Improving Care Transitions Discussion

Discuss 1

Identify a current healthcare policy in your current role that you would like to see revised. Why? What would be the projected outcomes?

In our discussion question #1, we will be looking at current healthcare policies that need revision. As you are reflecting on your response, how does the healthcare policy affect you? How does it affect other stakeholders?

One of the primary things to consider is being a nursing advocate. We are taught to be patient advocates but how many of us are actually nursing advocates? In becoming a nursing advocate expert, it is very important to understand the different modalities needed to successfully analyze a health policy.

This week’s graded topics relate to the following Course Outcomes (COs).

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4. Determine the effect of healthcare politics on the healthcare stakeholders, state and federal government, and the nursing profession (PO #9).

5. Analyze legislative process and the impact of special interest lobbies (PO #9

1. How have you seen the legislative process impact patient care in your nursing practice or in the practice of other nurse

2. Who are the stakeholders and how could they be used in political analysis that might be different from their use in political advocacy?

3. Can you discuss the strategies you could utilize for a stakeholder who might be utilizing illegitimate power instead of legitimate power?

Health Policy Brief use this policy

Improving Care Transitions

Rachel Burton

An example of a well-written policy brief is presented here. It was developed by Health Affairs and the Robert Wood Johnson Foundation. Website resource: www.healthaffairs.org/health policybriefs/brief.php?brief_id=76.

Improving Care Transitions: Better Coordination of Patient Transfers among Care Sites and the Community Could Save Money and Improve the Quality of Care1

What’s the Issue?

The term care transition describes a continuous process in which a patient’s care shifts from being provided in one setting of care to another, such as from a hospital to a patient’s home or to a skilled nursing facility and sometimes back to the hospital. Poorly managed transitions can diminish health and increase costs. Researchers have estimated that inadequate care coordination, including inadequate management of care transitions, was responsible for $25 to $45 billion in wasteful spending in 2011 through avoidable complications and unnecessary hospital readmissions.Improving Care Transitions Discussion

Several new federal initiatives aim to encourage more effective care transitions. In addition, debate continues over how to restructure fee-for-service payments to motivate providers across care settings to work as a team to make transitions smoother.

This brief examines the factors contributing to poor care transitions, describes the elements of effective approaches to improving patient and family experience with transitions, and explores policy issues surrounding payment reforms designed to address the problem.

What is the Background?

For years, health policy experts have identified poor care transitions as a major contributor to poor quality and waste. The 2001 Institute of Medicine (IOM) report, Crossing the Quality Chasm, described the U.S. system as decentralized, complicated, and poorly organized, specifically noting “layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful.”Improving Care Transitions Discussion

The IOM noted that, upon leaving one setting for another, patients receive little information on how to care for themselves, when to resume activities, what medication side effects to look out for, and how to get answers to questions. As a result, the conditions of many patients worsen and they may end up being readmitted to the hospital. For example, nearly one fifth of fee-for-service Medicare beneficiaries discharged from the hospital are readmitted within 30 days; three quarters of these 74readmissions, costing an estimated $12 billion a year, are considered potentially preventable, especially with improved care transitions.

Root Causes.

There are several root causes of poor care coordination. Differences in computer systems often make it difficult to transmit medical records between hospitals and physician practices. In addition, hospitals face few consequences for failing to send medical records to patients’ outpatient physicians upon discharge. As a result, physicians often do not know when their patients have been released and need follow-up care. Finally, current payment policies create disincentives for hospitals to invest in smoother care transitions. For example, although Medicare does not allow hospitals to bill for readmissions that occur within 24 hours of discharge, it does pay full price for most readmissions that occur after that time. This means that the prevailing financial incentive for hospitals is to not expend resources on improving care transitions because a poor transition often leads to readmission, which generates additional revenue.

Moreover, some analysts believe that Medicare and Medicaid payment policies have unintentionally created incentives to unnecessarily transfer patients back and forth between hospitals and nursing homes. Their suspicion is that nursing homes, which are primarily paid by Medicaid with generally low payment rates, unnecessarily transfer patients to hospitals to qualify for more generous Medicare payment rates when their patients return to them after discharge.

Lending credence to this claim, researchers have found that states with lower rates of Medicaid spending on dual-eligible patients under age 65 (people who are eligible for both Medicaid and Medicare) have higher rates of Medicare spending on these patients, and vice versa, suggesting that providers are gaming the system.

Transition to Primary Care.

As mentioned, one of the biggest barriers to smoother care transitions is the fact that primary care physicians often have little or no information about their patients’ hospitalizations. A review of the literature published in the Journal of the American Medical Association in 2007 found that physicians had received a hospital discharge summary about their patients, and had it on hand, in only 12% to 34% of first postdischarge visits. Even when discharge summaries are received, they often lack key information, such as test results, treatment course, discharge medications, and follow-up plans. The situation is even worse for those patients who have no usual source of care.

Patients often do not consistently receive follow-up care after leaving the hospital. Among Medicare beneficiaries readmitted to the hospital within 30 days of a discharge, half have no contact with a physician between their first hospitalization and their readmission. (Figure 8-1 shows 30-day hospital readmissions under Medicare as a percentage of admissions, by state.)

FIGURE 8-1 Medicare 30-day hospital readmissions as a percentage of admissions, 2009. (From Commonwealth Fund [2009, October]. Medicare 30-day hospital readmissions as a percent of admissions: National metrics. Washington, DC: Commonwealth Fund.)

This problem may be worsening because of an ongoing shift in practice patterns. Increasingly, outpatient primary care physicians are no longer visiting their patients when hospitalized, and hospitalized patients’ care is now being managed by hospitalists, physicians who only treat patients in the hospital. Although hospitalists are generally believed to have improved the quality and coordination of patients’ in-hospital care, their presence, and the removal of patients’ outpatient primary care physicians from the hospital, has led to an increased need for care coordination among providers that doesn’t always occur.

Care Transition Models.

Several models for improving transitions after hospitalization have been developed and rigorously tested. One of the most widely disseminated is the Care Transitions Intervention developed by Eric Coleman at the University of Colorado. This approach involves transitions coaches, primarily nurses, and social workers, who first meet patients in the hospital and then follow up through home visits and phone calls over a 4-week period. Improving Care Transitions Discussion

The coaches promote development of patients’ skills in four key self-care areas: managing medications; scheduling and preparing for follow-up care; recognizing and responding to red flags that could indicate a worsening condition, such as the onset of a fever or worsening breathing problems; and taking ownership of a core set of personal health 75information by having patients brainstorm and ask their providers questions about their conditions or self-care routine. In a large integrated delivery system in Colorado, the Care Transitions Intervention reduced 30-day hospital readmissions by 30%, reduced 180-day hospital readmissions by 17%, and cut average costs per patient by nearly 20%. The intervention has been adopted by more than 700 organizations nationwide.

Another rigorously tested transitional care model, developed by Mary Naylor and her colleagues at the University of Pennsylvania, involves a longer period of intervention targeted at a high-risk, high-cost subset of older adult patients, such as those hospitalized for heart failure. In six academic and community hospitals in Philadelphia, this approach reduced readmissions by 36% and costs by 39% per patient (nearly $5000) during the 12 months following hospitalization. Under the Naylor model, an advanced practice nurse not only coaches patients and their caregivers to better manage their care but also coordinates a follow-up care plan with patients’ physicians and provides regular home visits with 7-day-a-week telephone availability.

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What is in the Law?

The Affordable Care Act contains several provisions that could improve care transitions. These include both carrots (financial incentives) and sticks (financial penalties).

Among the carrot approaches, starting October 1, 2012, hospitals can receive increases to their Medicare payments if they achieve or exceed performance targets for certain quality measures, including whether they told patients about symptoms or problems to look out for postdischarge; whether they asked patients if they would have the help they needed at home; and whether they provided heart failure patients with discharge instructions. (See the Health Policy Brief published on April 15, 2011, for more information on improving quality and safety: healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_45.pdf.)

Among the stick approaches, also beginning October 1, 2012, the Centers for Medicare and Medicaid Services (CMS) can reduce payments by 1% to hospitals whose readmission rates for patients with heart failure, acute myocardial infarction, or pneumonia exceed a particular target. According to a recent analysis by the Kaiser Family Foundation, 76more than 2200 hospitals will forfeit about $280 million in Medicare payments over the next year because of these readmissions penalties.

Medical Homes.

The law also authorizes paying providers for care transition services as part of payments to primary care practices that operate as medical homes, practices that closely manage and coordinate the care of patients with chronic conditions. One demonstration project, which predates the Affordable Care Act, is the Multi-Payer Advanced Primary Care Practice Demonstration in which Medicare offers practices that have been formally recognized as medical homes in eight states up to $10 per beneficiary per month to cover the cost of medical home services, which include care transition planning.Improving Care Transitions Discussion

Another demonstration, the Comprehensive Primary Care Initiative, offers monthly payments to practices that average $20 per beneficiary in the first 2 years and then transitions to $15 plus the opportunity to earn shared savings in the last 2 years. Again, a portion of these programs are intended to compensate practices for the costs of care coordination and care transitions planning.

In addition, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration will pay $6 per beneficiary per month to health centers that adopt the medical home model and apply for Level 3 medical home recognition, having the most stringent requirements, from the National Committee for Quality Assurance (NCQA) by the end of the 3-year demonstration. NCQA’s medical home standards ask practices to establish processes to identify patients admitted to the hospital, share clinical information with the admitting hospital, obtain patient discharge summaries from the hospital, and contact patients for follow-up care, among many other expectations.

Medicaid and Medicare.

State Medicaid agencies can now offer providers enhanced reimbursement, such as through monthly care management payments, to cover the cost of “comprehensive transitional care” and other services if the practice qualifies as a “health home”; a practice that cares not only for Medicaid patients’ physical conditions but also helps them obtain such other services as behavioral health care and long-term care services and supports.

Also, a 5-year, $500 million Community-Based Care Transitions Program pays organizations that partner with hospitals with high readmission rates to provide care transition services for high-risk Medicare beneficiaries. All-inclusive payments cover the cost of care transition services provided to individual beneficiaries in the 180 days following an eligible discharge plus the cost of systemic changes made by partner hospitals to improve care transitions. So far 47 awardees have been announced, and applications continue to be accepted. Participating organizations initially enter into 2-year agreements, which can be extended annually through the end of 2015.

Incentives in New Payment Models.

The Medicare Shared Savings Program for accountable care organizations (ACOs) will give groups of providers an incentive to coordinate care more closely to keep patients healthy and out of the hospital because they will be eligible to share in the savings they are able to generate relative to a spending benchmark. The quality metrics that must be met by ACOs to benefit financially under the program include six that pertain to care coordination, including preventing unnecessary hospital readmissions. (See Health Policy Brief published on January 31, 2012, for more information on ACOs: healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_61.pdf.)

The Affordable Care Act also authorizes 5-year bundled payment pilots in Medicare and Medicaid to test whether making a single payment to one entity for services provided by several providers for an episode of care, such as a knee replacement, will give providers an incentive to work together to ensure that patients receive all the services they need, including hospital and follow-up care, in a more efficient manner. Managing care transitions to prevent costly hospital readmissions will be particularly important because, in the Medicare pilot, at least, the bundled payment will cover services beginning 3 days before a hospital admission for an 77eligible condition and extending 30 days after hospital discharge.

Signaling the importance of care transitions to the success of these efforts, the Medicare pilot requires bundled payments to cover the cost of transitional care services. CMS’s new Innovation Center has begun accepting applications from providers interested in piloting four bundled payment models through a separate Bundled Payments for Care Improvement initiative. The Medicaid pilot, meanwhile, requires participating hospitals to have “robust discharge planning programs.”

In addition, a new Medicare-Medicaid Coordination Office in CMS is charged with better integrating benefits for dual-eligible beneficiaries. It also works to ensure “safe and effective care transitions,” among other goals. This office has awarded contracts of up to $1 million each to 15 states to design models to coordinate primary, acute, behavioral, and long-term care for Medicare-Medicaid enrollees. CMS has also invited proposals from states to test two new payment models to better integrate care for this population and allow states to share in savings from these improvements. Twenty-six states, including the 15 states awarded demonstration design contracts, have developed proposals for this demonstration. The new payment and delivery system models are likely to focus on improving care transitions, among other strategies. (See the Health Policy Brief published on June 13, 2012, for more information on dual eligibles: healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_70.pdf.)

Improving Care Transitions Discussion