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Implementation of Timely and Effective Transitional Care Management Processes
The document outlines the implementation of effective transitional care management processes by the Weitzman Institute aimed at improving patient outcomes through follow-ups on ER visits and hospital discharges. It details the roles of healthcare professionals involved in the care process, identifies opportunities for improved data reporting, and describes best practices for centralized notifications of hospital events. Additionally, it emphasizes the importance of integrated care team meetings in managing patient care and provides supporting information on training for health centers nationally.
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Implementation of Timely and Effective Transitional Care Management Processes
- 1. Implementation of Timelyand Effective Transitional Care Management Processes Tuesday, March 21, 2023 3:00-4:00pm Eastern / 12:00-1:00pm Pacific 1
- 2. Continuing Education Credits Insupport of improving patient care, Community Health Center, Inc. / Weitzman Institute is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. A comprehensive certificate will be available after the end of the series, Summer 2023. 2
- 3. Disclosure • With respectto the following presentation, there has been no relevant (direct or indirect) financial relationship between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which would be considered a conflict of interest. • The views expressed in this presentation are those of the presenters and may not reflect official policy of Community Health Center, Inc. and its Weitzman Institute. • We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under investigation (not FDA approved) and any limitations on the information hat we present, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion. • This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $137,500 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. 3
- 4. At the WeitzmanInstitute, we value a culture of equity, inclusiveness, diversity, and mutually respectful dialogue. We want to ensure that all feel welcome. If there is anything said in our program that makes you feel uncomfortable, please let us know via email at [email protected] 4
- 5. National Training andTechnical Assistance Partnership Clinical Workforce Development Provides free training and technical assistance to health centers across the nation through national webinars, learning collaboratives, activity sessions, trainings, research, publications, etc. 5
- 6. Speakers • Mary Blankson,DNP, APRN, FNP-C, FAAN • Chief Nursing Officer, Community Health Center, Inc. • Veena Channamsetty, MD, FAAFP • Chief Medical Officer, Community Health Center, Inc. • Bibian Ladino-Davis • Behavioral Health Coordinator, Community Health Center, Inc. 6
- 7. Objectives • Describe processesfor following up on ER visits and hospital discharges, including roles and responsibilities • Discuss a best practice for centralized notification of ER visits and hospitalizations • Review other use cases for managing centralized notifications of hospital events: • Risk stratification and management - Integrated Care Team Meetings • Report of death of a patient and caring for the family 7
- 8. Areas Identified asOpportunities • Prior to 2016 - Decentralized sources of data where notification of ER visits and hospitalizations was provided to care teams directly through discharge notifications and ER visit notes, rather than a central source disseminating the information with robust processes • Standardized processes for reporting death of a patient • Consistency around Integrated Care Meetings to support our most complex patients • Standardized workflows to update and document in the EHR with regard to care transitions 8
- 9. Daily Follow-up onER Visits and Discharges 9
- 10. Daily Follow-up onER Visits and Discharges • CHC processes have evolved over time to reflect our priorities as well as our evolving understanding of our patient population and their use of the ER and hospital. • Overview: The BI Department sends a list of CHC patients to Bamboo Health on a monthly basis who have had a medical visit in the last 12 months OR who are on a Value Based Roster regardless of last visit date. • This ensures that we are notified if a patient visits a hospital for an ER visit or admission. • While Bamboo Health has an app that some groups use to manage their patient workflow in the hospital, we instead ingest a file with that information on a daily basis so that a file with a list of patients is distributed each morning. 10
- 11. Daily Follow-up on HospitalDischarges Triage nurses call each patient who meets certain criteria (e.g., Value Based Roster patient, specific dx, etc.) and, using a structured template, ask the patient a series of questions: 1. Why were you hospitalized? 2. How are you feeling today? 3. Were you discharged with any new meds to take at home? If yes, what are they? 4. Do you have any nurses or therapists visiting you at home? 5. Were you told to schedule appointments with any doctors besides your primary care provider? If yes, who? 11 • Nurses make up to three attempts to reach the patient by phone. Note: Bamboo Health does at times, provide a new phone number for the patient based on what the patient reported at the hospital and this can be valuable! • This same list of patients is also sent to the MA and they retrieve the hospital discharge note and scan into chart. • Our follow up rates are about 54% which is well above the rates for other health centers in our state (43%) and the Medicaid rate of 38.5%. • This information can be reviewed by the provider during the post-hospital visit.
- 12. Daily Follow-up on HospitalDischarges 12 Other uses of Hospital Discharge Information 1. Complete SDoH (PRAPARE) with patients who had a hospital discharge by the Triage Nurses. 2. Mail a congratulations card to new moms upon the notification of a birth. 3. Alert in NOVO so that if a patient was high risk/who met certain criteria (e.g., multiple ER visits; recent hospitalizations; high risk score) the PSA would delegate the call to Triage to talk with patients.
- 13. Daily Follow-up onER Visits • MA reviews the list and notifies PCP of any ER visits that require follow up • Other uses of ER information 1. For pediatric patients with an ER visit for asthma, a text message is sent to the patient to encourage them to schedule follow up with PCP (if a visit is not already scheduled) 2. For patients in a value based program that requires complex care patients who meet certain criteria to have follow up we send a text message to patient to schedule follow up visit 13
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- 16. Bamboo Health Process 16 •All patients in a Value Based Program • All patients who are discharged for COPD, Diabetes, Asthma, Hypertension, Delivery of newborn, Poisoning; F code (all BH diagnoses) Consider whether there are sufficient resources to follow up on all hospital events. Prioritizations may include: Other considerations
- 17. Special Considerations 17 Patients whohave not been seen in the last 3 years School Based Health Center patients who do not have CHCI as their PCP Other opportunities – upon patient admission to ER or hospital
- 18. Report of Deathof a Patient Process 18
- 19. 19 Notification of a PatientDeath • Weekly report of patients who, according to Bamboo Health, have passed away the prior week AND/OR whom we were notified about a patient’s passing. • The report includes: • Patient ID and Name • Date of passing • Hospital/facility • PCP • PCP Site • The report is disseminated to the Operations Managers, Senior Program Manager for Population Health and the Senior VP/Clinic Director.
- 20. 20 Response upon Learning ofthe Death of a CHC Patient Procedure addresses: • Sympathy Calls or Cards • Ensure family members are supported • Opportunity to offer further supportive services • Clarity on when calling family members is appropriate • Deactivation of the Patient Chart: • Ensures canceling of follow up calls and reminders • Updates the E.H.R status
- 21. 21 Response upon Learning ofthe Death of a CHC Patient Sympathy Calls or Cards to Family Member AND Contacting the family member would NOT be inconsistent with any prior expressed preference of the patient. Either: The family member was involved in a supportive and positive manner in the patient’s care per the professional judgment of the patient’s provider, or The patient signed a Permission to Share form allowing CHC to communicate with the family member about the patient’s care; Provider may call or send a written communication to the patient’s family member to express sympathy if all of the following criteria are met:
- 22. 22 Response upon Learning ofthe Death of a CHC Patient Deactivation of the Patient Chart 1. The staff person who is notified creates a telephone encounter (TE) with reason of “Report of Death”. TE is sent to site’s Operations Manager (OM). •The Provider or OM may enter details of the patient’s passing. •Information must include the date of passing •TE serves as documentation of passing. 2. OM cancels all future appointments and suppresses all recalls 3. IF TE was not generated by PCP, OM assigns TE to PCP as FYI •PCP may assigns to relevant BH or Dental provider if applicable for review/FYI •PCP/BH/Dentist assigns back to OM 4. OM updates the patient records as “deceased” to inactivate the patient’s chart 5. Any documentation about the patient death is scanned into patient record by the OM 6. OM marks TE as addressed
- 23. Integrated Care TeamMeetings 23
- 24. Integrated Care TeamMeetings • The purpose of the Integrated Care Meeting (ICM) is to coordinate a comprehensive plan to address risk factors impacting the health and well-being of our patients. Input from all team members is shared at these meetings to support optimal patient outcomes. • A dedicated Behavioral Health Coordinator is responsible for coordinating ICM at every site once a month for patients identified as high risk who would benefit. 24
- 25. Integrated Care Meeting: CHCCriteria for Patient Selection • Patients with a high risk score who have a PCP and BH Provider in common • Patients with recent hospital discharges or ER visits • Patients with recent discharge for BH diagnoses • Patients identified by PCP 25
- 26. Integrated Care Meetings •7 to 10 ICMs are held per month at different sites • 3 to 9 patients discussed at each ICM • PCP, BH Provider, Nurse, MA and other staff are present with psychiatric providers attending as feasible 26
- 27. Patient Primary Care Provider Behavioral Health Provider RNand/or MA Behavioral Health Care Coordinator Patient Case Study 27
- 28. • PCP Report: •Alcohol use disorder • Morbid obesity and is medically fragile • Behavioral Health Provider Report: • Last seen in therapy 4 months prior and recommended the patient return to therapy. • Auditory hallucinations, depression, anxiety and inconsistent part of suboxone program. • Recent hospitalization for chronic alcoholism, cardiac problems, seizures • RN and/or MA Report: • Patient due for any vaccines, labs, or DIs • Preventive care screening (Pap Smear, mammograms, colonoscopy, etc.) • Behavioral Health Care Coordinator: • Patient declined SDOH screening • As a result of the ICM, the patient was referred to CHW and outreach to patient to reengage in therapy. • Information about medications prescribed outside of CHC by external provider, added to medication list by Pharmacy Team • Collaboration between CHW and RN resulted in a motorized wheelchair for the patient Patient Primary Care Provider Behavioral Health Provider RN and/or MA Behavioral Health Care Coordinator Patient Case Study 1 The Patient: •45 year old male who is cared for at our homeless shelter site •Selected for discussion because of his high risk score (11.4, where 1.0 is the average risk score) from the payor. 28
- 29. • PCP Report: •Reported the patient had a history of osteoporosis, cannabis use disorder and memory problems. • Behavioral Health Provider Report: • Patient had PTSD; anxiety, borderline personality disorder and major depression. • Engaged in therapy (last seen the week prior) but BH provider indicated patient would benefit from a higher level of care. • Patient prefers to stay with CHC given the time going to IOP would be too much. The patient was also engaged with psychiatry at CHC. • RN and/or MA Report: • Patient due for any vaccines, labs, or DIs • Preventive care screening (Pap Smear, mammograms, colonoscopy, etc.) • Behavioral Health Care Coordinator: • Patient completed SDOH screening • The patient was referred to a CHW to support visit adherence. • Patient presented to PCP differently than to BH provider. Essential to have the discussion with all members of the care team. • Identified free transportation program to ensure access to the site. Patient Case Study 2 The Patient: •63 year old female selected for ICM b/c high risk score, 11.4. Patient Primary Care Provider Behavioral Health Provider RN and/or MA Behavioral Health Care Coordinator 29
- 30. Today's presentation covered... • The processes for following up on ER visits and hospital discharges • A Best practice for centralized notification of ER visits and hospitalizations • Managing centralized notifications of hospital events: • Integrated Care Team Meetings for risk stratification and management • Report of death of a patient and caring for the family 30
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- 32. Contact Information 32 For informationon future webinars, activity sessions, and learning collaboratives: please reach out to [email protected] or visit https://www.chc1.com/nca
Editor's Notes
- #2 Bianca (3:00-3:02) Would the audience want to know how many people are in the triage department? How many people does it take? How many discharges?
- #3 Bianca (3:00-3:02)
- #4 Bianca (3:00-3:02)
- #5 Bianca (3:00-3:02)
- #6 Bianca (3:00-3:02)
- #7 Bianca (3:00-3:02) Tierney
- #8 Mary (3:03-3:21) Describe processes for following up on ER visits and hospital discharges, including roles and responsibilities Discuss a best practice for centralized notification of ER visits and hospitalizations Other use cases for managing centralized notifications of hospital events: -Risk stratification and management - Integrated Care Team Meetings -Reports of patient passings, caring for the family
- #9 Mary (3:03-3:21) elements were in place of course—but definitely time for a new look Prior to 2016 - Decentralized sources of data where notification of ER visits and hospitalizations was provided to care teams directly through discharge notifications and er visit notes, rather than a central source disseminating the information with robust processes
- #10 Mary (3:03-3:21)
- #11 Mary (3:03-3:21) Speak to joys and concerns
- #12 Mary (3:03-3:21) Hospital Discharges – -Triage Nurses call each of the patients who meet certain criteria, (e.g., Value Based Roster pt, specific dx, etc.) and using a structured template they ask the patient a series of questions 1. Why were you hospitalized 2. How are you feeling today? 3. Were you discharged with any new meds to take at home? If yes, what are they? 4. Do you have any nurses or therapists visiting you at home? 5. Were you told to schedule appts w/any doctors besides your primary care provider? If yes, who? Nurses make up to three attempts to reach the patient by phone. Note: Bamboo Health does at times, provide a new phone number for the patient based on what the pt reported at the hospital and this can be valuable! This same list of patients is also sent to the MA and they retrieve the hospital discharge note and scan into chart. Our follow up rates were are about 54% which is well above the rates for other FQHCs in our state (43%) and the Medicaid rate of 38.5%. OTHER ways we’ve worked this data 1. SDoH/PRAPARE completed with patients who had a hosp discharge by the Triage Nurses. 2. Mail a congratulations card to new moms upon the notification of a birth 3. Alert in NOVO so that if a patient was high risk/who met certain criteria (e.g., multiple ER visits; recent hospitalizations; high risk score) the PSA would delegate the call to Triage to talk with patients ER VISITS -MA reviews the list and notifies PCP of any ER visits that require follow up OTHER ways we’ve worked w/ER visits 1. For pedi patients with an ER visit for asthma, a text message is sent to the patient to encourage them to schedule f/up with PCP (if a visit is not already scheduled) 2. For patients in a value based roster that requires complex care pts who meet certain criteria to have f/up we send a text msg to patient to schedule f/up visit
- #13 Mary (3:03-3:21) Mental illness – we have complicated process for managing patients who are discharged from the hospital for mental illness Hospital Discharges – -Triage Nurses call each of the patients who meet certain criteria, (e.g., Value Based Roster pt, specific dx, etc.) and using a structured template they ask the patient a series of questions 1. Why were you hospitalized 2. How are you feeling today? 3. Were you discharged with any new meds to take at home? If yes, what are they? 4. Do you have any nurses or therapists visiting you at home? 5. Were you told to schedule appts w/any doctors besides your primary care provider? If yes, who? Nurses make up to three attempts to reach the patient by phone. Note: Bamboo Health does at times, provide a new phone number for the patient based on what the pt reported at the hospital and this can be valuable! This same list of patients is also sent to the MA and they retrieve the hospital discharge note and scan into chart. Our follow up rates were are about 54% which is well above the rates for other FQHCs in our state (43%) and the Medicaid rate of 38.5%. OTHER ways we’ve worked this data 1. SDoH/PRAPARE completed with patients who had a hosp discharge by the Triage Nurses. 2. Mail a congratulations card to new moms upon the notification of a birth 3. Alert in NOVO so that if a patient was high risk/who met certain criteria (e.g., multiple ER visits; recent hospitalizations; high risk score) the PSA would delegate the call to Triage to talk with patients ER VISITS -MA reviews the list and notifies PCP of any ER visits that require follow up OTHER ways we’ve worked w/ER visits 1. For pedi patients with an ER visit for asthma, a text message is sent to the patient to encourage them to schedule f/up with PCP (if a visit is not already scheduled) 2. For patients in a value based roster that requires complex care pts who meet certain criteria to have f/up we send a text msg to patient to schedule f/up visit
- #14 Mary (3:03-3:21) -May want to say something about CONNIE and how this may impact our processes
- #15 Mary (3:03-3:21) Dashboard utilized to drill down on data for what we’re doing
- #16 Mary (3:03-3:21) Ensure that patients who do not need to return to PCP but rather need to go to their OB/GYN or their surgeon as a first step are identified so outreach is not the same to them - priority is for them to see the specialist
- #17 Mary (3:03-3:21) This is a level of detail not needed -> it is noting WHICH PATIENTS we do the hosp f/up process on – so we f/up on: ALL pts with are on a Value Based Roster ALL pts who are discharged for COPD, Diabetes, Asthma, Hypertension, Delivery of newborn, Poisoning; F code (all BH diagnoses)
- #18 Mary (3:03-3:21) ~18 min Other types: -incarceration So this is like, special circumstances and how to handle them
- #19 Veena 3:22-3:32 ~10 mins Or Process upon receiving report of a patient death Veena can speak on from provider perspective?
- #20 Veena 3:22-3:32 We may be notified of a patient death in may ways. This may come from the family, the staff may know from the community, sometimes from others involved in the patient care, and sometimes it may be discharge summary or ED note. In addition to these ways, CHC do also have patient deaths as part of this larger ‘Bamboo Health” report which is reviewed by Pop Health. Tierney made modifications to this slide
- #21 Veena 3:22-3:32 While may not be transition of care, it is important that this procedure be followed with sympathy, respect, and closure . Generally, the patient’s primary medical provider or primary behavioral health provider initiate the communication, but this may process may also be started by the Bamboo Health Report or even the Population Health team, when we learn of a patient death. The response procedure really has 2 parts…
- #22 Veena 3:22-3:32 While may not be transition of care, does involve Generally, the patient’s primary medical provider or primary behavioral health provider should initiate the communication.
- #23 Veena 3:22-3:32 Once CHC has received notification of passing, through any means, the following steps will be completed: Generally, the patient’s primary medical provider or primary behavioral health provider should initiate the communication. OM marks TE as addressed
- #24 Bibian 3:33-3:48
- #25 Bibian 3:33-3:48 When did we start doing them? 2017.
- #26 Bibian 3:33-3:48 High risk score – where do we get it?
- #27 Bibian 3:33-3:48
- #28 Bibian 3:33-3:48
- #29 Bibian 3:33-3:48 SDOH: Housing, transportation and food insecurity
- #30 Bibian 3:33-3:48 Patient requested a letter for DCF and PCP declined to write it the way the patient requested it so patient went to BH provider.
- #31 Mary 3:49-3:50 Describe processes for following up on ER visits and hospital discharges, including roles and responsibilities Discuss a best practice for centralized notification of ER visits and hospitalizations Other use cases for managing centralized notifications of hospital events: -Risk stratification and management - Integrated Care Team Meetings -Reports of patient passings, caring for the family
- #32 Bianca 3:51-3:59
- #33 Bianca 4:00