As part of its efforts to provide better coordinated care to Medicare beneficiaries at a lower cost, the Michigan Pioneer Accountable Care Organization (ACO) at Detroit Medical Center has partnered with post-acute providers and works with them face to face to coordinate care and ensure that patients get what they need in a timely manner.
The ACO was ranked No. 1 in the nation in healthcare savings among Pioneer ACOs in 2014, says Roger Wiseman, president of the Michigan Pioneer ACO and senior vice president for population health for the Detroit Medical Center market. “We have been successful in saving in each of our three years in the Pioneer ACO. The savings are due to a lot of factors, but certainly our care management is at the top of the list,” he says.
The ACO has forged a close relationship with home care agencies and skilled nursing facilities, Wiseman says. Other initiatives include working closely with hospital case managers, follow-up calls to patients discharged from the hospital or emergency department, and visits from a home health nurse when patients are still in the hospital.
“When our ACO team looked at the whole continuum, we saw that at every point where patients transition, there is a big hole where a critical piece of information doesn’t go through,” says Joan Valentine, RN, MSA, corporate director for transitions in care at the Michigan Pioneer ACO. “We knew we needed to build a collaborative relationship with post-acute providers and communicate as patients transition.”
As a result, care coordinators from the ACO attend weekly rounds at the home health agencies and skilled nursing facilities to discuss patients, their care plans, and goals. “Meeting face to face works a lot better than trying to work together over the telephone. Because of the collaboration, we have been able to help patients get what they need,” Valentine says.
In the early days of the ACO, the organization’s team met with the owners of the five largest skilled nursing providers that control 60-plus skilled nursing facilities in the area to talk about ways to coordinate care. “We know patients are readmitted from skilled nursing facilities frequently and we wanted to work with the facilities to prevent the unnecessary readmissions. The multidisciplinary rounds give us an opportunity to collaborate to meet patients’ needs and move them along the continuum in a safe manner,” she says.
When patients are facing a long stay in a skilled nursing facility, the team looks for ways to move the patient along and preserve their Medicare benefits.
“The skilled nursing staff often alerts us to patient needs and we can intervene and get them assistance,” Valentine says.
For instance, the staff at a skilled nursing home was proposing that a younger man who was extremely obese be transferred to a long-term care facility in part because he couldn’t participate in therapy because of his size. He was depressed and had major issues with edema and fluid retention. The ACO team worked with the facility to arrange for a different lift, a different bed, and a larger wheelchair so he could get out of bed and move around. They brought in a nutritionist to work with him on a modified diet.
“He had a huge support system within his church and they rallied around him. We educated them on his dietary needs and told them that bringing in food from the outside was not in his interest,” Valentine says.
The patient was discharged to an adult foster care home, lost 100 pounds, and eventually went back to his home with support from home care. “He hasn’t been back to the hospital. He used his benefits but we knew that was the right thing. He was too young and mentally acute to give up. Because of the close relationship between our team and the skilled nursing team, we were able to find out what he needed and get it for him,” she says.
When patients are ready to transfer home from a skilled nursing facility, the ACO care coordinators make sure the skilled facility and the home health agency communicate and help facilitate the transfer home, Valentine says.
The participating home care agencies agreed to give the ACO’s patients priority in scheduling appointments and for their nurses to document in the ACO’s medical record, Valentine says.
The weekly multidisciplinary rounds at the home care agencies give the ACO care coordinators insight into what is going on in the patients’ homes and what services the ACO should arrange so the patients can live independently and stay healthy, Valentine says.
“The home care nurses tell us what they are seeing in the home and we work together to leverage community resources. Home health is not always the only answer for all needs a patient may have, but we may not know about their other needs. The home health nurses advocate for the patients and help us understand what we need to do for them,” she adds.
For instance, the home health nurse may report that the patient needs housekeeping assistance, Meals on Wheels, or that the caregiver needs support. The care coordinators can alert the social workers to set up the services.
The home care nurses play an important role in medication management for newly discharged patients, Valentine says.
“Patients can’t always remember everything they are taking and sometimes the final medication reconciliation just before discharge may not be as accurate as we think. We rely heavily on home health providers to assist us in getting the whole picture,” she says.
The home health nurse asks patients to bring out all their bottles of medication and goes over them with patients to make sure they are taking the right thing. “The reality is that what they related at the hospital and what’s in the home may be very different,” she says.
The ACO receives real-time information on admissions, discharges, and transfers from Detroit Medical Center. “When we find out about an admission, we talk to the hospital case manager and social workers and give them information to help them understand the patient and what the discharge needs may be. We tell them we have been working with the patient, and give them information about the patient’s history, their support at home, and the home care agency that has been seeing the patient. In some cases, we may know that patients have been admitted several times to different hospitals and can share information on the services they received,” she says.
The organization receives an alert when patients are ready for discharge and arranges for a home health nurse to visit the patient in the hospital before discharge.
When the team identifies a patient with a chronic disease who seems to be getting worse, a nurse case manager goes to the physician office, meets with the patient, and collaborates with the physician on developing a plan of care, Valentine says.
“We are not only reacting to patients who are already receiving interventions, we are looking for patients who are escalating and helping them learn to control their disease and stay healthy,” she says.
Staff at the ACO’s call center follow up with patients who have been discharged from the hospital or the emergency department. They use a script and ask specific questions to determine if the patients understand their discharge instructions, if they have filled their prescriptions, if a home care provider has set up an appointment if the service was ordered, and if they have made a follow-up physician appointment.
“If the patient has not made an appointment, we make the appointment for them. When our staff calls, they often can get a visit scheduled sooner than if the patient calls,” Valentine says.
When patients sound confused or say they don’t understand their treatment plan, they are referred to a nurse who either talks to them or to their caregiver. If they have questions about medication, they are referred to a pharmacist.
“The telephonic staff is like a detective: They try to figure out what the patient needs. There is so much pressure to move patients out of the hospital that there is a lot of opportunity for care coordination when people get home,” Valentine says.
When patients visit the emergency department two times within a month, the call center staff calls them to find out what is going on and works on getting the patients community-based resources to help support them. They also inform the patients’ physicians that they are using the emergency department frequently.
CMS announced changes to the accountable care organization model last spring, Wiseman points out.
“The accountable care organizations are changing, but what’s not changing is the core principal and core belief that care coordination, keeping the patient at the center, and communicating across the continuum of care are the keys to success. These apply whether the patient is covered by Medicare, Medicaid, or a commercial insurer,” Wiseman says.
