Care Transitions and Chronic Care Management

Merging Transitional Care Programs with Chronic Care Management Models at the community level is the key to long term cost control and patient satisfaction where the dual eligible, frail elderly are concerned. These initiatives should be given great consideration where transformation and reform of the healthcare system that meets the needs of these beneficiaries is concerned.

First let’s define these two terms:

A Transitional Care Program is using LCSW, RN and Advanced Practice Nurse, and clinical pharmacist in a team to provide, pre and post hospital discharge, patient education and assistance in the following areas: medication self-management, use of a personal health record, follow-up with Primary Care and Specialty Physicians, warning signs of potential health problems, and advanced care planning.

A Chronic Care Management Model is the ongoing application of population/ condition unique healthcare protocols to improve aggregate health and avoid acute exacerbations of chronic conditions avoiding additional medical cost and generalized worsening of individual(s) health.

In this week’s blog we are going to focus on what an effective Transitional Care program looks like. Next week we will discuss how an effectively deployed Chronic Care Management model keeps the successfully transitioned patient out of the hospital over the long- term and then; in our November 29th post, we will explain how a fully integrated Home and Community Based healthcare provider like Pyramid Home Health Services can be a hospital, managed care plan or state government’s best partner where meeting the need for consistent and broad geographic deployment these services is concerned.

So why do we need Transitional Care programs? The difficulties of moving from one health care setting to another are challenging for anyone and particularly so for a frail elderly individual. It is at this point of transition that the likelihood of emergency department visits and hospital readmission really spikes. Just think about it; you’ve just been discharged from a hospital after having had a multi- day stay and following a procedure; you have new and discontinued medications to deal with, a modified ability to meet your routine and/or new self- care needs and now something just doesn’t feel right. It’s not hard to understand how this scenario so frequently leads to an ambulance ride to the nearest ER and then readmission to the hospital.

So what do the Transitional Care Team members do? How can an LCSW, RN and clinical pharmacist avoid the undesirable outcome described above?

1- They Identify the High-Risk Senior before they are discharged. Team members can make daily telephone rounds discussing with the hospital’s in-patient case managers the health status of patients pending discharge and determine who on the hospital’s census needs to be added to the list of persons the Care Transition Team needs to meet in person and begin to engage.

2- Before discharge the Care Transition Team can meet with the patient, develop a basic rapport and elicit consent for a home visit to occur no later than 72 hours post discharge and preferably within 48 hours. At this time the Care Transition Team coordinates with the physician that will follow the patient upon discharge and ensures all appropriate orders and conveyance of referrals to required ancillary care providers occurs.

3- Provide the patient a “Transition Packet” that contains their medical record, advanced directives or election documents therefore if the patient does not have an advanced directive, list of clinical warning signs and relating to their condition, symptoms to be aware of and actions to take to avoid condition worsening, and a list of the urgent care locations in the vicinity of the patient’s discharge address with contact information and hours of operation should they need seek medical care unexpectedly.

4- Conduct the 1st post-discharge home visit. At that visit the team must, (A) Make sure the patient has a current list of all their prescription and over the counter medications, screen that list for adverse reaction, ensure the patient understands why they are taking each medication, how to take the medications and if there are any barriers to the patient’s medication compliance. When identified, address those barriers. (B) Review and explain the contents of the patient’s medical record. Make sure they understand the importance of sharing the same with their primary care physician, specialists, and post- acute ancillary care providers. (C) Schedule the necessary follow-up visits then and there and confirm or transmit to the following physicians all discharge orders. (D) Review with the patient their condition specific warning signs. (E) Complete a full patient health evaluation and affect a baseline health status post discharge with a copy retained by the patient in their Transition Packet and to be shared with following physicians and other post- acute providers.

5- At least 1 follow-up call with 48- hours of initial home visit and continued contact as necessary.

As documented by the National Transitions in Care Coalition, effective Transitional Care Programs have a huge and positive impact where reducing ER and hospital re-admission risk for the frail elderly is concerned. In some initiatives observed rates of re-hospitalization have decreased by as much as 60% with ER visits decreasing by more than 30%.

Pyramid Home Health Services has 16- Regional Care Management Teams; each of whom is staffed by LCSW/ MSW, RN and Advanced Practice Nurses, and MTM certified Pharmacists. Additionally, our HIPPA compliant Tele-Health Portal can provide the patient’s physicians the ability to participate with, real time, the patient and their Pyramid Team while all are in the patient’s home.

Traditionally, HCBS and Home Health Services more specifically, have been thought of as “Post -Acute” and “Post Discharge” services. Notwithstanding, the same professionals that make up a Pyramid Home Health Care Team can also deliver a very effective Transitional Care Program for Hospitals and Managed Care companies working to improve the success and satisfaction rates of their patients and beneficiaries transitioning from the in-patient to home setting.  Where these organizations are concerned Pyramid Home Health Services represents a more cost effective solution than implementation of their own teams to accomplish the same or their contracting with call center based third parties who have to further contract with additional providers to actually and meaningfully “touch” a patient. Simply stated, Pyramid Home Health Services permits Hospitals and Managed Care entities to avoid the added cost and managerial responsibilities associated with doing it themselves and the unnecessary cost of adding a middle-man to the equation. When coupled with the financial capacity and willingness to contract on an “At Risk” basis, Pyramid Home Health Services represents a great partner for Hospitals, Managed Care Entities and State Government wishing to improve Care Transitions for Missouri’s dual eligible.

If you would like to discuss implementing a Transitional Care Program for your patients or beneficiaries please contact us at or via phone at 888-880-6565.

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