tm curaspan whitepaper care transitions: the bridge to...

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Today’s healthcare environment is shifting away from fee-for-service delivery and financial models toward

value-based purchasing models. The new models include bundled payments, accountable care

organizations (ACOs) and government programs that promote value-based purchasing, all features of a

new approach designed to improve continuity and coordination of care and reduce healthcare costs

overall (Centers for Medicare & Medicaid Services, 2015). Providers adapting to these new models will find

themselves working together in ways they haven’t before. The most successful among them will

concentrate their efforts on what connects them — care transitions. In the new world, effective, well

managed care transitions are more important than ever.

Care transitions happen throughout and across all healthcare providers. Every encounter a patient has with

the healthcare system produces at least one care transition. High-risk patients often require multiple

transitions for a single episode of care. Since high-risk patients tend to also be the highest cost patients, any

organization that does not have strong and effectively managed care transition workflows will not survive

within value-based purchasing models.

Care Transitions: The Bridge to Success in Emerging Models of Care

Curaspan Whitepaper

What is a Care Transition?

A transition of care, or care transition, is the

movement of a patient from one care setting to

another (Centers for Medicare & Medicaid Services,

2014). It could be a straightforward transition

between units within the same hospital or a more

complex transition from the hospital to an external

care setting (Coleman, MD, MPH & Fox, 2004).

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“The movement of a patient from one

care setting to another.”

One of the problems in the management

of care transitions is lack of standardization

— across the industry, across systems and

sometimes even across a single

department.

One of the problems in the management of care

transitions is lack of standardization — across the

industry, across systems and sometimes even across

a single department (NTOCC Measures Work Group,

2008). Much of the variation can be attributed to

the manual tasks and processes in care transition

workflows not supported by technology. Printing

patient medical records, faxing referrals and playing

phone tag are all manual, error-prone care transition tasks that can lead to process variation. Process variation

can lead to miscommunication and confusion, which can lead to poor patient outcomes and increased costs.

For example, it’s estimated that 66 percent of medication errors occur during care transitions alone (Santell,

2006), and medication errors are estimated to cost at least $3.5 billion each year (Institute of Medicine of the

National Academies, 2006). Thus process variation can also be a significant barrier to achieving efficient and

effective episodes of care for high-risk, high-cost patients.

1-800-446-9614 | Curaspan.com | © 2015 Curaspan Health Group, Inc.

Transitions across care settings are complicated by the fact that

there are multiple providers, settings and administrative factors

that impact a single episode of care. An episode of care is the

timeframe for which a patient receives care and services for a

presented clinical condition (Centers for Medicare & Medicaid

Services, 2014). The various care providers and settings are part of

a larger community care network, with the patient at its center. As

a patient transitions across the care network, the quality and

efficiency at each stop along the way impact the quality of the

entire episode of care for that patient.

Who is Involved in a Care Transition?

The care settings that have the most direct impact on the patient’s care are the accountable providers.

Accountable providers share responsibility for the patient’s care during the transition. How well these providers

collaborate before, during and after a transition can significantly impact the patient’s condition.

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Strategic Organizations

Payers

Transitions across care settings are complicated by the fact that there are multiple providers, settings and administrative factors that impact a single episode of care.

SNFs LTACs

HospicesHospitals

Primary CareHome Health DMEs

Care Navigators


Care Transitions Are Complicated.

1. Clinicians determine during his admission that Peter

will need to go to a skilled nursing facility (SNF) for

rehab following discharge from the hospital.

2. The hospital compiles a list of clinically appropriate

and available options close to Peter’s home and

reviews those options with Peter.

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Care transitions also involve supporting providers who aren’t directly responsible for the patient during

transitions, but nevertheless impact the care the patient receives during the transition. Additional members of

the care network include organizations responsible for the monitoring and oversight of patient care, such as

ACOs and clinically integrated networks.

Payers3. Peter and a member of his care team — usually a case manager — work together to find a SNF.

4. The case manager sends Peter’s referral information, usually via fax, to multiple SNFs selected from the list.

5. Clinicians at each SNF use Peter’s care plan, medications, functional status, cognitive status and other key

clinical information to determine if they are able to care for his specific needs.

6. If more information is needed to make the determination, the hospital and each post-acute provider

exchange this information via fax or telephone. The SNF will also need completed regulatory assessments

and insurance information prior to discharge.

7. As soon as one of the selected SNFs accepts Peter’s referral via phone, Peter is prepared for hospital

discharge and the case manager schedules transportation to move Peter to the SNF.

8. Peter’s primary care provider is informed of Peter’s pending discharge and the care Peter received in the

hospital.

9. The case managers work to schedule any follow-up appointments that Peter may require.

Chronic Conditions

Peter Smith Age: Gender

Marital Status

72

Widower

Medicare FFS

Yes

Healthy Lives

Rose Smith, Daughter

• Diabetes • Arthritis • COPD • Hypertension

Medical Record MRN# 12345-67

Male

Insurance

Part of ACO

Name of ACO

Primary Caregiver

So what does a “successful” transition of care actually

look like? Consider Peter Smith, an elderly patient with

four chronic conditions who is admitted to the hospital

and receives a new diagnosis of atrial fibrillation (AF).

Peter’s care transition starts as soon as he is admitted

to the hospital when he is screened and evaluated for

his possible post-hospital discharge needs. His care

transition might look like this:

DMEs


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37 Nurses

6Social

Workers

3Home

Health Aids

19 Outpatient Visits

4Occupational

Therapists

2 differentHospitals

6 weeks at 2 SNFs

5 months of Home Care

2 EmergencyAmbulance Rides

6 Community Referrals

22 Prescriptions for 8 Medications

8Physicians

4Physical

Therapists

This is a simplified example of a single care transition. In reality, miscommunications, delays and manual

processes can slow down the transition process, or even lead to a readmission. Imagine if Peter had three

hospital admits in one year, which would mean three different care transitions from the hospital and multiple

care transitions from post-acute facilities to his home, where he may require home health services and

follow-up from his primary care provider. Over the course of a year, Peter’s utilization of the healthcare system

could look something like this:

In 2012, 29.7% of health care expenditures were attributed to the top 5% of individuals with four or more chronic conditions.

Peter is the type of patient who puts the most stress on the

healthcare system. Care transitions tend to “parallel transitions in

health status,” so the sicker a patient is the more he or she will utilize

the healthcare system and the more transitions he or she will

encounter (Coleman, MD, MPH & Fox, 2004). In 2012, 29.7% of

healthcare expenditures were attributed to the top 5% of individuals

with four or more chronic conditions (Cohen, PhD, 2014). It is

estimated that one in four adults has multiple chronic conditions

(Centers for Disease Control and Prevention, 2014) and these

patients can cost up to seven times as much as patients with only

one chronic condition (Stanton, MA, June 2006).

Care Transitions Impact High-Risk, High-Cost Patients the Most.


As U.S. healthcare spending continues to rise (Chantrill,

2014), initiatives that reduce costs while improving care

for high-risk, high-cost patients will have the greatest

impact. One way to do both is to improve care

transitions across the community care network.

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Healthy

Managed Chronic Conditions

Multiple Chronic Conditions

Initiatives that reducing costs while improving care for high-risk, high-cost patients will have the greatest impact.

Tackling Care Transitions Across the Care Continuum.

3. Proactively measure outcomes and efficiency

4. Implement technology that supports

care transitions

There are four steps networks can take to improve their care transitions. These steps support today’s high-quality,

low-cost initiatives. 1. Build a high-quality post-acute network

2. Standardize workflows for care transitions

across the network

1. Build a Quality Post-Acute Network

As networks partner with more post-acute providers, the financial and regulatory needs of each post-acute

provider type — and how they may differ from that of other types in the network — must be considered. It is

important to build relationships with post-acute providers while simultaneously identifying those post-acute

providers that will enhance the quality of the network.


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So what makes a good partner? The four key characteristics to look for when evaluating post-acute providers

are access, efficiency, collaboration and quality.

Access - Access should be defined in terms of patient needs and is a good way to determine if a hospital has

the right mix of providers in its network. To evaluate access, ask:

• Does the mix of providers support both the clinical and financial needs of patients?

• How often are patients sent outside the network?

• Does the network have capacity at the right times?

Efficiency - Providers that aren’t efficient or take too long to respond to referrals may require performance

improvement interventions or may not be good options for partnerships. Questions to ask to assess efficiency

include:

• Is the intake process manual or does it capitalize on technology?

• Is the staff at each post-acute provider in the network well trained and well managed?

• Are post-acute providers aligned with the right supporting providers?

Collaboration - Collaboration is needed to standardize workflow and reduce variation in care across

transitions. Consider the following:

• How willing are post-acute providers to work on key quality initiatives?

• Is patient information being shared across interoperable technologies to support clinical decisions?

• How well do downstream post-acute providers collaborate and adapt to changes in a patient’s

condition?

• How prepared are care teams to receive patients at the next setting?

Quality - Measuring quality during transitions can help networks drive improvements and make better choices

about where to send patients. Questions to ask on quality include:

• How is provider quality of care measured during the care transition process?

• Can readmission data and patient satisfaction trends be tracked?

• Are care teams across the network following standardized protocols?

• Does a specific patient population tend to be readmitted from a certain post-acute provider?


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2. Standardize Care Transition Workflows Across the Network

Any member of the network already transitioning patients has transition processes in place, but do those

processes support high-quality, low-cost care? Unfortunately, simply adding and training more staff to handle

workflows is not scalable, just as using separate, distinct processes for each patient, or even each provider,

cannot be sustained. Care transition workflows must be designed to provide each level of care with the

consistent, high-quality information they need to make better decisions faster. To do that, you need

technology. Standardized care transition workflows should apply to every accountable provider in the

network. In assessing workflows, here are five critical questions to consider:

• Are the care transition workflows sustainable in a value-based care environment?

• Do the workflows fit across the entire care network?

• Are any patients transitioned to providers outside the network?

• What information does the next level of care need to care for the patient?

• How is patient information shared across the network?

• Do transition workflows meet regulatory requirements for all providers?

3. Proactively Measure Outcomes and Efficiency

It is no longer enough to measure quality and efficiency just at the hospital. The care that a patient receives

at each care setting has downstream effects on providers that treat the patient later in the care episode.

Measuring care episodes across the network can help pinpoint bottlenecks by showing where patients are

spending the most time, and quality issues by evaluating the care they are receiving at each setting.

Just as care within each setting has a downstream effect on care at other settings, so does the care a patient

receives while being transitioned between settings. For example, a bad care transition from a hospital to a

SNF can impact the care the patient receives at that SNF and lead directly to a readmission.

Efficiency

• Fall Rate• Hospital-Acquired Infections• Patient Satisfaction

• Readmissions• Patient Satisfaction• Function Status

In-Setting Metrics

Between-Setting Metrics

• Length of Stay• Patient Throughput

• Administrative Delay Days• Provider Response• Provider Acceptance

Quality

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Enhance Security - A significant security breach can damage reputations and the bottom line. One of the

most important benefits technology offers in transitions of care is security risk reduction. Providers

communicating and exchanging protected health information (PHI) using faxes are at higher risk for a security

breach than those using secure transmissions. Under meaningful use, the government promotes the use of

CEHRTs and Direct mailboxes for secure transmissions during care transitions as a way to encourage more

secure clinical collaboration across networks. In addition, when systems are interoperable, important clinical

information can be sent more securely because there are fewer gaps when transmitting protected data

between systems.

Track and Measure Data - Good technology measures outcomes and efficiency throughout the care

transition process and shines a light on what is and isn’t working in the network. Great technology provides

that data in real time so that it can be used to inform actions and take advantage of opportunities.

Improve Interoperability - Information is most valuable when it is

available at the point when the decisions are made that affect

the care of a patient. Technology that is interoperable and

vendor-agnostic offers that value. True interoperability is about

sharing the right information at the right time with the right provider

so that the information is available when and where it can do the

most good.

Care Transitions Are Vital for Success

In an emerging healthcare environment that values — and pays for — coordination and continuity of care,

few processes are more important to a network of providers than the ones that connect them. Provider

organizations that adapt and thrive in the coming years will be those that recognize the importance of care

transitions, establish strong transition of care workflows and invest in the technology to make them work.

4. Implement Technology that Supports Care Transitions

Establishing post-acute networks, care transition workflows and appropriate measures of quality and

efficiency are all vital steps toward improving care transitions, but none will scale without technology.

Technology is fundamental in supporting connected networks, especially technology that is interoperable.

Technology reduces dependence on employees with important institutional knowledge and maintains

workflows even when there is staff turnover. Care transition technology should complement electronic health

records, which may vary by provider, and help manage patient transitions across episodes. It should support

efficient clinical workflows, secure protected health information (PHI) and measure the effectiveness and

outcomes of care transitions.

Reduce Process Variation - Care transition technology curbs manual process variation, which can lead to

miscommunication and mistakes. Standardization, especially through technology, streamlines the care

transition process by shortening response times, and supports better clinical decisions by requiring specific

and complete clinical information.

Information is most valuable when it is available at the point where the decisions are made that affect the care of a patient.


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Works Cited

Centers for Disease Control and Prevention. (2014, May 9). Chronic Diseases and Health Promotion. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/chronicdisease/overview/

Centers for Medicare & Medicaid Services. (2014, August 13). CMS.gov. Retrieved from Episode Grouping for Medicare and Supplemental Quality and Resource Use Reports (QRURs): http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Episode-Costs-and-Medicare-Episode-Grouper.html

Centers for Medicare & Medicaid Services. (2014, April 10). Frequently Asked Questions. Retrieved from CMS.gov: https://questions.cms.gov/faq.php?faqId=9690

Centers for Medicare & Medicaid Services. (2015, January 26). Better Care. Smarter Spending. Healthier People: Paying Providers for Value, Not Volume. Retrieved from CMS.gov: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

Chantrill, C. (2014). USgovernmentspending.com. Retrieved from US Health Care Spending History from 1900: http://www.usgovernmentspending.com/healthcare_spending

Cohen, PhD, S. B. (2014). Statistical Brief #448: Differentials in the Concentration of Health Expenditures across Population Subgroups in the U.S., 2012. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://meps.ahrq.gov/mepsweb/data_files/publications/st448/stat448.shtml

Coleman, MD, MPH, E. A., & Fox, P. D. (2004, September). One Patient, Many Places: Managing Health Care Transitions, Part I: Introduction, Accountability, Information for Patients in Transition. Annals of Long-Term Care, 12(9), 25-32. Retrieved from http://www.caretransitions.org/documents/One%20Pt%20Many%20Places%20Part%201%20-%20ALTC.pdf

Institute of Medicine of the National Academies. (2006). Preventing Medication Errors: Quality Chasm Series. Washington, D.C.: National Academies Press. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/2006/Preventing-Medication-Errors-Quality-Chasm-Series/medicationerrorsnew.pdf

NTOCC Measures Work Group. (2008). Transition of Care Measures. Washington, D.C.: National Transitions of Care Coalition. Retrieved from http://www.ntocc.org/Portals/0/PDF/Resources/TransitionsOfCare_Measures.pdf

Santell, J. P. (2006). Catching Medication Errors at Admission, Transfer, And Discharge. United States Pharmacopeia, 69(1), 77. Retrieved from http://connection.ebscohost.com/c/articles/19501826/catching-medication-errors-admission-transfer-discharge

Stanton, MA, M. W. (June 2006). The High Concentration of U.S. Health Care Expenditures: Research in Action, Issue 19. Rockville, MD: Agency for Healthcare Research and Quality. Retrieved from http://archive.ahrq.gov/research/findings/factsheets/costs/expriach/index.html

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