Category Archives: Care Transitions

Care Transitions by Pyramid Home Health Services

Pyramid Home Health Services assists many Missourians recently discharged from an in-patient hospital stay to rehabilitate at home through the services of its home health division. These services provide individuals with the skilled nursing, therapy, social service and dietary assistance required to recover in the comfort of their own home. Beginning in 2014, Pyramid Home Health Services will begin providing comprehensive care transitions management under contract to health plans and hospitals operating in Missouri.
Many individuals are discharged to home without a specific need for traditional home health services but who are still at risk for complications that may lead to unnecessary ER usage or a re-hospitalization within 30-days of discharge. The key to avoiding this undesirable outcome lays in successfully managing those patients transition from the in-patient setting to the community. Pyramid Home Health Services Care Transitions is a 30-day program specifically developed to avoid ER usage and hospital readmission during that period. Specifically the program:
1- Makes in-person/ in-facility contact with patients at high risk for re-hospitalization prior to their discharge from the hospital. Pyramid Home Health Services staff develops a rapport with the patient and ensures they are knowledgeable of their condition, medical record, medications and, generally, their own responsibilities relating to a successful recuperation at home prior to their leaving the hospital. All patients receive a “Transitions Packet” containing vital information regarding their condition, warning signs and symptoms, discharge medications and instructions, the contact number for Pyramid Home Health Services’ 24×7 nurse line, their physician(s) contact information and follow-up visit dates, and list of the addresses and hours of operation of emergent care clinics nearest their home.
2- Conducts pre-discharge assessment of the safety and accessibility of the patient’s home and provides a written report to the patient’s following physician(s), the discharging hospital, and their health plan covering any identified safety hazards, barriers to self- care or family assisted care, and required home modifications or DME that may be necessary for a successful transition to home. Additionally, if necessary, Pyramid Home Health Services will coordinate orders and referrals for ancillary services, supplies and pharmacy and ensure any required services, supplies or medications are in the patient’s home upon their return.
3- Delivers a home visit within 48- hours of discharge, or sooner where required, to evaluate the return to the home process, the patients satisfaction with the same, address health questions and concerns, check vitals, and review medications and the patient’s knowledge thereof regarding regimen/ dosage(s)/ side effects. Where beneficial Pyramid Home Health Services provides tele-health based MTM (Medication Therapy Management) with a MTM certified pharmacist. Additionally, Pyramid Home Health Services staff reviews and updates the transitions packet, schedules necessary follow-up physician visits and/or ancillary care provider visits, arranges necessary transportation thereto and again reviews with the patient relevant condition warning signs/ symptoms. A written report of this visit is provided to the patient’s following physician(s), the discharging hospital and the patient’s health plan.
4- Within 48-hours of the initial home visit and no less than weekly thereafter Pyramid Home Health Services conducts check-up calls with the patient at pre-arranged times to review their stability at home and their satisfaction with the home transition process. Included in these calls is reminder of and verification of the patient’s making their required physician appointments. If necessary, Pyramid Home Health Services will conduct additional home visits should its calls to the patient or in-bound calls from the patient indicate a potentially worsening condition. Written report of these calls/ visits will be made available to the patient’s following physician(s), discharging hospital and health plan.
If you are a Missouri Hospital or Health Plan and would like to discuss contracting with Pyramid Home Health Services to manage the Care Transitions process for your patients and beneficiaries visit us at or call us at 888-880-6565.

Delivering the Right Care at the Right Time

The Institute of Medicine defines appropriate and affordable care as “Delivering the right care at the right time with the right provider in the right setting.” Technology enabled home health providers like Pyramid Home Health Services in partnership with Patient’s Physicians represent a uniquely well suited team to ensure delivery of the type of maximally coordinated and effective care contemplated in this definition. Within the operational perimeters of Affordable Care Act (ACA), these partnerships provide a distinct advantage for both Physician and Home Health company and, more importantly, for patients.

Nearly a quarter of Medicare beneficiaries have five or more chronic conditions. These individuals account for approximately two thirds of total Medicare Spending. As we’ve discussed in earlier blog posts, the care provided for these individuals, especially where they are dual eligible, is largely uncoordinated and disjointed. This is one reason why this population of patients is fully 100-times more likely to experience a preventable hospitalization than non- chronically ill Medicare beneficiaries. Under the ACA, failure to better coordinate and manage these patients’ care has a huge price tag for providers; particularly hospitals, in the form of readmission penalties and forgone revenue from “Shared Savings” opportunities. Additionally, failure to deliver quality outcomes can imperil long standing referral relationships as “At Risk” providers can ill afford to be further imperiled by low performing partners. Through the application of these economic consequences, the ACA is very definitely driving a strong shift up and down the continuum of care toward delivering desired outcomes at lower cost.

Embedded in the ACA are multiple opportunities for Physicians and Home Health Companies to work together to deliver better outcomes for chronically ill patients. One of the first areas evidencing this opportunity can be found in numerous Independence at Home Demonstration (IAH) programs. Basically IAH are Physician, Nurse Practitioner or Physician Assistant led house call programs. Under IAH guidelines providers are paid for their services but they have the opportunity to share in 80% of Medicare’s savings after meeting a minimum 5% total savings of the fee for service average for beneficiaries in their practice region. While the IAH demonstration specifically is only permitted to enroll up to 10,000 Medicare beneficiaries nationwide; its pay for performance metrics are embodied in numerous other ACA initiatives.

Where Medicaid is concerned, the ACA establishes the opportunity for State Medicaid plans to create Health Homes. Eligible beneficiaries are those who qualify for medical assistance under a state plan or waiver and who have two or more chronic conditions or who have a chronic illness and a concomitant mental health condition. We in Missouri were the first in the nation to establish health home programs and today they are operating within FQHC and CMHC state-wide. These initiatives couple per member per month payment for care coordination with the opportunity for states and providers to share in the Medicare savings resulting from better coordinated care.

The ACA additionally funds a vastly expanded national preventive health initiative. Annual physical examinations, health risk assessments, and personalized disease prevention services are all mandated to be fully covered for all Medicare beneficiaries.

In the healthcare landscape molded by the ACA, Pyramid Home Health Services represents a perfect practice extender for Missouri Primary Care Physicians. With new patients resulting from expanded insurance coverage generally as well as the aging of the baby boomer population, it’s going to be tough for Primary Care Physicians to meet the increased demands on their time. Through the use of Pyramid Home Health Services’ Nurse Practitioners, RN, and HIPPA compliant Tele-Health portals, these practitioners are enabled to see patients at home without incurring the expense and inefficiency of personally travelling from house to house. When cast from their offices these interactions are billable per the standard 2014 Physician Fee Schedule; so with Pyramid Home Health Services, Physicians can focus on those patients who are most critically in need of their personal, physical presence while also meeting the demands of their growing patient base by treating many of those patients in the comfort of their own home.

Where Physicians are participating in population health management strategies like IAH, Health Homes and under risk based contracts with managed care entities, utilizing Pyramid Home Health Services staff and its various monitoring technologies provides a powerful tool to identify issues prior to their becoming ER visits and hospitalizations. Where these relationships are concerned, Pyramid Home Health Services can work with these providers on a shared risk or per member, per month basis. Including in these arrangements are various levels of home monitoring, laboratory, referral to ancillary services and our MTM certified Pharmacists.

An effective partnership with Pyramid Home Health Services offers Missouri Physicians the opportunity to further their patient relationships by making themselves and their practices more available to all patients all the time; which is exactly in-line with the policy push implicit in the ACA, “To deliver the right care at the right time with the right provider in the right setting.”

If you are a Physician in Missouri and would like to talk further about how we can help you extend your practice into your patient’s home, visit Pyramid Home Health Services online at or call us at 888-880-6565.

Chronic Care Management

Let’s presume the starting point for a particular individual’s engagement with a Chronic Care Management program begins after transition from an inpatient stay back to home. As a part of the care transition process, the individual, optimally, is in possession of their healthcare record and understands their health status upon discharge. Using this baseline, the Chronic Care Management team can begin the long term job of keeping that individual in the community and avoiding acute events.

The core job of the Chronic Care Management team is to provide the extensive and ongoing supports required to help the patient and their caregivers handle obstacles that arise and have the potential to result in an exacerbation of their chronic condition. Success is measured in improved health and quality of life, reduced hospitalizations and ER visit, reduced duplication of diagnostic tests and decreased overall medical expenses.

The caseload management approach utilized by Pyramid Home Health services’ regional care teams, MSW/ LCSW, RN and MTM certified pharmacist coupled with para- professional care givers is a model that lends itself perfectly to the cause of Chronic Care Management. These teams are skilled in disease specific patient education. They actively manage the inflow of information from medication screens, tele-monitoring devices in patient’s homes and family caregivers and react as necessary. Where acute incident seem to be developing they communicate effectively with the patient’s broader medical team, intervene as necessary and stop the advancement of symptoms that can lead to the ER or a hospitalization.

Notwithstanding the capability of our credentialed team members, Chronic Care Management is not solely the responsibility of credentialed clinicians. For example, many chronically ill individuals know what they should be doing to control their disease(s). Many just don’t do it or they need help doing things like checking their insulin, remembering to weigh daily, take medication and make physician appointments. Sending a trained clinician to the home of these individuals daily to help with these sorts of issues is simply not cost effective over the long term. Sending one of Pyramid Home Health Services’ Para-professional care givers, utilizing our automated medication reminder call program, multi-dose medication packaging, pre-scheduling services for physician visits and assistance arranging transportation is. Matching the appropriate support and assistance to the most cost effective deployment thereof is an important part of an effective Chronic Care Management program.

Pyramid Home Health Services provides HCBS, Home Health and Pharmacy services for a large population of Missourians residing in both rural and urban areas. Our Care Management teams effectively serve patients in 110 Missouri counties daily. Should you require assistance implementing a Chronic Care Management Program or require the same for a family member, patient or patient population contact Pyramid Home Health Services at 888-880-6565 or visit us at

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.