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The Five Elements of Optimal Care Delivery: Managing Patients Across Settings

Care progression is a foundational element of care delivery optimization. When healthcare organizations succeed at connecting the dots for patients across the outpatient, inpatient and post-acute settings, patients are equipped with the support and tools they need to participate in – and improve – their health.

Patient progression through home health and skilled nursing facilities is especially important in today's landscape, as is a strong connection to the primary care provider. The transition period after a hospital stay or procedure represents a critical time that can mean the difference between a full recovery and an adverse event. Meanwhile, payment is now tied to readmission rates, patient satisfaction, 30-day outcomes and the cost of care for 30 days post-discharge.

In effect, how a hospital manages patient progression to the next care setting has become a critical extension of its optimized care delivery model, with important implications for the organization’s reputation and financial viability, as well as patient outcomes.

Successfully transitioning patients to the post-acute care setting requires both care managers and post-acute providers to seamlessly coordinate and communicate.

A strong care management program is contingent upon alignment across the organization, as well as access to data that appropriately risk-stratifies patients. Beyond its importance as a reimbursement determinant for providers, risk stratification has become essential in creating the cross-continuum roadmap to boost healthcare efficiency.

In order to ensure care managers are not spending time searching for “appropriate” patients, care teams should reach consensus on standardized processes, including risk assessment tools and algorithms, to identify patients who will most benefit from care management services in order to improve health and prevent emergency department (ED) visits.

With access to the right technology and risk-stratification and socioeconomic data, care managers can:

  • Prioritize patients most in need of care management support. Care managers seek to focus on medium- and high-risk patients, who may fall into these categories for a number of reasons, including their likelihood for readmission, poly-pharmacy medication regimen or socioeconomic status. Characteristics such as health literacy and social support can be just as indicative of transitional success as clinical risk factors such as medication issues and prior readmissions.
  • Assign patients to the most appropriate care teams for their needs. High-risk and/or high-cost patients may require individual care plans, while other patients will benefit from coordination with specialty care or referrals to community services.
  • Continually monitor cross-continuum care management processes, particularly for patients with chronic conditions, for opportunities to improve. Care managers work with many patients who have chronic conditions such as COPD, diabetes and hypertension, and can help coordinate and educate on appropriate care in the appropriate setting. A recent Premier analysis found that six prevalent chronic conditions contribute to the majority of U.S. healthcare spending, and estimates suggest that up to 27 percent of ED visits in the U.S. could be managed in physician offices, clinics and urgent cares.

A strong cross-continuum care management model includes close partnerships with post-acute care and primary care providers.

Value-based payment models are driving providers to work together to improve outcomes and save money. This means hospitals and post-acute providers must build more effective partnerships. As partners, they can align around complex clinical management; evidence-based practices; standardization of processes and measures; and improved resource utilization. For the care manager on the ground, this collaboration with post-acute care providers leads to better and safer care for patients due to decreased variation, as well as more effective transitions for patients who are headed to home health or skilled nursing facilities.

Recognizing that patients with chronic conditions need more preventative and proactive care to avert disease progression and the escalation of care, care managers should help patients understand how to access their primary care providers (PCPs) for urgent issues. A thoughtful PCP and care manager engagement strategy includes routine meetings that foster information exchange, support patient transitions and determine who ultimately has responsibility for the patient. As leaders promote a culture of openness and communication, they empower the organization in its journey toward high reliability.

Organizational alignment contributes to care management success.

It is beneficial to appoint a single executive leader to be fully accountable for care management efforts across the system. This role functions best when paired with a physician champion and placed in the hierarchy alongside other C-suite leaders to ensure alignment with all system priorities. This often involves moving to a team-based care model, which requires well-defined roles and responsibilities for all team members.

The reporting infrastructure for care management will often determine whether care managers prioritize financial implications or clinical coordination. Some organizations have found success by positioning care management roles under the chief nursing executive or chief medical officer, where the focus is less on reviewing utilization and incentives – as it may be if care management is aligned under a chief financial officer – and more on clinical coordination and creating relationships with community partners.

There is no doubt that hospitals are improving their approach to care management by building multidisciplinary teams and assigning patients to care managers who weave together services delivered across care settings, from post-acute to primary care. In managing patients across settings, a properly aligned care management program helps avoid preventable ED visits and unnecessary hospital admissions, improve patient satisfaction and achieve healthier patient populations.

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