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By: Stephanie Jackson  |  Type: Article  |  On: October 27, 2017

CMS’ Discharge Planning Proposed Rule and the IMPACT on Post-Acute Care Transitions

The IMPACT Act, which is still in the process of being implemented today, was an effort to standardize those assessments across all PAC providers, so that case managers and others would be able to compare apples to apples and make the best care decisions for their patients.

No one knows better than a case manager the importance of quality data to help facilitate a safe transition of care for our patients. Quality data includes accurate, relevant and current information about the patient AND the post-acute care entities. In September 2014, Congress passed the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. At the time, patient assessment data was standardized by provider type, but not across the different post-acute care (PAC) settings. So, a skilled nursing facility, a physical rehabilitation center, and other types of PAC facilities might have completely different sets of questions they asked during patient assessments, and different ways of recording that information. The IMPACT Act, which is still in the process of being implemented today, was an effort to standardize those assessments across all PAC providers, so that case managers and others would be able to compare apples to apples and make the best care decisions for their patients.

“In essence, the act seeks to standardize data elements used through various patient and resident assessment instruments by aligning certain data elements across instruments, to support our ability to measure and compare quality across the providers and settings of care,” said Patrick Conway, MD, MSc., CMS Acting Principal Deputy Administrator, and Deputy Administrator for Innovation and Quality, and CMS Chief Medical Officer, in a 2016 video from MLN Connects published on YouTube.1 “The act allows interoperability, which permits the seamless exchange of information across providers—not only PAC providers, but other providers who offer care to individuals as well. In the ideal state, important information would follow the patient, as services are delivered in hospitals and by physicians, long-term and PAC providers, and home- and community-based service providers. This will be a critical step towards coordinating care and proving Medicare beneficiary outcomes.” 

Certainly, the goals Conway mentioned are the same goals of case managers everywhere—to have a uniform way to measure and compare PAC providers in order to make the best possible decision for each patient based on his or her individual needs. But we’ve still got a ways to go.

In October 2015, just over a year after the introduction of the IMPACT act, CMS announced the Discharge Planning Proposed Rule, which would “revise the discharge planning requirements that hospitals, including long-term care hospitals and inpatient rehabilitation facilities, critical access hospitals, and home health agencies, must meet in order to participate in the Medicare and Medicaid programs,” according to CMS’ website.2 “The proposed changes would modernize the discharge planning requirements by: bringing them into closer alignment with current practice; helping to improve patient quality of care and outcomes; and reducing avoidable complications, adverse events, and readmissions.” Importantly, CMS says, the proposed rule would also, finally, “implement the discharge planning requirements” of the IMPACT Act.

Under the proposed rule, hospitals and critical access hospitals would be required to:

  • Develop a discharge plan within 24 hours of admission or registration;
  • Provide discharge instructions to patients who are discharged home (proposed for hospitals and critical access hospitals only);
  • Have a medication reconciliation process with the goal of improving patient safety by enhancing medication management (proposed for hospitals and critical access hospitals only);
  • For patients who are transferred to another facility, send specific medical information to the receiving facility; and
  • Establish a post-discharge follow-up process (proposed for hospitals and critical access hospitals only).

With already-heavy workloads, case managers are going to need sophisticated tools in order to be ready to meet these requirements when the rule takes full effect. For example, in order to develop a discharge plan within 24 hours as the proposed changes require, case managers will need to find a way to sift through information about hundreds of different PAC providers quickly and efficiently. Luckily, software solutions exist now that allow case managers and other hospital workers to do just that—a comprehensive database with contact and geographical information, quality scores, medical and non-medical resources, and corresponding financial information for a variety of PAC providers.

Another critical feature of such a database, when it comes to meeting the requirements of the new CMS proposed rule, is that both the clinical care team and the patient and family members can access the database to make sense of the choices available. That’s because the new rule has a lot more focus on taking into account the patient’s input in their own care. “The proposed rule emphasizes the importance of the patient’s goals and preferences during the discharge planning process. These improvements should better prepare patients and their caregivers to be active partners for their anticipated health and community support needs upon discharge from the hospital or post-acute care setting,” says the CMS website. “In addition, patients and their caregivers would be better prepared to select a high-quality post-acute care provider, since hospitals, critical access hospitals, and home health agencies would be required to use and share data, including data on quality and resource use measures. This results in the meaningful involvement of patients and their caregivers in the discharge planning process.”

Case managers are committed to providing the highest quality and most complete post-acute care information to our patients. We realize the importance of patient and family buy-in of the discharge plan and its direct impact on keeping the patients from being readmitted to the hospital, and I believe that most of my colleagues support the proposed rulings in the IMPACT Act to help make this a reality. We also know, however, that it’s really difficult to access current, clean PAC data (that we trust) in an efficient manner. We need a resource database that not only provides lists, qualifications and special offerings of post-acute care providers but offers quality scores to help assure the case manager is creating the best discharge plan. We have a ways to go, but I’m confident that this type of solution will blaze a new trail for our patients and care team members.

About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 

 

 

References:

1. https://www.youtube.com/watch?v=LQpGMg2-bhQ

2. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-10-29.html  

Read in about 6 minutes
By: Stephanie Jackson  |  Type: Blog  |  On: October 11, 2017

Fitting the pieces together: Why is choosing quality post-acute care so hard?

Have you ever tried putting together a 1,000-piece jigsaw puzzle with all the pieces facing upside-down? Picture this scene and you have some idea what it’s like to come up with a quality post-acute care plan for patients.

Have you ever tried putting together a 1,000-piece jigsaw puzzle with all the pieces facing upside-down? Do you think you could do it? How about if you have five other people at the table, jostling for space, elbowing one another, rearranging the pieces you had just organized, each with their own agenda and strategy for getting to the complete picture? And what if none of those people was talking to each other? Picture this scene and you have some idea what it’s like to come up with a quality post-acute care plan for patients.

When patients are admitted to the hospital, it can be scary for them and their loved ones. All they want is to get better. Dealing with a health crisis can be overwhelming, even before you add the pressures of thinking about what will happen after the patient leaves, who will pay for it, and what their quality of care will be like. Many patients and families can only focus on the moment of the acute health crisis.

According to a 2015 report, “Report to the Congress: Medicare Payment Policy,” from the Medicare Payment Advisory Commission,1 about three million Medicare beneficiaries are hospitalized for a serious condition and then discharged to a post-acute setting in the US each year. As case managers, we know that in addition to providing the immediate care each of those patients need, there are healthcare workers behind the scenes, gathering at the table to put the pieces of post-acute care and discharge together from the moment the patient walks through the door. Stakeholders include the case manager, the patient, his or her family, the entire care team, and even the payers. Due to the complexities of many discharges, sometimes it seems like each person involved has his own cluster of puzzle pieces and is trying to put the whole picture together without being able to look at what anyone else is working on.

Mary, a sweet, 70-year-old lady who was living independently before her stroke, wants to return home and live life the way it was prior to her event. Her sister Lisa wants her in a rehab facility close to where Lisa lives so she can visit and help out. Mary’s daughter Susan, who has two kids and a full-time job, is sick with worry about how the family will afford the care Mary needs. On the healthcare side, physicians are feeling pressure to discharge as quickly as possible to keep the “revolving door” open and empty the bed for the next patient who needs it; CMS is imposing limits on both how long Mary can stay and penalties if she is readmitted (often a result of being discharged too soon); and case managers are scrambling to find the post-acute care options that are amenable to everyone involved, but more importantly, offer the highest quality of care for Mary’s individual needs. In this tense situation, it’s easy to forget what the final image will look like—a tranquil scene where everything fits just right.

Oftentimes, it feels like there are just too many moving parts to keep track of. Post-acute care options are abundant: skilled nursing facilities, physical and occupational therapy, nurses to administer medications, equipment providers, home health care, and more. How does Mary’s case manager or family know which facilities are best for stroke recovery, which ones have the best doctors, the lowest readmission rates, and the best quality outcomes? How can anyone decide how all these disconnected pieces fit together?

For many years, the responsibility fell squarely on the shoulders of the case manager—it became his or her job to flip all the puzzle pieces over, separate and organize them, and direct everyone at the table to work towards a complete picture. This challenging task involved researching facilities for every individual patient, acting as a liaison between all stakeholders, and making decisions that meet everyone’s best interests.

FierceHealthcare reports that in September 2016, expert panelists at the California Associations of Physicians Group (CAPG) Colloquium recommended four steps healthcare teams can take2 to make this task more manageable:

  • Order an evaluation to explore the possibility of home health
  • When discussing next site of care, ask, “Why not home?” to ensure the topic is broached
  • Consider palliative care options, which may best be administered at home
  • Communicate closely during handoff to a post-acute care facility (or with home caregivers) for high-risk patients

To take these and other steps in the right direction, healthcare teams need the right tools and data to make the best decisions. A July 2016 article in Hospital & Health Networks, titled “Why Post-Acute Care Partners Are Critical to Hospitals' Future,”3 notes that hospital executives “lack the formal mechanisms that might enable direct control of post-acute care, so they must establish relationships, processes and infrastructure to achieve coordination and control with trusted post-acute care partners.”

Fortunately, recent technology has provided the processes and infrastructure required, making the task of choosing post-acute care more manageable. What is needed is a robust database that both the clinical care team and the patient and family members can access to make sense of the choices available. Such a comprehensive database—with contact and geographical information, quality scores, medical and non-medical resources, and corresponding financial information—is the only way to get everyone working together to build the complete picture.

Sometimes it can be hard to remember that everyone involved is building the same puzzle and working to the same end goal—the best possible care for the patient. With the right tools, together we can create a finished picture that we can be proud of, with pieces that interlock in precisely the right way.

 

About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 

 

 

References:

1. http://www.medpac.gov/docs/default-source/reports/chapter-7-medicare-s-post-acute-care-trends-and-ways-to-rationalize-payments-march-2015-report-.pdf?sfvrsn

2. http://www.fiercehealthcare.com/healthcare/send-patients-to-appropriate-post-acute-care-to-improve-outcomes

3. http://www.hhnmag.com/articles/7421-why-post-acute-care-partners-are-critical-to-hospitals-future

Read in 5 minutes
By: Stephanie Jackson  |  Type: ArticleBlog  |  On: October 02, 2017

It’s Not All About Reducing Length of Stay

If I’ve heard it once, I’ve heard it 100 times (a day), “How can we reduce the length of stay for our patients?” This question is increasingly becoming the Achilles’ Heel of a case manager’s discharge plan.

If I’ve heard it once, I’ve heard it 100 times (a day), “How can we reduce the length of stay for our patients?” This question is increasingly becoming the Achilles’ Heel of a case manager’s discharge plan. That, in combination with the pressures to reduce potentially avoidable readmissions, keeps case managers up at night. I believe the length of stay in a hospital is heavily correlated to a readmission. A premature discharge is just as risky as an admission that drags on unnecessarily, and I’ve always challenged hospital administrators on their constant pressure to discharge my patients as quickly as possible. Oftentimes, this strategy is counterproductive and results in patients being pushed out of the hospital too soon, causing them to end up right back in the emergency room.

Nationally, according to the Centers for Medicare and Medicaid Services (CMS), the average length of a hospital stay decreased by a significant 44 percent from nine days in 1990 to five days in 2014.[1] Now don’t misunderstand, we all agree the preference for patients and their families is to return to life outside the hospital as soon as possible. The longer the patient remains in the hospital, the greater the likelihood of an adverse event –  hospital acquired infections, medication errors, unnecessary and costly tests and procedures, falls, etc. That being said, we need to focus less on reducing length of stay and more on optimizing the treatment plans while the patient is hospitalized.

Granted, it’s hard to dispute the high costs of an extra day or two in the hospital. In 2014, the average cost per inpatient day was $2,346 at non-profit hospitals and $1,798 at for-profit hospitals.[2] However, the costs of a readmission are even higher. This is true, not only in terms of dollars, but from the patient’s perspective as well. A whole new set of tests are run, new medications with new side effects are prescribed, a more complicated discharge planning process occurs, and the emotional roller coaster associated with a readmission is stressful for everyone.  

A recent study out of New York[3] examined 12,341 admissions from 79 physicians to determine how a shorter length of stay impacts patient outcomes. The results were compelling and found that patient admissions from “short length of stay physicians” were associated with a significantly higher “30-day mortality”. Clearly, a premature discharge from the hospital can be dangerous to your health.

So, how do we optimize length of stay to achieve the best outcomes? Once again, we look to the case manager to coordinate the plan. The case manager is the quarterback. She must remain in constant communication with the patient’s entire care team from the minute the patient is admitted. She must listen carefully to the physicians’ proposed treatment plans, including the expected timing of the discharge and alert the team to potential barriers, especially the often overlooked impact of social determinants that can negatively influence the patient’s transition to the next level of care. Oftentimes, the case manager concludes that one or two additional days in the hospital will greatly lessen the chance of a readmission.

Of critical importance to the case manager’s successful care plan is access to the highest quality post-acute services available to the patient based on his personal situation: insurance coverage, financial means, family support, living arrangements, ability to resume his routine activities of daily living, etc. Often, the patient can safely return home if he has the support he needs.

One of my many memorable patients, Frieda, was a 90-year-old, highly independent woman who had a history of Congestive Heart Failure (CHF). She was admitted to the hospital with CHF exacerbation. We implanted a pacemaker, diuresed her through a medication adjustment, increased her oxygen requirements and educated her on her diet and salt intake. She was ready to go home. The medical team and her family, however, didn’t agree with Frieda’s plan. I remember her taking my hands into her own and pleading with me to help her return home. I convinced the team to postpone her discharge for a day and a half (despite exceeding the strict length of stay guidelines) to give me the opportunity to create a safe plan for my patient. Guess what? Frieda returned home, albeit with the support of many resources.

We need to constantly advocate for our patients, and now we can do just that, with tools and technology that didn’t exist a decade ago. I believe an optimal length of stay can be achieved with not only a carefully executed plan of care, but access to the latest technology and comprehensive medical and ancillary resources.


About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 


 

[3] J Gen Intern Med. 2015 Jun;30(6):712-8. doi: 10.1007/s11606-014-3155-8. Epub 2015 Jan 24. Increased Risk of Mortality among Patients Cared for by Physicians with Short Length-of-Stay Tendencies.

 

Read in about 5 minutes
By: Carelike Team  |  Type: Article  |  On: September 28, 2017

Readmission Costs Are Real and Case Managers Are on the Hot Seat

For those of us working in the U.S. healthcare system, the term “readmission” is heard on a daily basis, and it’s a term we don’t take lightly. For Case Managers and Discharge Planners, the term invokes a feeling of stress as we are responsible for making sure our patients are discharged with an airtight plan that will prevent a return to the hospital. The pressure is real.

For those of us working in the U.S. healthcare system, the term “readmission” is heard on a daily basis, and it’s a term we don’t take lightly. For Case Managers and Discharge Planners, the term invokes a feeling of stress as we are responsible for making sure our patients are discharged with an airtight plan that will prevent a return to the hospital. The pressure is real. The ramifications directly impact our jobs not to the mention the hospital’s bottom line and, most importantly, our patients’ quality of life.

The Affordable Care Act's Hospital Readmission and Reduction Program (HRRP) applies financial penalties for readmissions of Medicare patients that are higher than expected according to algorithms derived by the Centers for Medicare and Medicaid Services’ (CMS). The penalties are imposed against a hospital’s total book of Medicare business and constitute significant reimbursement reductions for hundreds of hospitals across the country. According to the Kaiser Family Foundation, total Medicare readmissions penalties will increase to $528 million in 2017, which is an increase of $108 million over 2016[1].

To reduce readmissions, we need to understand some basic facts. First, a readmission occurs when a patient is admitted to a hospital within a pre-determined time period (Medicare defines this time period as 30 days) after being discharged from a prior hospitalization and includes readmissions to any hospital, not just the one where the patient was originally hospitalized. Furthermore, Medicare doesn’t take into consideration cases where a patient is readmitted for a diagnosis completely unrelated to the original hospitalization. For example, if my mom’s discharge diagnosis was Congestive Heart Failure and she returns to the hospital due to a hip fracture, the hospital still gets dinged for a readmission.

Currently, the HRRP focuses on six conditions: heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), elective hip or knee replacement, and coronary artery bypass graft (CABG). CMS will likely continue to add conditions to this list to maximize savings and improve quality over time.

So, what does this mean for the Case Manager? If you consider the six conditions eligible for penalties, you can see that these are high acuity diagnoses in need of complicated discharge services. These patients often require one or more interventions including:

  • Transfer to a skilled nursing facility for more intense post-acute rehabilitation
  • Follow-up by a Registered Nurse for medication management, especially those with polypharmacy and/or high-risk medications, vital sign assessment, wound care, etc.
  • Physical Therapy/Occupational Therapy to regain strength after a hospital stay
  • Durable Medical Equipment (DME) such as oxygen, walker, wound care supplies, etc.
  • Home care to assist with Activities of Daily Living, transportation, shopping, etc.

CMS not only imposes stiff penalties for readmissions, but it has also established requirements regarding which facilities patients can be sent to, which home care agencies can follow patients and which DME companies can provide supplies. In addition, there is an important element to consider around the regulations of patient choice in making decisions for the post-acute care they require. Patients need access to information to make the most informed choices.

These criteria pose challenges for the Case Manager as she tries to coordinate services and comply with regulations while at the same time, remaining cognizant of the need to discharge the patients in a timely manner. What we lack, quite frankly, are the tools necessary to facilitate this process. We need a resource database that not only provides lists, qualifications and special offerings of post-acute care providers but offers quality scores to help assure the Case Manager is creating the best discharge scenario for the patient. Furthermore, it’s essential to understand the need for a database that captures both medical and non-medical providers. The non-medical resource team is just as vital as the medical team in restoring the patient to his or her level of independence prior to the admission. Armed with this type of information, Case Managers and Discharge Planners can tackle our readmission challenge and provide the highest quality care to our valued patients.

 

About Carelike

 

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 

 

[1] http://www.kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/

Read in 4 minutes
By: Stephanie Jackson  |  Type: Press Release  |  On: September 26, 2017

Carelike Recognized Among 2017 “Health Management Companies to Know” in Becker’s Hospital Review

Carelike, a next generation data and technology company providing national post-acute care resources and information to case managers, discharge planners, patients, and caregivers, has been selected as one of the top Health Management Companies to Know by Becker’s Hospital Review which highlights companies that make a significant difference in population health.

September 26, 2017—Atlanta, GA – Carelike, a next generation data and technology company providing national post-acute care resources and information to case managers, discharge planners, patients, and caregivers, has been selected as one of the top Health Management Companies to Know by Becker’s Hospital Review which highlights companies that make a significant difference in population health.

Carelike embodies this mission of improving care, particularly in the post-acute space, by offering more than 370,000 care providers and resources in its database. This data is available internally to all stakeholders involved in the patient’s care including physicians, case managers, and other providers in the hospital as well as externally, to caregivers, family members, and the patients themselves. Unique access to the data via custom web portals, a mobile app, and text messaging provides the information needed to transition patient care and achieve the best possible health outcomes in a seamless, efficient, user-friendly way.

“We are pleased to be recognized by Becker’s Hospital Review for our unique approach to gathering critical data from more than 400 sources along with our ability to deliver the information to the right stakeholders in the right moment. Post-acute care is increasingly in the spotlight in value based care and is an area that’s information-starved. We have the only platform of its kind that identifies, in real time, the right next step in the transitions of care journey. We believe addressing this information gap has the potential to make a greater impact on patient outcomes than virtually any other intervention a hospital, health system or advocacy group could implement today,” said Shae McBride, Vice President, Strategy at Carelike.

Carelike’s comprehensive database of post-acute resources spans the entire care continuum and is comprised of both medical and non-medical providers, including skilled nursing facilities, home health, physical and occupational therapy, medical equipment and supplies and community support programs. According to McBride. “It’s access to the right resources post-discharge, including non-medical services that have the largest potential for improving patient outcomes. Our Carelike platform is a must-have for any care provider seeking a solution for a safe, efficient and high-quality transition of care for the patient, the family and the entire care team.”

 

About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 

Read in 2 minutes
By: Carelike Team  |  Type: Article  |  On: September 19, 2017

So, What If It Was YOUR Mom Who Needed Care?

Throughout my years practicing as an RN Case Manager, I can attest to the often heart-wrenching challenges of families trying desperately to find the best care for their loved ones during unexpected, tumultuous health circumstances.

Throughout my years practicing as an RN Case Manager, I can attest to the often heart-wrenching challenges of families trying desperately to find the best care for their loved ones during unexpected, tumultuous health circumstances. Picture the frequent scenario where Mom is living alone, managing her life quite nicely with the support of family and friends, and suddenly she experiences an adverse health event – a fall, a new diagnosis, or a complication of her chronic illness that lands her in the hospital.

The family rallies its troops to coordinate plans to provide the support and strength needed to allow Mom to return to her prior level of independence at discharge. They rely on the resources of the hospital to help them craft the discharge plan. Namely, they look to the Case Manager for information on where to go, what to do and when to start the process. Every day, family members ask, “Can you please just let me know the best resources available for my mom to help her safely return home after discharge?” You’d think the answer would be, “Sure, together let’s research the best options based on readily available, accurate qualitative and quantitative data.” Unfortunately, most of us can’t say that. The data simply doesn’t exist and where it does, it’s stored in multiple, disparate siloes making it impossible to manage across a challenging patient census.

We are a data driven society. We research nearly every purchase, large or small before making a buying decision. We pour through Google searches, Consumer Reports, Amazon, etc., etc. to identify the best value for our money. We wouldn’t consider purchasing a car, a bike or even a skateboard without understanding the pros and cons of the item. Why then are we willing to accept the lack of performance, outcome and cost data on such personal, life-changing decisions as selecting the highest-quality care providers for ourselves and our loved ones?

 

Work In Progress (A Common Phrase in Healthcare)

We’re certainly making progress in several areas along the healthcare spectrum; hospitals and physicians are increasingly being ranked by organizations like the Centers for Medicare and Medicaid Services’ (CMS) Hospital Compare and Physician Compare websites and third-party reviewers like Healthgrades, ZocDocs, WebMD and others. Where we lack clean, accurate and reliable data is in the post-acute care arena - home health and private duty agencies, durable medical equipment companies, infusion, dialysis and wound care centers, assisted living facilities, etc. This integral part of the care continuum has largely been ignored despite its significant impact on quality of life as well as the sheer volume of the population requiring care. According to the U.S. Department of Health & Human Services, 70% of people turning 65 will utilize some form of long-term care during their lives whether skilled or custodial care, facility or home based, or community support services.

Post-acute care data decays rapidly, rendering it nearly useless to those of us who rely on current and complete information to execute optimal care plans for our patients. This data deficiency has historically resulted from a lack of standardization of healthcare data including cost and quality metrics on services outside the four walls of the hospital. The post-acute data issue is further exacerbated by high levels of staff turnover within these organizations, antiquated or absent technology and negligible operating margins with little wiggle room to invest in analytics. However, in the fee-for-service world, a hospital’s accountability for the patient ends at discharge, so the lack of post-acute data, while frustrating, doesn’t impact the hospital’s bottom line. As long as the Case Manager documents a safe transition plan to the next level of care, there will be no penalties imposed if the patient returns to the hospital due to a complication or discharge failure.

 

The New Post-Acute Paradigm –  It’s All About Outcomes

The advent of value-based care, including CMS’ Hospital Readmissions Reduction Program, Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), Medicare Bundled Payments for Care Improvement Initiative (BPCI) and other government and private payer value-based models, is turning the industry on its head. Providers along the entire care continuum must collaborate with each other and share data to help improve care transitions, care delivery, patient outcomes and the patient experience or face stiff financial penalties, patient dissatisfaction, provider disengagement and a breakdown of the system.

The aforementioned initiatives represent only the tip of the iceberg for the healthcare industry in terms of new regulations, new models of care and the resulting new data requirements to validate program effectiveness. I’m hopeful the proposed changes to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) will soon be a reality. This act, designed to improve transparency and patient experience during the discharge planning process, will require hospitals and post-acute care providers “to use data on both quality and resource use measures to assist patients during the discharge planning process, while taking into account the patient’s goals of care and treatment preferences”. 

That all being said, I’m confident that every hospital, payer or other risk-bearing entity, family member, and patient would agree that a unified, comprehensive database of current medical and non-medical services and the corresponding financial arrangements and quality indicators is a necessary component to achieving the best medical, behavioral and social outcomes for those we serve. Since I left my role as a hospital discharge planner in 2012, a wide variety of new applications and databases have emerged as potential solutions to this dilemma.

In fact, it is now possible to imagine a world where Mom’s transitional healthcare needs are carefully and deliberately matched to providers through real-world, evidence-based data.

Can your organization provide this needed service for your patients?

Please feel free and reach out to me directly to share your own experience in optimizing care within the realities of healthcare today. I’d love to hear how your organization is helping to accomplish this lofty goal while traversing the rocky road to value-based care.

 

Contact Carelike to help improve the efficiency of discharge care.

 

For more information about Carelike, please contact Katy Weisbrodt:

O: (404) 250-8376   |   C: (770) 851-8653   |   kweisbrodt@carelike.com   |   www.carelike.com/hospitals


About Carelike

Carelike's extensive database of medical and non-medical transition care providers allows your discharge team to improve their efficiencies. Provider data is augmented with proprietary professional quality metrics as well as CMS scoring. Our technology provides ease of use standalone portals or EHR integration to help discharge teams select the best care providers. 

 

Organize your patient and family communication with our CareTrait technology. Comply with CMS initiatives including the proposed patient discharge IMPACT Act rule and significantly reduce the burden on this already over-stretched group of professionals. The solution greatly improves communication between discharge teams, patients and families and prioritizes preferred community-based services enabling the case manager to fulfill their responsibilities while improving care coordination. 

 

 

Read in about 6 minutes
By: Carelike Team  |  Type: Article  |  On: September 15, 2017

Wait, What? He’s Being Discharged Tomorrow?

These words elicit a wide range of emotions based on whom they’re being spoken to and the preparedness of the responsible parties including the discharge planner, the patient’s family and of course, the patient himself. The discharge planner silently chuckles with doubt as she sits in the multidisciplinary rounds

These words elicit a wide range of emotions based on whom they’re being spoken to and the preparedness of the responsible parties including the discharge planner, the patient’s family and of course, the patient himself. The discharge planner silently chuckles with doubt as she sits in the multidisciplinary rounds and hears these words from the powers that be, knowing full-well the ensuing challenges of a successful discharge within 24 hours. The family members nod in cautious agreement while reeling with fear of the unknown. Who will care for their loved one? What services will he need? What costs will be incurred? The patient is either excited, clueless or filled with trepidation. 


Those of us who share the title of Case Manager, Care Manager, Discharge Planner, etc. and are licensed as a Registered Nurse or Social Worker are part of a club that’s small but elite, powerful yet not always respected, and resourceful but often lacking necessary resources. We’d all agree there are basically three types of discharges: Piece of Cake, Bit of a Challenge, and the Total Train Wreck. While we all love those Piece of Cake patients with the perfect, loving, caring family and a simple medication cocktail ordered at discharge, we also know that the Challenge and Train Wreck discharges are imminent and will require time, energy and patience. 

And, we’re working in an environment riddled with uncertainty, constantly changing regulations and more “disruptive” new government and private payer initiatives than ever before including the “volume to value” conundrum which instructs us to prevent inappropriate admissions and readmissions while at the same time understanding that “heads on beds” yields money and frankly our job security. The Centers for Medicare and Medicaid Services’ (CMS) 30-day readmission penalties are at the forefront of hospital executives’ agendas due to the significant financial penalties they can potentially impose on a hospital.


Furthermore, as a result of the evolving trend towards ambulatory care, the vast majority of hospital inpatient admissions are those with very clinically complex conditions. Yet, hospitals continue to carefully monitor lengths of stay to optimize reimbursement which further complicates the discharge process and shortens the amount of time the case manager has to create a safe and efficient transition to the next level of care whether that be to a long-term acute care facility, a skilled nursing facility, or home with some level of professional or custodial support.

To further support the radical changes in the industry, CMS is proposing amendments to the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) which defines initiatives and measures to improve the quality of post-acute care. According to CMS, “The IMPACT Act requires hospitals, critical access hospitals, and certain post-acute care providers to use data on both quality and resource use measures to assist patients during the discharge planning process, while taking into account the patient’s goals of care and treatment preferences.” Participation in the Medicare and Medicaid programs will be dependent on aligning with these new requirements. 

So, where do we go from here? A quick “Discharge 101” lesson will confirm the challenges those of us in the field face every day and should also help those unfamiliar with the process understand the complexities and roadblocks we face in facilitating transitions along the care continuum. 

The formula for a successful discharge plan:

  1. Is initiated immediately upon admission through a comprehensive assessment of the patient’s needs including family support, living arrangements, equipment needs to help with activities of daily living (ADLs), financial considerations and insurance coverage
  2. Considers not only the patient’s medical and emotional needs but also the social determinants that impact the discharge in ways that are often grossly underestimated
  3. Has buy-in from the patient, family and medical team

Once the plan is established, it’s time to execute the various action items. This is where the “fun” comes in for the discharge planner. Imagine Freddie, our “Bit of a Challenge” patient who was admitted on Monday, and according to the medical team is ready for discharge Friday. Freddie is a 91 year old, feisty gentleman with a history of COPD, degenerative disc disease and diabetes. To top it off, Freddie lives alone in a two-story house, has family who occasionally checks on him, relies on the city bus system for transportation and enjoys his bourbon.  The case manager is tasked with taking each of these considerations into account and formulating a plan that will enable a safe discharge and prevent a readmission. (And, by the way, we are held accountable for inappropriate readmissions and are measured against this metric in our reviews…)


Freddie will need the following minimal level of services to successfully transition out of the hospital:

  • Home Health Care: RN to monitor for medication adherence, check vitals, etc.; a dietician to advise on his food intake to manage the diabetes and coach him on the effects of alcohol on his blood sugar; and PT/OT to perform a home safety evaluation and educate him on the importance of a safe exercise routine
  • Durable Medical Equipment: Oxygen due to his worsening COPD; a wheeled walker; diabetic supplies
  • Home Care (Private Duty): Nurse’s aide to assist Freddie with bathing, cooking, shopping, finances
  • Transportation and other ancillary support services: Referral to the Area Agency on Aging

Keep in mind that Freddie isn’t even a Train Wreck patient, and he’s only one of 15-20 plus patients on the case manager’s census needing to be followed throughout the admission. 

So… it’s no surprise that the discharge is a lengthy, complicated and often stressful process and is typically left to the case manager to coordinate all of these care interventions and services. Unfortunately, while we possess strong critical thinking skills and are multitasking masters, we lack the tools necessary to effectively perform our responsibilities. 

If you speak with any care manager, you’ll find that with all the increased legislation, measurement and oversight, their responsibilities have drastically increased – while there are still only so many hours in a day. What many people may not know is there is hope on the horizon. There are now innovative software and database applications that have the power to streamline and organize information – helping you to identify the most appropriate next level of care with just a few clicks rather than spending hours of research and coordination. As you can tell, I’m very passionate about the critical role that care managers play in the care continuum. Please feel free and reach out to me directly if you’d like any additional information or if I can help you in any way. In the meantime, here’s hoping for more Pieces of Cake, and fewer Train Wrecks!
 

How accurate and up-to-date is your organization’s post-acute and community care data? 
For more information about Carelike, please contact Katy Weisbrodt:
O: (404) 250-8376   |   C: (770) 851-8653   |   kweisbrodt@carelike.com   |   www.carelike.com/hospitals  

About  Carelike
Carelike provides a national database consisting of more than 370,000 post-acute and community care providers that allows the case manager to more efficiently locate all the necessary providers required for a safe discharge and takes into account the patient’s medical needs, social needs, and financial constraints. 
In addition, our CareMatchTM technology will help hospital case managers comply with CMS initiatives including the proposed patient discharge IMPACT Act rule which significantly reduces the burden on this already over-stretched group of professionals. The solution greatly improves communication between the hospital and community-based services and enables the case manager to fulfill her responsibilities and coordinate care with each of the various stakeholders involved in the discharge.

Read in 6 minutes
By: Stephanie Jackson  |  Type: Article  |  On: May 08, 2017

Leveraging CMS reimbursements for post-acute and chronic patients

With proper billing-code utilization and the right care-coordination technology to match the best providers with care seekers, physicians and health care organizations involved in the discharge planning and care coordination of chronic and post-acute patients can be reimbursed for these services.

Since 2015, the Centers for Medicare & Medicaid Services (CMS) has been reimbursing doctors and health care organizations for providing chronic care management. Unfortunately, many organizations are not receiving this reimbursement and may be missing out on federal funding for some of the sickest Medicare beneficiaries. With proper billing-code utilization and the right care-coordination technology to match the best providers with care seekers, physicians, and health care organizations involved in the discharge planning and care coordination of chronic and post-acute patients can be reimbursed for these services. 

What are the CMS reimbursements?

As reported by ModernHealthCare, CMS made payments for chronic-care claims for just 513,000 Medicare beneficiaries of the approximately 35 million individuals eligible for this program. (To be eligible, individuals must have two or more chronic conditions.) Some of this gap stems from physicians' overall lack of awareness of the billing code for care management. However, by speaking with physicians, coordinating chronic-care services and using the right care-management billing codes, CMS will reimburse physicians and health care organizations for their time. 

The source noted that approximately 70 percent of Medicare beneficiaries have two or more chronic conditions. Examples of the covered conditions include, but are not limited to:

  • Alzheimer's disease and related dementia.
  • Arthritis (osteoarthritis and rheumatoid).
  • Asthma.
  • Diabetes.
  • Hypertension.
  • Depression.
  • Cancer.

Hospitals that partner with acute care nurses, discharge planners and care coordinators can take advantage of the average $42 per patient per month reimbursement for chronic-care service coordination and specialist consultations.

As noted in ModernHealthCare, another reason some health care providers are not taking advantage of this opportunity is due to the necessary written patient permission for the reimbursements. However, the 2017 add-on now eliminates the need for written consent and allows a verbal okay from patients.

According to CMS, the payable CCM service codes include:

  • CPT code 99490: covers 20 minutes of clinical staff time once a month for patients with two or more chronic conditions at significant risk of death or functional decline. The chronic care management services are required to have established, implemented, revised or monitored a comprehensive care plan.
  • CPT code 99487: covers 60 minutes per month of clinical staff time for complex chronic care involving moderate or high complexity medical decision making.
  • CPT code 99489: covers additional 30-minute block for qualified clinical staff time, once per month.
  • HCPCS code G0506: an add-on, covers qualified clinical staff time for the initiating visit with a patient to develop a comprehensive assessment and care plan.

Some of the services included under the CCM cover:

  • Continuity of care with designated care team members.
  • Comprehensive care management planning.
  • Transitional care management.
  • Coordination with home- and community-based clinical service providers.

Qualified clinical staff include:

  • Physicians.
  • Certified nurse midwives.
  • Clinical nurse specialists.
  • Nurse practitioners.
  • Physician assistants.

CMS also noted that CCM services are priced in both facility and non-facility settings, including skilled nursing, nursing, assisted living or other facility settings.

Reducing patient hospital readmittance

Patient readmittance in the first 30 days results in a CMS reimbursement penalty, so it's imperative that discharge nurses have top quality care providers for post-acute and chronic patients.

Unfortunately, research studies showed that 17.3 percent of Medicare fee-for-service patients aged 65 and over were readmitted within 30 days in 2012, according to the National Health Statistics Report. Readmissions occurred due to care coordinators poorly managing transitions during discharge, infections or complications caused by the hospital stay or the reappearance of the condition that led to the hospitalization in the first place.

Reducing readmissions falls on care coordinators in charge of locating care providers with the skills and qualifications that best suit the needs of the patient.

To accomplish this, care coordination companies, such as hospitals or health IT companies, are building discharge-planning software. However, these platforms need a robust database of talented and experienced care providers to ensure post-acute and chronic patients recover quickly and do not need readmittance.

 

Care coordinators need to reduce the hospital readmission rate of chronic patients.

Care coordinators need to reduce the hospital readmission rate of chronic patients.

Follow-up calls between visits to primary care physicians

One way to help reduce the chances for chronic and acute patient readmission is to provide ongoing treatment and care following a hospital discharge. This enables an open dialogue and regular visits to ensure the patient is following the physician's recommendations. 

Individuals receiving ongoing treatments from their primary care physicians and suffering from two chronic conditions need extra care providers in between doctor visits. Aligning these care services along with the CMS reimbursement is important to capture lost revenue opportunities.

How Carelike can help

Sometimes the biggest obstacle to taking advantage of the CMS reimbursement is finding the best-suited care providers to deliver post-discharge and follow-up services. Matching a nurse without the right qualifications can lead to readmission, which penalizes the reimbursement. Often, as noted by the Center for Healthcare Quality & Payment Reform, the inability to receive good primary care support in the local community is a main contributor to preventable readmissions.

Care coordinators arranging for discharge planning or long-term follow-up services for chronic patients need easy access to a wide range of care providers. Further they need the ability to accurately tailor their searches to locate the most appropriate health care professional to align with unique care seeker needs. By identifying the best local care providers for managing post-discharge chronic care patients, hospitals can reduce their readmission rates and ensure they're receiving the full CMS reimbursement.

Carelike creates a custom portal for care coordinators, who can then use licensed data that focuses on either national or local/regional care providers. Hospitals that already have their own systems can rely on Carelike's API that simply plugs into existing systems for easy access to the extensive database.

Using Carelike's dashboard, care coordinators can easily track patient statuses, add noted, document care transitions and take advantage of the extensive database of providers who all manage chronic and post-acute conditions. This provides an additional layer of context during the transition phase that's crucial for communicating additional information about patients.

Companies in the process of building a software solution to meet the growing need of matching care providers with care seekers could benefit from using the Carelike database.

Carelike provides the technology and resources to help hospitals, health care organizations and care coordinators take advantage of CMS reimbursements for chronic care and post-acute care management. Click here to learn more about Carelike.

Read in 5 minutes
By: Stephanie Jackson  |  Type: Blog  |  On: September 21, 2017

Home Safety Checklist

Your house can too easily turn into a maze of hazards for your loved ones.

Your home is your safe haven, but for seniors or those with a chrronic illness, a house can too easily turn into a maze of hazards. In fact, according to the National Institute of Health, 60 percent of falls occur at home, but these incidents may be preventable. If you're caring for a loved one,  there are steps you can take to create a sound living environment. Use this checklist as your guide for making modifications for a happier, healthier home:

1.  Ensure home has adequate lighting

No matter how good your eyesight is, maneuvering in the dark is next to impossible. Keep others safe by equipping the home with adequate lighting. Go around the house and check for burned-out bulbs and replace them as necessary.

Additionally, consider the overall lighting structure. Walk through the house at night with the lights on, and see where the home could use some brightness. Perhaps one hallways is particularly dark, or you have to walk upstairs before being able to turn on the second-level light. In this case, you might benefit from bringing in an electrician who can install light fixtures in these spaces.

 

2.  Install grab bars to promote safety at home.  (Fall-proof the bathroom)

The bathroom is one of the most common places for falls due to activities like climbing in and out of a tub and stepping on wet surfaces. According to the U.S. Centers for Disease Control and Prevention, the older someone is when they slip in this room, the greater their risk for injury.

It only takes a few modifications to make the bathroom a little safer. Consumer Affairs advised installing grab bars near the tub and toilet. Remember, towel racks are not a replacement for grab bars, as they are not as sturdy and could easily dislodge from the wall under a person's weight.

To prevent falls in the shower itself, use non-slip bath mats or considering placing a shower chair in the tub. The latter option is especially beneficial for seniors who have trouble balancing.

3.  Clean up

This simple task holds a lot of importance. Straightening up a home by clearing clutter, tucking away electrical cords and bringing stools back next to the table they belong to can go a long way in reducing the risk of tripping. The National Safety Council also advised wiping up spills as soon as they occur to prevent the senior from slipping on a wet surface.

4.  Remove un-necessary decor

Throw rugs are also a common cause for falls, as seniors may trip over their raised edges. Make sure rugs stay flat to the ground, or get rid of them altogether. You can certainly make someone feel accepted in your home without a welcome mat!

Read in 2 minutes
By: Stephanie Jackson  |  Type: Article  |  On: May 01, 2017

How to effectively communicate with a care provider

As a patient, your relationship with a care provider is essential in recovery, preventing disease and maintaining your overall health.

As a patient, your relationship with a care provider is essential in recovery, preventing disease and maintaining your overall health. This is especially true if you are seeking home health services. Although health professionals can run tests and observe your medical data to reach conclusions or diagnoses and offer treatment, a lot of investigatory work they do comes from effective communication with you or your loved one.

Why communication matters in health
Many patients don't realize how much power they have in determining their own health outcomes, and a lot of that starts with the way they communicate with care providers. Patients actually have more access to information about preventative disease, alternative medicine, and traditional treatments than ever before with the internet as well.

That's why, according to the Family Caregiver Alliance, many medical professionals are now seeing the doctor-patient relationship as a partnership. The Johns Hopkins Bloomberg School of Public Health also concluded that communication between doctors, patients, and their families actually improves patient health because they are more engaged and knowledgeable.

 

Come prepared to talk about your medical history with your care provider.

Come prepared to talk about your medical history with your care provider.

That means that you need to prepare for your medical appointments, break down barriers between yourself and your caregivers, and learn how to adequately communicate with medical personnel in a meaningful way. Not only does this remove the risk of medical error on their end, but it also helps you become better educated in your own health.

Learning how to communicate with health professionals
Communicating about your medical history with someone you just met might seem a little daunting, but there are ways to remove those barriers. Here are a few tips to help you prepare for your next appointment:

  • Have a list of questions prepared beforehand: In the days leading up to your appointment, write down some of the lingering questions you have about a certain condition or your general health. This ensures you don't leave anything important out, and it makes the appointment flow much more smoothly.
  • Think about bringing along a family member or friend for support: This can be especially helpful for those with physical disabilities or patients with cognitive decline. These individuals can keep notes about your care professional's treatment recommendations and also help you remember details about your medical history.
  • Be honest about your medical history: In order for your doctor to make the right recommendations, he or she will need to have a full and clear account of any conditions you may have struggled with in the past, whether they are physical, emotional or mental.
  • Include details about your mental health: Far too many people put their mental health on the back burner, but this aspect of your well-being is just as important in your recovery. If you have been noticing a cognitive decline or symptom of dementia, your care professional needs to know. Tackling these issues early on is key to prevention, and it starts with communication.

Clear communication with your doctor isn't just important for medical professionals, it's also imperative in keeping your health in the best shape possible moving forward. 

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