The transition of care is a critical time for patient intervention to prevent readmissions and emergency room visits, according to Dr. Holly Dahlman, CEO and lead physician of Green Spring Internal Medicine in Maryland.
"Transition of care visits are vital to the healthcare system," Dahlman said, speaking during the HIMSS20 Digital session, Using Encounter Notification to Optimize Transitions of Care. "We know that patients do not oftentimes understand their medication instructions at the time of discharge."
Also, patients may have post-hospital delirium, which runs the risk of medication confusion.
In addition, at the time of transition there can be pending test results such as biopsies that can affect care.
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Green Springs set out to determine what the practice could do to improve readmission rates and lower costs. At this time, around 2016, the cost of a readmission was estimated at $14,400 for a total national cost of up to $40 billion annually.
In one year, about one in four patients over the age 65 will experience a transition of care, Dahlman said, with the risk being four times higher for those over 65. About half of these transitions involve hospitals.
The cost associated with a readmission is typically more than the initial visit, she said.
Hospitals can reduce liability, avoid readmissions and its penalties, prevent costs -- especially in accountable care organization models -- and give higher patient satisfaction through connecting with patients shortly after they leave the hospital or other care facility.
Green Springs is part of Maryland Primary Care Program or MDPCP program, a Comprehensive Primary Care Plus pilot started in January 2019.
It set goals to reduce readmissions, unnecessary hospitalizations and ER visits. It successfully did all three.
In 2018, the practice showed a 14% readmission rate. By 2019 the practice managed to drop that rate to 8.9%.
Green Springs got there through several initiatives.
First, the practice set up appointments to get patients into the office for a transition of care visit to clear up any confusion over medications and decrease the risk of a therapeutic disruption. For instance, Dahlman said, a patient who had been hospitalized with pneumonia went home and stopped taking what she thought were her acid reflux blockers, but instead, she had stopped taking her antibiotics.
Green Springs worked with the Chesapeake Regional Information System for our Patients, or CRISP, a health information exchange in Maryland that provides discharge data on patients in Maryland, the District of Columbia and West Virginia.
Hospitals provide a patient roster to CRISP, which sets up notifications for the providers to receive real time notifications whenever a patient is admitted, discharged or transferred to or from a hospital and also whether the patient was in the ER.
Green Springs places these encounter notifications on a unified landing page to create a transition of care protocol.
The care coordinator receives a discharge summary and gets labs and test results from the unified landing page or the hospital medical records system.
Armed with this information, the care care coordinator will reach a patient by phone to reconcile medications. The patients can schedule a follow up visit within 14 days and ideally, within seven days.
However, several issues arose that needed to be resolved.
First, the practice needed to decide who would be responsible for getting the information and contacting the patients. Early on, Green Springs had two different nurse practitioners on the job and after that, other qualified personnel.
Staff turnover, vacations and competing priorities meant a lot of new training.
Beyond allocating the time for someone to do the outreach, there were issues and time delays in reaching patients or their caregivers.
And then, patient buy-in could be a challenge.
"Some patients said, 'I'm getting too many calls from care teams and the hospital,'" Dahlman said.
There were challenges in how the practice received the encounter notifications. Sometimes it was by fax.
Getting ahold of the appropriate person at the hospital level was also an issue. Very few hospitals call the practice upon a patient's discharge, Dahlman said.
But getting the information was necessary because of a three-month time lag in getting claims data.
"We also once upon a time were lacking the discharge status in the encounter notification," Dahlman said. "This resulted in calls to patients at their discharge to find out some of them had died. We reported it to CRISP and they were able to fix this problem."
In the future, Dahlman would like to see greater interoperability between hospitals, practices and care managers and having a single sign-on for the EHR.
What hasn't been an issue is reimbursement.
In 2013, the Centers for Medicare and Medicaid Services began reimbursing primary care teams one to two weeks after hospital discharge. Performing medication reconciliation and getting early test results were found to be key steps in stopping readmissions.
There is good reimbursement for the transitions of care visit, Dahlman said.
Billing codes are 99495, for a visit within 7-14 days. This pays $220. Another billing code is 99496 when a visit occurs within seven days and pays $265. These codes must be filled with a level four or five visit code
"Truly this is our best paid visit in primary care," Dahlman said. "And the reason why Medicare is invested in it is, of course, the high cost of hospital readmission."
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