Barriers to Care Transitions

1. Barriers to Care Transitions • Each health plan has different forms and different requirements for authorizations • Multiple health plan formularies • Providers (Hospitals, Physicians) aren’t incentivized to reduce readmissions • No/low funding for services such as telehealth, medication dispensing, nurse visits • Patients don’t want to pay co-pays to see a Physician after leaving the hospital • Enrollees unable to access transportation quick enough to see physician

2. Barriers to Care Transitions con’t • Access issues – not enough Medicaid providers • Low reimbursement rate is a disincentive to see patients • Reimbursement and coverage provides disincentives • Hospital activity to reduce rehospitalizations (ex: f/u phone calls) • Palliative Care and Hospice programs • LTACH level of care • Patient compliance • Transient population • Enrollees move in and out of eligibility • Patient can’t afford medications

3. Barriers to Care Transitions con’t • Inadequate handover communication from hospitals • Medication lists not complete or accurate • Patient education materials not patient-centered • Patient’s caregivers aren’t included in the education and discharge process • Hospital discharge planning fragmented • Misaligned transition processes between hospitals and health plans

4. How to address the Barriers? • PCPs incentivized to keep appointments open for follow-up visits; see patients in the hospital • Case Management for all high-risk patients • Coverage for patient advocates and coaches • Cover first home visit regardless of qualifying criteria (need for medication reconciliation) • Transportation for patients; must be timely • Standardization of forms and benefit design and formularies • Coverage for off-formulary medications • Shared-savings program with hospitals • Provide hospitals with lists of which providers will accept patients – home health, skilled nursing, etc.

5. How to address the Barriers? con’t • Redesign patient education materials and process • Teach-back • Include the learner/caregivers • Discharge planning upon admission • Multi-disciplinary discharge teams/process • Standardize handover information and establish real-time communication • Medication Reconciliation • Improved communication between hospital and health plan case managers • Promote patient self-management

6. The Care Transitions Intervention • Use of Transition Coaches – RNs, Socials Workers & Community Health Works • Coaches help newly discharged patients and their caregivers learn skills to keep them out of the hospital • Medication self-management • Use of a personal health record • Timely primary and specialty care follow-up • How to recognize red flags and how to respond • Transition Coach visits the patient in the hospital before discharge and visits in the home over 4 weeks • One community reduced readmission by 14% * • http://www.caretransitions.org/ Butcher, Lola. How to Save a Bundle on Hospital Readmissions. Managed Care, July 2009 *The Hospitalist, February 2011. http://www.the-hospitalist.org

7. Transitional Care Model • Targets adults 65+ with 2 or more risk factors • Poor self-health ratings • Multiple chronic conditions • Recent hospitalizations • Transition Care Nurse coordinates the patient’s discharge plan with the family and hospital staff • Transitional nurse helps patient manage post-discharge care and facilitates communication with outpatient providers and community services • Home visits and phone calls for up to 3 months after discharge • Helps patient/family understand condition, how to care for themselves, recognize problems,, and how to take medications correctly • Aetna: Reduced readmissions in the 3 months after discharge by 25% • Cost saving of $439 pmpm was achieved • http://www.transitionalcare.info/ Butcher, Lola. How to Save a Bundle on Hospital Readmissions. Managed Care, July 2009

8. Other Innovations According to research conducted by America’s Health Insurance Plan’s Center for Policy and Research, there are three important trends: • Health Plans are rebuilding primary care by placing nurses, social workers an case managers in settings such as hospitals, skilled nursing facilities and patient homes • Health Plans are building patient relationships by helping members understand their care plans, checking their symptoms, arranging for services and enabling them to have follow-up visits • Health Plans are connecting patients with pharmacists directly, by phone or in person, to review medications. Innovations in Reducing Preventable Hospital Admissions, Readmissions and Emergency Room Use: An Update on Health Plan Initiatives to Address National Health Care Priorities. AHIP, Center for Policy and Research, June 2010