Tag Archives: Care Coordination

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Components of a Hospital Readmission Prevention Program

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Hospital readmission prevention programs, such as the one my Accountable Care Organization (ACO) conducts, try to make sure the patient coming home from the hospital fully understands their discharge instructions and removes any roadblocks that would prevent the patient from following those instructions.

With our program one of our nurse Care Coordinators contacts the patient within two days of discharge from the hospital.  They make sure the patient sets up an appointment to see their physician within 1-2 weeks and, most importantly, review the Discharge Instructions the patient was given upon discharge from the hospital.  Basically, there are 4 areas that are covered:

  • New Or Worsening Symptoms (NOWS) – The Care Coordinator  asks the patient how they are doing to determine whether they may be feeling worse than when they were in the hospital, either due to worsening of known symptoms or the development of new ones.  In my experience, it never ceases to amaze me how often patients minimize such worsening in their condition and delay contacting their physician.  Directly asking about NOWS helps identify their occurrence and teaches the patient their importance and the need to inform their doctor immediately when they are present.
  • Medication Reconciliation – Have there been changes made to the medications the patient was taking before entering the hospital?  The Discharge Instructions that the patient was given before discharge include a list of the medications they should take, but often questions arise once the patient is home.  The Care Coordinator   goes over the discharge medicines with the patient and compares those to the ones the patient was taking before.
  • Appointment Adherence – Has the patient made follow-up appointments that have been recommended so they continue to recover?  These could be with specialists seen in the hospital as well as the primary care physician.  In addition, certain testing may have been recommended as well.  These are usually specified in the Discharge Instructions, too.
  • Self-Management – Are there things the patient was instructed to do to help their recovery?  If they had surgery, how do they manage the dressings of the surgical site?  If they are a diabetic, do they need to check their blood sugars more frequently than before the hospitalization?  What about their activity level and diet?

In each of these areas, the Care Coordinator makes sure that the patient knows what to do and has no obstacles to carrying out their discharge instructions.  Each day our 22 Care Coordinators reach out to dozens of Medicare beneficiaries who have been discharged from the hospital and, thanks to their efforts, miscommunications are corrected and problems solved on a daily basis to help these patients complete their recuperation at home.

For Your Health – Dr. Bob

How Do Accountable Care Organizations Work?

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In my last post I gave an overview of what Accountable Care Organizations (ACOs) are.  Before I start to explain the care coordination strategies they commonly use,  I’d like to go a little deeper into how an ACO has patients (Medicare beneficiaries) attributed to it and where savings can be found while maintaining quality.

Beneficiary Attribution

Let’s consider an ACO formed by a primary care medical group.  These physicians practice primary care and would include family practitioners, internists and, since the patients we’ll talk about are Medicare beneficiaries, geriatricians.  Medicare would look at all the claims for services of any patient the medical group took care of within the past several years (usually 3).  Medicare determines from which physician the patient got most of their primary care services & attributes that patient to that physician.  A key point to remember is that even though a Medicare beneficiary is attributed to a specific primary care physician, the patient can see any physician they want.  The patient is not a “member” of the ACO.  However, since that patient is attributed to the ACO, all their health care services become the responsibility of the ACO to coordinate.  The patient has all the freedom to go to any physician in the country who accepts Medicare for their health care needs.  They are still regarded as being in the traditional Medicare program.

Cost Benchmark

Once Medicare has attributed their patients to the ACO, it calculates a cost benchmark that will serve as the target for the ACO.  The benchmark is derived by a formula that looks at the previous three years of costs for the attributed beneficiaries and is adjusted for inflation.  If the ACO is able to provide quality care as measured by 33 quality measures and keep costs under the benchmark they will share in a portion of the savings with Medicare.  For most ACOs there is no penalty if costs are over the benchmark.  The ACO is not responsible for paying the care providers.  Medicare still does that.  Remember, the costs are all the costs (except Part D drug costs) for the attributed beneficiaries, including hospitalizations, tests, surgical procedures and physician charges.

Cost Reduction Opportunities

So where will the savings come from?  There are several main areas – areas that won’t compromise quality, but rather increase it.  Our system of health care delivery is hardly an efficient one.  Important clinical information is often not transmitted promptly to the next person involved in a person’s care.  Consequently, tests are often repeated unnecessarily.  More importantly misunderstandings and miscommunications can result in complications and poor clinical results that require more services which just add to the costs.

In my next post I’ll talk about the opportunity surrounding hospital discharges as an example of how care coordination can improve quality and lower costs.

For Your Health – Dr. Bob