and engagement in managing their health and attaining desired health care outcomes. Throughout all this, providers must recognize the value of assessing how patients feel about the process, Lattimer said. She told of a presentation she gave at a longterm care facility. A 92-year-old resident came up afterward and said, That was an excellent presentation. But don t do this for me. I want you to do it with me. We don t talk about cases. We talk about people. Utilization review is not case management. Patrice Sminkey, Chief Executive Officer, The Commission for Case Manager Certification Such an approach is what moves discussions about transitions from lip service to action, said Serbin. What is required to move transitions of care from lip service to practice? Any strategy that requires the patient s active engagement in her/his treatment plan and personal health goals, with the case manager making every effort to ensure the patient understands her/his disease processes and informing the patient of best practices, while serving as their advocate. Collaborate Collaboration can t be separated from patient-centeredness. Patientcentered care requires advocacy; the professional case manager collaborates with clinicians about a patient s needs, connects recommendations with the physicians orders, interacts with specialists and ensures the patient is fully informed and understands. All four thought leaders agreed: Multidisciplinary, high-performing teams are essential. The evidence supports their value. 7,8 The team circles around the patient, explained Sminkey. Some in that circle touch the patient; others may not. Collaboration and partnership are key, and it means including the entire team pharmacist, occupational therapists, administrators and support personnel. I mean everybody. A highfunctioning, fully-integrated team must include everyone involved in a patient s care. Unfortunately, team-based care is not a core component of nursing or medical education, Lattimer said. Even if it s covered in a textbook, it s certainly not modeled by the education system. How many classes do we have that are interdisciplinary? Do we ever 7 Mitchell, P, et al Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC. 8 Bodenheimer, Thomas. Building Teams in Primary Care: Lessons Learned. California Healthcare Foundation, July

6 bring a team together in the classroom? How do you teach them in silos and then expect people to work together as a team? Focus on what works One challenge facing the Commission and the professional case manager is how to demonstrate value in smooth care transitions, Serbin observed. We have to demonstrate value to the community at large and the clients we serve. It can be a challenging message to convey. It can be done, however, and metrics are already in place. NTOCC has developed a framework for transitions measurement. It also identified seven essential transition interventions, 9 which can serve as a checklist: 9 Compendium/SevenEssentialElements.pdf Medication management: ensuring the safe use of medications by patients and their families. Transition planning: a formal process that facilitates the safe transition of patients from one level of care to another, including home. Patient and family engagement/education: education and counseling of patients and families to enhance their active participation in their own care, including informed decision-making. Information transfer: sharing of important care among patient, family, caregiver and health care providers in a timely and effective manner. Follow-up care: ensuring patients and families have timely access to key health care providers after an episode of care. Take baby steps, identify what works and then build on that success. Replicate it on a larger scale. Continue to move forward now. Patrice Sminkey, Chief Executive Officer, The Commission for Case Manager Certification Health care provider engagement: open and timely communication among health care providers, patients and families. Shared accountability across providers and organizations: enhancing the transitionof-care process through accountability for care of the patient by both the health care provider (or organization) transitioning and the one receiving the patient. Readmissions just the beginning Following the nine million hospitalizations of Medicare patients per year, almost one in five patients is readmitted within a month of discharge. These readmissions are frequently cited as evidence of a fragmented system in general and poor transitions in particular. As disturbing as they are, they aren t the whole story. Skinner cited a recent study from Penn State that looked at an equally important metric: the number of patients who end up in the emergency department shortly after discharge. Nearly one quarter of patients end up in the ED within 30 days of being discharged from a hospital. Unless these visits lead to admission, they are not part of calculating readmission rates. A Report on U.S. Hospital Readmissions, Robert Wood Johnson Foundation, Feb Rising KL, White LF, Fernandez WG, Boutwell AE. Emergency Department Visits After Hospital Discharge: A Missing Part of the Equation. Lattimer noted these are the interventions that have demonstrated effectiveness across different models of and approaches to care coordination. Celebrate what works. There s no need to start from scratch, she added. Research shows what s effective. Focus on success, agreed Sminkey. Too often, naysayers carry the day. What must happen both to improve transitions and to demonstrate the value of the case manager is to identify what works and move forward. Take baby steps, identify what works and then build on that success. Replicate it on a larger scale. Continue to move forward now. 6

7 Move forward The current fragmented approach to health care delivery puts patients at risk and creates inefficiencies in the system, driving up costs. Improving transitions of care is an ongoing process and an ongoing challenge. Professional case managers, working at the top of their license, have the opportunity to de-frag the system and help achieve the Triple Aim. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates the options and services required to meet the client s health and human service needs, Sminkey said, drawing on the Commission s definition. This process clearly aligns with successful transitions of care. Today it takes a collaborative team of physicians and nurses who address the clinical issues, as well as pharmacists involved with medication reconciliation and management and social workers focused on psycho-social issues, said Lattimer. It s the professional case manager, whether a nurse or social worker, who works with the team to pull it all together. Thought leaders from the Commission and CMSA must work together to continually build awareness of and attention to professional case management, and clarify how care coordination and transitions of care fit into the case management process. The time is now and the message is clear, Sminkey said. Professional case managers have the skills and training to help heal our broken system, to connect patients and providers and to coordinate care across the continuum. They are not only ideally suited to creating successful transitions of care they are essential to it. n About the Experts Cheri Lattimer, RN, BSN, executive director CMSA and NTOCC Cheri Lattimer is the CEO and president of Consulting Management Innovators (CMI), providing outsourcing and advisory services to the care management and health care industries. She serves as the executive director for the Case Management Society of America, executive director for the National Transitions of Care Coalition and the director of the Case Management Foundation. Her leadership in quality improvement, case management, care coordination and transitions of care is known on the national and international landscape. She was a contributor and reviewer for the CMSA Core Curriculum for Case Management and The Integrated Case Management Manual Assisting Complex Patients Regain Physical and Mental Health. She has been quoted in several publications and serves on several national boards and committees. Patrice Sminkey, CEO, CCMC Sminkey comes to the Commission from URAC, where she most recently served as senior director of sales. She brings a proven track record in operations management in small and large operations, multilevel services and cross-functional teams. She has extensive experience in client management and coordination. As CEO, Sminkey oversees the management of all activities related to the Commission s operations, including all programs, products and services; and the provision of quality services to and by the Commission. She works with CCMC s volunteer leadership to evaluate and develop potential new products for implementation by CCMC, and she establishes and maintains communication and working relationships with other organizations, agencies, groups, corporations and individuals. 7

8 About the Experts (continued) Nancy Skinner, RN-BC, CCM, CMSA president Nancy Skinner, RN-BC, CCM, has for the past 20 years primarily served as a national case management educator. She currently serves as principal consultant for Riverside HealthCare Consulting. In that role, she develops programs that reflect the state of the science of case management and other transitional care strategies. In 1998, she was honored as the Illinois Case Manager of the Year; in 2002, she was named CMSA National Case Manager of the Year. In 2008, she received the CMSA Lifetime Achievement Award. She has accepted numerous CMSA leadership positions, including president, vice president, and board director. Skinner is a founding advisory task force member of the National Transition of Care Coalition. A frequent national and international speaker, she serves as primary faculty for the University of Southern Indiana case management certificate course. Kathryn M. Serbin, BSN, MS, CCM, Chair, CCMC Serbin is Section Chief, Women s Health Clinic and senior nurse, Surgical Clinics Ambulatory Care Center of the James A. Lovell Federal Healthcare Facility. She holds the Navy rank of captain and has been in the reserves since In 2006, Serbin was deployed to Landstuhl Regional Medical Center (LRMC), Germany as part of a contingent of Navy personnel (active and reserve) from 10 Operational Health Support Units, the first Navy contingent to provide support to LRMC. Serbin served in the Behavioral Health Directorate at LRMC and instituted the first inpatient case management program there. In 2009, she was appointed by the Navy Surgeon General as the mental health specialty leader for reserve corps nursing. She is the recipient of numerous awards and commendations for meritorious service. Commission for Case Manager Certification Commerce Parkway, Suite C n Mount Laurel, NJ n (856) ccmchq@ccmcertification.org n Join our community of professional case managers! Written and produced by Health2 Resources. Copyright 2013, CCMC