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HIMSS: Transition Care Helps Keep Patients Out of EDs


Care transitions are perilous times for patients, and that’s maybe even truer coming out of the hospital than going in. But with a little attention and some fairly simple measures, organizations can streamline the process to run more smoothly and safely.

That was the message Lehigh Valley Health Network’s Tori Chestnut and Jim Shull delivered Tuesday morning to attendees at HIMSS ’18, the Health Information and Management Systems Society’s annual conference and trade show, occurring this week in Las Vegas. LVHN’s attention to the process has yielded some tangible benefits. 

The Pennsylvania network is a sprawling one, with eight campuses and around 160 physician practices totaling about 2,800 providers. It admits 70,000 patients a year. Across that web, it had complex CMS requirements for transition care billing that were nonetheless leaving opportunities missed. Those requirements included telephonic or e-mail contact within two days of discharge; a review of discharge information and communication with relevant community partners; and face-to-face contact between the patient and their primary care provider within seven days for simple cases and 14 days for complex ones. Only with all those boxes checked could the organization bill for transition care. 

Lehigh’s specific problem was this: Those responsibilities were distributed across about 45 practices and so were performed in a variety of ways. Different staff and organizational subcultures in different locations had different priorities. As well, needed community services were scarce in Pennsylvania’s rural areas; LVHN’s discharge registry was view-only, not interactive, meaning efforts were often duplicated; and there was no way to stratify patients by clinical risk. What it added up to was that just 62% of discharged patients eligible for transitional care coverage were getting the necessary outreach. 

The first step of the solution was to centralize resources. LVHN dedicated staffers to TCM (transitional care management) activities who couldn’t be pulled away by other responsibilities. But staff were still spending multiple hours a day reviewing the registry and huddling in meetings. So the next advance was to link patient documentation to an upgraded discharge registry. They also created graduation criteria, by which patients could move out of the program, and team chat rooms for real-time communication, which replaced the daily huddles. “That sounds small,” said Chestnut, who oversees LVHN’s population health integration, “but it made a big difference to our team.”

What resulted, Shull said, was better staff productivity; an improvement of more than 20% in call compliance (the rate of patients getting their follow-up calls within two days); and a reduction of 8.4% in discharged patients’ ED utilization from six months before to six months after the change. 

Once all LVHN practices adopt the new measures, Shull said, they expect call compliance to top 90%. But even now the network is billing TCM codes at higher rates than routine follow-up visits. That’s contributed to an overall return on investment of approximately 4.5:1. 

Population health is a new field, Chestnut noted, meaning there aren’t yet a lot of defined best practices to adopt and adapt. “We were kind of tasked with figuring it out ourselves,” she said. But by taking the time to capture accurate data, leveraging technology by automating as much as possible, and utilizing economies of scale, health systems can recoup more costs while maintaining patient safety.

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