The healthcare system has a large population of elderly patients, many with multiple healthcare issues or chronic conditions. Taking part in a care management program can help these patients become healthier by educating them about their disease processes and the importance of medication compliance, regular blood work, annual tests, and preventative measures such as flu and pneumonia shots and mammograms, and colonoscopies.
Care management services provide patients with contact to inform them of their conditions in terms they understand and to involve them in personal healthcare goals. In this way, patients are more likely to want to be involved in reaching their goals and becoming healthier. The intent is to keep these patients out of the emergency room and hospital as much as possible.
What is Care Management?
“Care Management programs apply systems, science, incentives, and information to improve medical practice and assist consumers and their support system to become engaged in a collaborative process designed to manage medical, social, and mental health conditions more effectively. The goal of care management is to achieve an optimal level of wellness and improve coordination of care while providing cost effective, non-duplicative services.” (“Care Management Definition and Framework,” Center for Health Care Strategies, Inc., 2007.)
1. Transitional Care Management is a Medicare service that became effective Jan. 1, 2013, per cms.gov. The care management team or nurse navigator will call a patient or caregiver within two days of inpatient discharge to discuss medication, a new diagnosis, or important follow up appointments with the purpose of reducing and preventing readmissions and medical errors.
2. Chronic Care Management (CCM), according to The Centers for Medicare & Medicaid Services (CMS), is a chronic care management services, which are a critical component of primary care that contributes to better health and care for individuals. The goal is to provide the patient and family with the best care possible to keep them out of the hospital and emergency room and to minimize overall medical cost. The program is used to help patients achieve a better quality of life through continuous care and management of their chronic conditions. Patients collaborate with healthcare providers to set healthcare goals, thus making it more likely they will accomplish those objectives.
One patient I worked with is a successful participant in the CCM program. He initially visited the emergency department because of unstable vital signs, weakness, dizziness, and uncontrolled hypertension. He had been out of his medication for three months, was admitted for congestive heart failure and atrial fibrillation, and spent four days in the hospital. He also had uncontrolled diabetes with a Hemoglobin A1C of 10.7 percent and his average fasting blood sugars at home were running in the 300s.
The patient consented to the CCM program for his chronic conditions of atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, diabetes, hypertension, and obesity. He was very eager and willing to learn about his disease processes and to take his medication on a regular basis. He was given information on Medicaid services to help with medication expenses and was educated on Metformin titration and use of his insulin.
I also regularly contacted him for a report on his blood sugar and blood pressure readings. In just two short months the patient has stopped smoking and his fasting blood sugars are now running in the low 130s. He has a better relationship with his son and granddaughter, is more physically active, and is making better food choices. He is due for a repeat Hemoglobin A1C level next month.
This is just one of many examples of what care management can do for a patient. As a nurse navigator, my patients become like a part of my family. I am blessed to be able to educate and support our patients and their families and to help them to make better healthcare choices that can potentially save their lives.
Terri Hibbs, BSN, RN, CCCTM is a care navigator for Baptist Health Hardin Family Medicine.
Each year, approximately 16 percent of patients in United States hospitals are readmitted within thirty days of discharge. Readmissions and the additional treatments they entail are costly to both patients and insurers. Increasingly, they are costly to hospitals as well.
A portion of readmissions is unavoidable, such as a planned readmission for chemotherapy or an unexpected adverse event unrelated to the original diagnosis. However, many other readmissions are preventable through high quality clinical care and effective patient education and discharge procedures.
The Financial Impact of Hospital Readmissions
To reduce hospital readmission rates nationwide, the Centers for Medicare and Medicaid Services (CMS) began financially penalizing hospitals with higher than expected readmission rates via their Hospital Readmissions Reduction Program (HRRP) that began in 2012. The cost of those penalties across United States hospitals increased significantly from a total of 290 million dollars in fiscal year (FY) 2013 to an estimated 563 million dollars in FY 2019.
Failure to reduce readmissions has become more expensive over the program’s lifetime. In the first year of the HRRP, the maximum penalty was 1 percent of Medicare reimbursements withheld. By design, that maximum penalty has since increased to 3 percent.
National hospital readmission rates have dropped since the program launched, but not enough to decrease penalties. Of the 3,129 general hospitals evaluated in the HRRP in 2019, 83 percent received a penalty.
The increases are due in part to additional health conditions included in the program. In the program’s first year, CMS evaluated the readmission rates of patients with heart attacks, heart failure, and pneumonia to determine whether a hospital faced penalties. Today, CMS also measures readmission rates of patients with chronic lung disease, hip and knee replacement, and coronary artery bypass graft surgery. Scheduled readmissions are not counted.
Additionally, the program is set up such that CMS evaluates each hospital’s readmission rates relative to the national average for each condition. Even as readmission rates drop overall, there will always be hospitals that have more readmissions than the national average.
A 2016 study on hospital profitability published in the journal Health Affairs found that most hospitals in the United States are not profitable, and the median acute care hospital is losing 82 dollars per discharge. Given those numbers, it’s imperative for hospitals to reduce readmission rates and reduce the amount of Medicare reimbursements left on the table.
Readmission Rates and Causes in the United States
Some patients will always be readmitted after discharge. However, the wide range of readmission rates across hospitals suggests that there are addressable factors behind readmissions. In some cases, a readmission may be related to what happened during the original hospitalization. In other instances, patient readmission ties to what happens after discharge from the hospital.
A study on preventability and causes of readmissions published in JAMA Internal Medicine in 2016 reviewed the cases of 1,000 general medicine patients readmitted within thirty days of discharge across twelve United States hospitals from April 1, 2012 to March 31, 2013. Of those 1,000 readmissions, 26.9 percent were potentially preventable.
According to the study, common factors in potentially preventable readmissions were related to what happened at the time of discharge and after the patient went home. The authors cited emergency department decision making at the time of readmission, patient failure to keep important follow-up appointments, premature discharge, and lack of patient awareness about who to contact after discharge as the most common factors.
The study’s authors concluded that “High-priority areas for improvement efforts include improved communication among health care teams and between healthcare professionals and patients, greater attention to patients’ readiness for discharge, enhanced disease monitoring, and better support for patient self-management.”
CMS’s steep penalties are motivated by a desire to provide better patient care and, in doing so, to reduce healthcare costs. One of the best ways for hospitals to prevent unnecessary readmissions is by calling patients after their discharge to check in on symptoms, review medications and treatment plans, and offer patients an opportunity to ask questions about their recovery.
Post-Discharge Patient Education
Often, a patient is readmitted because they didn’t follow the correct medication regimen, lacked understanding of the treatment plan, or failed to follow up with their primary care physician after discharge.
Ideally, patients receive thorough education about medication regimens and treatment plans throughout their stay and at the time of discharge. However, literacy and comprehension rates vary across patient populations, and patients don’t always understand written or verbal discharge instructions.
Additionally, at the time of discharge, patients are preoccupied with the logistics and excitement of going home. Attempts at patient education might not be effective, no matter how well delivered. Once patients have arrived home, the complexity of managing their new medications and daily routines on their own becomes much more apparent.
Several studies have found that other factors, including the patient’s social support network, marital status, gender, and income can affect a patient’s ability to follow discharge instructions and manage their care at home.
Whether it’s addressing a lack of comprehension regarding a patient’s treatment plan or addressing a lack of support in enacting that treatment plan, a post-discharge phone call can provide a way for hospitals to help patients stay well at home.
Using Calls to Reduce Readmissions
Hospitals have many opportunities throughout a patient’s healthcare journey to reduce the chance of readmission. One commonly cited way to reduce readmissions is by improving patient education around managing their care after discharge.
Specifically, implementing a post-discharge phone call to review medication regimens and treatment plans, discuss symptoms and other concerns, and check in on home health services and follow-up appointments helps reduce readmission rates.
A paper published in the American Journal of Medicine in 2001 found that when pharmacists called patients two days after discharge to review whether they had obtained and understood how to take their medications, patients were much less likely to visit the emergency department within thirty days of discharge. Ten percent of those who received a phone call from a pharmacist went to the ED, compared to 24 percent of patients who did not receive a call.
In another program, IPC The Hospitalist Company (IPC) tested the effect of post-discharge call center outreach on readmission rates. Nurses at the IPC call center called 350,000 discharged patients from October 2010 through September 2011. During the calls, nurses talked through each patient’s symptoms, medications, home health services, and follow-up appointments. The nurses answered patient questions about discharge instructions and, if the patient had a serious medical need, contacted the patient’s hospitalist or primary care physician.
Nurses successfully reached 30 percent of patients. This program prevented an estimated 1,782 avoidable readmissions over the course of a year.
Setting Up a Post-Discharge Call Program
Research suggests that the best time for a post-discharge call is within the first two to three days after a patient arrives home. At this point, the patient has had the opportunity to settle in, fill medications, make follow-up appointments, and it is still early enough for a nurse’s call to make an impact. Many patients won’t answer on the first try, so nurses should plan to call more than once.
The first step in setting up a post-discharge call program is to ensure that call center staff have the best number to reach each patient. Sometimes the number in the patient’s record is different from their home or cell phone number. IPC The Hospitalist Company found that by asking patients for the best number to reach them or their caretaker, they were able to increase their successful call rate from 30 percent to more than 40 percent of discharged patients.
Customized Care Call Scripts
Providing nurses with diagnosis-specific scripts can help make care calls more efficient and effective, as many conditions have standard red flags nurses should check in on, such as weight gain after discharge for heart failure. Virtually any type of script is easy to create, including common scripts for post-surgery, diabetic, and pediatric post-discharge calls. Setting up a unique script with detailed questions for each, helps to ensure patients understand discharge instructions, address any medication questions, and help ensure the patients are not experiencing symptoms that would cause them to be readmitted.
Nurses should also have access to physicians’ discharge notes to review patient-specific follow-ups. Physician discharge notes must be completed in a timely manner to give nurses the information they need for the calls.
To supplement the post-discharge nurse phone call, organizations can also use HL7 integration to receive discharge notifications and set up automated appointment reminder calls. This helps increase the likelihood that patients make it to their appointments and receive the prescribed follow-up care.
To avoid penalties and help patients to stay healthy at home, hospitals can leverage call centers and post-discharge phone calls with customized scripts to check in on symptoms, review medications and treatment plans, and remind patients of follow-up appointments. Studies suggest that such measures reduce the rate of readmissions.
For hospitals, implementing a discharge call center program can help avoid or reduce Medicare readmission rate penalties. For patients, the program can improve their post-discharge care management and health.
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What does your healthcare contact center stand for? How do you stand out in an industry with many options? Understanding who you are is the first step to determining your distinctive characteristics. But why does this matter?
This is important because when you have a unique quality then your stakeholders have something to rally around. They have a reason to be proud. Short of that you offer nothing to draw them in and keep them close. They have nothing to celebrate.
Though this most obviously applies to outsource call centers, it’s also applicable to in-house operations too. Here are some categories to consider.
The first place most call centers look at to distinguish themselves is their service level. They often focus on quality service. Though there are many ways to define this, some look at customer satisfaction (CSAT). Most every call center claims to offer quality service. However, saying it and doing it are two different things. To trumpet service quality with integrity requires that a third-party confirm it. Self-pronounced claims of quality service mean nothing.
Aside from quality, other service level considerations might be answering calls quickly (average speed to answer: ASA) or handling requests on one contact (first call resolution: FCR). Other ways to stand out include a low error rate or around-the-clock accessibility.
A second area to consider is how you relate to your staff. Though few employees—if any—will say they’re overpaid or over appreciated, look at how you regard your staff. Employees who receive proper compensation and know how much they’re appreciated tend to work harder and produce better outcomes. The side effect of this is improved service to callers, as well as a healthier financial position.
In call centers, where margins are thin, leaders often struggle with their compensation packages. They know that a 5 percent increase in payroll can move a profitable (or cash-positive) operation into an unprofitable (or cash-negative) one. Yet others successfully apply the adage of “pay more and expect more.”
Not all approaches to enhancing the relationship with your staff, however, require a financial investment. Also consider intangible ways to stand out. This includes letting employees know how much you appreciate them, connecting with them on a personal level, and even taking a simple step of giving them a sincere “thank you” for their work.
A third area to consider is the financial aspect. Is your operation fiscally strong? A call center that produces consistent positive cash flow has long-term viability. This means they generate profits for their owners or are a profit center for their organization. They stand out. Having financial stability can permeate an entire operation with positivity.
Next, do you provide your staff with the best tools possible? Is their work environment something they’re proud to enter every day? Though these may not seem as relevant of a consideration to use to define your call center, they can be. Employees in a top-notch work environment will speak highly of their jobs and their employer to their families and friends. This can ripple through the local area, elevating the call center in the process.
Though it’s good to address all these areas and strive to make them as good as you can, it’s impossible to make everything a priority. Attempting to do so will cause all areas to suffer.
Without neglecting any of these considerations, however, strive to elevate one above all others. Let this become the distinctive characteristic that your call center is known for and celebrated. This will help you stand out among all others and have a lasting impact for all stakeholders: your callers, your employees, and your organization.
Peter Lyle DeHaan, PhD, is the publisher and editor-in-chief of AnswerStat. He’s a passionate wordsmith whose goal is to change the world one word at a time. Read more of his articles at PeterDeHaanPublishing.com.
Started in 1996 to support TeamHealth physicians, TeamHealth Medical Call Center evolved over time, outgrowing its brand identity and core message, which is a natural part of every dynamic, growing business. Now, more than two decades later, they have evolved to become a premiere provider of medical call center solutions, offering services to more than fifteen thousand providers in individual and group practices, hospital systems, universities, community health centers, and other medical organizations across the United States. Today they are more dynamic than ever, and their new brand of AccessNurse reflects this reality.
Since their conception, providing access to medical care has been the underlying theme and pulse of the call center. Woven into every fabric of their new brand is the word access: from their story to how they treat clients and their patients. The new AccessNurse name is a textual representation of what they offer, believe in, and represent: providing clients and patients with 24/7 access to definitive nurse care. They also supplement this new name with the tagline, “A TeamHealth Company” to reinforce their alignment with TeamHealth and the medical integrity, experience, and resources that go along with that relationship.