Using Inbound and Outbound Calling Programs

Transcription

1 timely follow up Clinical Escalation ebook 7 Steps to Successful Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs Care team coordination Reduced readmissions

2 Contents 02 part 1 Why all the fuss about hospital readmissions? 03 part 2 The importance of reaching out to patients post discharge 05 part 3 What is post discharge calling and why do I need it? 07 part 4 7 steps to reducing readmissions with post discharge calling 12 part 5 Some final thoughts 14 About SironaHealth

3 PART 1 Why all the fuss about hospital readmissions? The Center for Medicare and Medicaid Services (CMS) is changing the way we look at readmissions Sparked by healthcare reform, a renewed focus has been placed on managing and reducing hospital readmissions considered to be preventable. Beginning in October 2012, CMS is incorporating pay-for-performance incentives designed to encourage health systems to extend care beyond the hospital setting to ensure their patients are complying with their at home care plans. A LITTLE BACKGROUND In 2007, the Medicare Payment Advisory Commission (MedPAC) reported to congress that, of the Medicare patients who had been rehospitalized within 30 days of discharge in 2005, 13% were for reasons deemed potentially preventable accounting for $12 billion (or $7,000 per beneficiary) in Medicare spending. In 2009, a New England Journal of Medicine study found that 18-20% of Medicare patients were re-hospitalized within 30 days, and a staggering 33% were readmitted within 90 days of discharge. the way forward Congress took notice of these alarming trends and specifically addressed readmissions when drafting their new healthcare legislation. As a result of the March 2010 signing of the Patient Protection and Affordable Care Act, CMS now has the authority to withhold hospital payments for excessive readmissions. Hospitals are now financially at risk for patients re-hospitalized for reasons considered to be preventable and need to move quickly to improve follow up care. Why a wait and see approach won t work As of October 1, 2011, patients discharged from hospitals will have an impact on penalties applied to readmissions in Hospitals need to be actively evaluating their current performance, forecasting what their financial penalties will be, and implementing strategies to reduce these readmissions. CMS will be focusing first on: Congestive Heart Failure (CHF) Acute Myocardial Infarction (AMI) Pneumonia Then in 2014, likely adding: Chronic Obstructive Lung Disease Coronary Bypass Grafting Percutaneous Coronary Interventions Vascular Procedures ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 2

4 PART 2 The importance of reaching out to patients post discharge Developing the right readmission reduction strategy While the Center for Medicare and Medicaid Services has implemented financial penalties for hospitals with excessive readmissions, they haven t provided any instructions on how to successfully reduce them. This leaves many hospitals wondering what the right approach is. And while there are indeed many solutions to consider, there is one universal thing that needs to happen in order to impact readmission rates and that s timely follow up. Leaving the hospital can be a stressful process for patients Patients are tired, nervous about the transition home, concerned that their condition could worsen, and (in far too many cases) unclear as to what they need to do now that they ve left the hospital. Or in other words... They are at risk for readmission. And with all that a patient goes through during their hospital stay, it s not surprising that despite your best efforts some patients won t understand, retain, or follow the home care instructions you provided at the point of discharge. Patients that don t understand / follow their home care instructions are at risk of serious complications with their recovery. In fact, this is a major factor for most hospital readmissions, especially in regards to medication compliance. Health Lit er a cy (noun) An individual s ability to read, understand, and use healthcare information to make decisions and follow instructions for treatment. ~ Wikipedia To avoid readmissions relating to poor health literacy, you need to connect with patients shortly after discharge to ensure they understand what to do and why it s important. KEY TAKEAWAY You need to connect with patients within hours after discharge to make sure they understand and follow their home care instructions. ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 3

5 PART 2 The importance of reaching out to patients post discharge Coordinating patient follow up and monitoring is critical Many patients don t see a physician promptly after they have left the hospital. In fact, 50% of Medicare patients had no interaction with a physician between the time they were discharged and when they were readmitted. This constitutes a significant gap in care for the patient. This gap in care allows health deterioration to go unnoticed by the care team until severe complications arise that require readmission. Physician follow up is a critical part of the patient s care plan, but sometimes patients don t have the means (or motivation) to make and keep their appointments. As you build your post discharge follow up programs, appointment reminders and scheduling become key components of a successful hospital readmission reduction strategy. Not only do you need to be able to facilitate the appointment, it s equally important to educate the patient as to why the follow up is needed. Follow up improves the patient experience & HCAHPS scores Patients who don t understand their discharge instructions, or are otherwise unsure of what they need to do to manage their follow up care, are more likely to have an unfavorable perception of their overall hospital experience negatively impacting your HCAHPS scores. Connecting with your patients after discharge not only improves patient safety, but provides your patients with piece of mind that they have a support system in place in the event they have questions or require additional care. ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 4

6 PART 3 What is post discharge calling and why do I need it? What is post discharge calling? Post discharge calling services are outbound programs that consist of both clinical and non-clinical professionals who rapidly assess a patient s current health status, offer clinical decision support, schedule appropriate follow up care, and gather feedback on what their overall hospital experience was. Hospitals use post discharge calling to quickly engage patients who have left the hospital, identify patients who are at risk of being readmitted, and initiate support services that will lead to healthy patient outcomes. Post discharge calling services help hospitals cost-effectively manage their patient population beyond their four walls. The best post discharge calling programs serve as front line care coordinators for the hospital, using guideline driven processes to facilitate follow up care across the patient s entire care team. What post discharge calling isn t The goal of post discharge calling programs is to identify what barriers patients are facing with their home recovery, and then connect them to the hospital resource that will help manage their home care appropriately. Post discharge calling is not: A stand-alone satisfaction survey that collects information about the patient experience without providing any escalation to relevant healthcare resources. About reactive service recovery for patients upset about their hospital experience. A one time thing. Continuous follow up engagement is needed to successfully reduce readmission rates. ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 5

7 PART 4 What is post discharge calling and why do I need it? While timely follow-up is critical, that alone isn t enough to prevent readmissions. To be effective, you need a care team that can connect, evaluate, and escalate patients to appropriate care and/or administrative resources. Jeff Forbes, President, SironaHealth Why does my hospital need post discharge calling? Roughly 20% of hospitalizations in the United States are readmissions. But which of those readmissions were potentially avoidable? As CMS rolls out their Hospital Readmission Reduction Program, your hospital will need a cost-effective way to reach out to all your discharged patients and identify potentially avoidable readmissions. Telephone based programs are ideally suited to accomplish this task. Catch symptoms early, before they lead to a readmission Patients can develop new symptoms at any time during their recovery. And while many patients (and their care providers) will seek help, others will ignore new symptoms and put off calling their doctor. Calling programs keep you in contact with all your discharged patients, reminding them to seek help when they need it. Essential to assigning appropriate follow up care To avoid a costly readmission, some of your patients may require one-on-one care from a clinical professional. Sending a clinician (doctor, pharmacist, nurse, etc.) to every patient who has been discharged isn t financially feasible for many hospitals. Post discharge calling allows you to identify, segment, and prioritize in person coaching services so that they are delivered only to the patients who need them. CMS financial penalties may just be the beginning We ve seen this before. When CMS implements a new financial incentive or launches a new healthcare pilot program, commercial insurers will likely follow suit. ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 6

8 PART 4 7 steps to reducing readmissions with post discharge calling Following up with patients hours after discharge: a critical step in reducing readmission rates Communication is the key to keeping your patients safe. Engaged and informed patients are much more likely to understand and follow their discharge instructions correctly, making it less likely they will need to be readmitted. To help get you started, we ve outlined the 7 steps needed to launch a successful post discharge calling program. 7 steps continued on next page > ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 7

9 PART 4 7 steps to reducing readmissions with post discharge calling 01 Conduct follow up calls hours after the patient s discharge 02 Confirm the patient understands their home care and medication instructions Catching potential complications early is critical to reducing hospital readmissions and the telephone remains the most effective way to connect with patients after discharge. The key is to have a post discharge calling program that not only engages with patients quickly, but can rapidly assess what the next appropriate course of action is. And the next appropriate course of action doesn t automatically mean emergency clinical intervention (although that is important!). What s required is a post discharge follow up program that is tailored to meet the specific needs of each patient and their families. Follow up calling programs that connect with patients quickly after discharge, and can coordinate next steps, are extremely effective in identifying and filling any gaps in care that can lead to readmission. INSIDER TIP Your post discharge follow up calls need to build on the trust your hospital staff has already created. This means having compassionate individuals make the calls, asking relevant questions, and being able to resolve any issues, clinical or otherwise, quickly. One of the first things you need to do during a follow up call is to confirm that the patient understands their post discharge instructions and that they are following them. Why? Because non-compliance with post discharge instructions is a driving factor for preventable readmissions. The goal of your post discharge calling programs should be to identify any misunderstandings and/or risky behaviors early in order to resolve them before they can cause a readmission. We recommend that, at minimum, your post discharge advocates: Confirm that the patient received their post discharge instructions before they left the hospital. Ask the patient if they understand their home care instructions and if they need any clarification on what they need to do. Find out if the patient was able to successfully fill their medication prescriptions. And if they haven t, why not. Ask if the patient has any questions about their medications. Confirm that the patient is taking them as prescribed. 7 steps continued on next page > ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 8

10 PART 4 7 steps to reducing readmissions with post discharge calling 03 Provide clinical decision support and health coaching 04 Facilitate appropriate next steps As you make post discharge follow up calls, you will encounter patients experiencing health issues. For patients experiencing acute symptoms, this means providing them with clinical decision support (e.g. nurse triage) in order to identify what the appropriate next course of action is. If the person conducting the follow up call isn t a clinician, there needs to be a process in place that can escalate them to a licensed professional (like a registered nurse) right away. Using clinical guidelines, the triaging nurse will recommend self-care, physician follow up, urgent care, or emergency services. Some patients may require follow up health coaching Other patients may require additional coaching from a clinical professional (e.g. pain management, medication adherence, exercise). Make sure there s a process in place to trigger additional outreach. Your goal should be to resolve any and all barriers to recovery identified during the follow up call as quickly as possible. As we discussed in Step 3, escalating symptomatic patients to a clinician is a critical part in facilitating appropriate care however, this is not the only type of escalation needed to reduce readmissions. To reduce readmissions, your post discharge follow up service needs to be prepared to: Help the patient schedule their follow up appointment(s). Find the patient a doctor that meets their follow up care needs in the event they do not have a primary care physician. Coordinate patient transportation services as needed. Arrange any additional follow up services (telephonic health coaching, in-home nurse visit, medication management, etc.). INSIDER TIP While many follow up calls can be handled by a non-clinician (that can escalate to a RN when needed), you might consider having clinicians make outbound follow up calls for patient conditions that have a higher risk of complication. 7 steps continued on next page > ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 9

11 PART 4 7 steps to reducing readmissions with post discharge calling 05 Make it easy to reconnect with a registered nurse anytime, day or night 06 Keep all members of the patient s care team in the loop Questions can arise at anytime, and so can symptoms. The ideal post discharge calling program is a blend of both outbound and inbound programs giving patients 24x7 access to your support services. Provide your patients with a telephone based support line that will allow them to immediately connect with a clinician if they have questions. Staff your support line with RNs who have access to telephone triage guidelines in addition to any relevant patient data. And make sure the promotion of your inbound support line is an integral part of your discharge process. Otherwise, patients won t know to use it. Some promotional ideas: Assign a dedicated 800 number for your patient support line. Include promotional materials such as brochures, magnets and key tags with your written discharge instructions. Remind the patient about the nurse support line at the end of the initial post discharge follow up call. When it comes right down to it, reducing readmissions can t be solved by one provider it requires the entire care team. The best way to reduce readmissions is to employ a team approach to providing patient care utilizing physicians, specialists, registered nurses, pharmacists, and other healthcare professionals. Problem is, if the rest of the team isn t in the care loop, they don t know when they need to intervene with the patient. As you take a lead in conducting post discharge follow up calls, you need to be able to share what you learn with the rest of the patient s care team. For health systems that have implemented an Electronic Medical Record (EMR), this means automatically writing call results directly to the EMR. However, for systems that don t currently have an EMR implemented, other provider communications (fax, text, secure , etc.) are needed. When everyone on the care team is on the same page, you can identify and resolve care issues quickly, before they can cause a readmission. INSIDER TIP The same escalation rules outlined in Step 4 should apply to your inbound nurse advice line allowing you to connect patients to the appropriate healthcare resource at the moment of engagement. 7 steps continued on next page > ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 10

12 PART 4 7 steps to reducing readmissions with post discharge calling 07 Use feedback captured during the call to improve the discharge process Have a high number of patients who did not receive their discharge instructions? Are patients not filling their medications? Do patients need help scheduling follow ups? Tracking and trending this data is critical if you wish to reduce readmissions not to mention improve the patient s experience during the discharge process. The key is to have the right reports. Having a clear picture of what causes readmissions allows you to make improvements to your discharge process which could be anything from assigning more clinical resources to working with local taxi companies to coordinate patient travel. The first step in reducing readmissions is to understand why they are occurring, and the best way to do that is to gather and share feedback. INSIDER TIP Share the feedback you gather with your entire hospital team. Your team can t solve problems without knowing what they are. ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 11

13 PART 5 Some final thoughts Launching the right post discharge calling program In order to effectively reduce your hospital readmissions, you need to have a process in place that allows you to connect with patients after discharge, and that enables you to manage their health as they transition to a different level of care. The telephone has proven to be a cost-effective and reliable channel for engaging and coaching patients about their health. Your job is to implement a post discharge calling program that is staffed with the right healthcare professionals, utilizes the most appropriate guidelines, can quickly escalate to local clinical and administrative resources, and can automatically keep everyone in the patient s care team up-to-speed on their health status and needs. Readmissions are not primarily about people being re-hospitalized because of mistakes made in the hospital. [Readmissions] are about making transitions effectively. Stephen Jencks, M.D., a former senior clinical adviser to CMS How SironaHealth does it To help you manage and reduce your hospital readmissions, we provide outsource post discharge follow up services. Staffed by registered nurses and specially trained discharge advocates, we help your patients successfully transition home, or to another care facility, by conducting guideline driven outreach calls 24 to 72 hours after discharge. During the post discharge call, our advocates will: Clarify discharge instructions. Remind patients to refill their prescriptions. Schedule follow up care appointments. Escalate the patient to a registered nurse for symptomatic triage or care advice as appropriate. To learn more about how we can help you reduce your hospital readmissions, please visit: sironahealth.com/post-discharge ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 12

14 References Page 2: MedPAC (June 2007) Report to the Congress: Promoting Greater Efficiency in Medicare Page 2, 4: Jencks S, et al. Rehospitalizations among patients in the Medicare fee-forservice program. New England Journal of Medicine Page 2: Patient Protection and Affordable Care Act of 2010, Pub. L. No , 124 Stat. 119 (2010, March 23). Page 6: Fazzi R, Agoglia R, Mazza G, Glading-DiLorenzo J. The Briggs National Quality Improvement / Hospitalization Reduction Study. Caring: National Association for Home Care magazine. 2006; 25(2):70. Photo credits SironaHealth greatly acknowledges the following photographers for sharing their original works via flickr and the Creative Commons license. Page 2: Flickr user name jonworth-eu ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 13

15 About SironaHealth Healthcare needs have changed. Most contact centers haven t. That s why we re here. We are a multi-channel health contact center that offers healthcare companies a unified way to coordinate patient care across telephone, web, , and mobile channels. SironaHealth programs help your patients make the appropriate healthcare choices whether it be choosing the proper physician or knowing when they should seek emergency care all while keeping their entire care team in the loop. Our guiding purpose is to deliver healthcare solutions that keep your patients safe by guiding them to the appropriate level of care with compassion and speed. Care Solutions Nurse Advice Line (aka Telephone Triage) ER Decision Support Care Reminders Pre-Admission Assessment Post Discharge Follow Up Engagement Services Physician Referral Services Referral Class Registration Patient Services Custom Survey Automated Voice Software & Support Call Center Software Smartphone Apps Infrastructure Co-source Services Contact us SironaHealth 500 Southborough Drive, South Portland, ME SironaHealth.com twitter.com/sironahealth linkedin.com/company/sironahealth-in facebook.com/sironahealth ebook: 7 Steps to Post Discharge Follow Up Care Using Inbound and Outbound Calling Programs 14