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Applying Transition Management Tools to Care for Chronic Patients Vera Dvorak, MD Julie Garcia, MSW, ACM, LNHA Inova January 28-29, 2013 Integrated Transitional.

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Presentation on theme: "Applying Transition Management Tools to Care for Chronic Patients Vera Dvorak, MD Julie Garcia, MSW, ACM, LNHA Inova January 28-29, 2013 Integrated Transitional."— Presentation transcript:

1 Applying Transition Management Tools to Care for Chronic Patients Vera Dvorak, MD Julie Garcia, MSW, ACM, LNHA Inova January 28-29, 2013 Integrated Transitional Care Inova System of Care Strategy

2 Resourceful, Community Oriented Flexible Quality Driven Efficient Accountable Clinical Outcomes & score cards Quality measures Wellness PCMH EBM Research Programs/ Plans aligned to strategy IT integration Shared service synergy Business unit synergy Integrated Transitional Care Case management, Ambulatory Inpatient, Observation, ED- Discharges Pharmacy Home Services Discharge clinics PACE, FQHC Data Driven Strategic Planning Analytics Medicare, Medicaid Indigent, Commercial population Internal customers External customers Relationships Satisfaction

3 Inova Transitional Care Management There is no longer a discharge process as traditionally understood by the physicians Discharge became a relay, passing the baton with all health related information among patients, nurses, caregivers, physicians, pharmacists, clinics, community services, FQHC, home services, SNF Results: a.reducing duplication of services b.improved decision support c.chronic disease management d.high patient satisfaction

4 Inova Transitional Care Medication reconciliation MD follow-up appointment in 7-10 days Education - Patient and/or caregiver knowledge of red flags Individualized treatment plan Multidisciplinary rounds Case managers Social workers Palliative care Rehab / Nutritionist Nursing Inpatient – MD Driven Multidisciplinary Discharge

5 Inova Transitional Care TCM – CM Driven Execution of discharge instructions Medication reconciliation 7 day follow up Warning signs and self management

6 Strategies for Safe Transitions Inova Transitional Services Discharge Clinics Inova hospitalist oversight Focus: Unmanaged Medicare, Medicaid, Uninsured and no medical care Comprehensive medical care, pharmacy assistance, case management, disease management and education RN assigned specifically for TCM population > 30 days if still waiting for medical home

7 Scope of Inova TCM Disease Groups CHF Diabetes COPD/Pneumonia Complex medical Payer Types Unmanaged Medicare Unmanaged Medicaid Uninsured Source/Status of Referrals Inpatients/Observation ED TCM Hospital CM Others Exclusions Commercial payers SNF/ALF ESRD Hospice

8 Inova’s Approach to a Transitions Model Enhanced Tools, Services and Strategies Wider scope Inpatient Case Management Transitional Services Discharge Clinic Home Visits Shared documentation software Community partnerships SNF collaborative approaches

9 Enhanced Tools and Strategies Home Visits Use Inova VNA Home Health Provide 1-3 non-skilled home visits as needed Use existing nurse staffing/scheduling Work with hospital liaisons Shared Software and Communication Allscripts for referrals EPIC conversion Milliman Care Guidelines Analytics- create reports to assist with comprehensive screening Readmission notification in real time

10 Enhanced Tools and Strategies Community Partnerships Safety net clinics Coordination of diabetic supplies Appointments fast tracked Pre-enrollment Identified contacts Participation with Allscripts Community partnerships with AAA 5 counties Shared fax form SNF Collaborative Visits, group meetings, Medical Director relationships Share data Education support

11 TCM Admissions by Disease March - December 2012

12 TCM Admissions by Payer March - December 2012

13 TCM Admissions by Patient Status March - December 2012

14 Overall Inpatient 30 Day Readmission Rate by Length of Engagement Inpatient Payer/DiseaseTCM Patient CategoryTotal ReferralsIP 30-Day Readmission Rate Total 30 Day Readmissions AllEnrolled > 28 Days % 20 Enrolled Days %31 Enrolled < 15 Days8850.0%44 Unable to Contact %22 Declined928.7%8 Other2330.4%7 All Payers Total %132 March – August 2012

15 Inpatient 30 Day Readmission Rate by Payer Inpatient PayerTCM Patient CategoryTotal ReferralsIP 30-Day Readmission RateTotal 30 Day Readmissions MedicareEnrolled > 28 Days % 15 Enrolled Days8127.2%22 Enrolled < 15 Days4643.5%20 Unable to Contact %11 Declined729.7%7 Other2025.0%5 Medicare Total %80 UninsuredEnrolled > 28 Days % 3 Enrolled Days3423.5%8 Enrolled < 15 Days3250.0%16 Unable to Contact7910.1%8 Declined156.7%1 Other366.7%2 Uninsured Total %38 MedicaidEnrolled > 28 Days % 2 Enrolled Days520.0%1 Enrolled < 15 Days1080.0%8 Unable to Contact1520.0%3 Declined50.0% Medicaid Total7418.9%14 March – August 2012

16 ED Referrals TCM Enrollment length Total Referrals Total 30-Day IP admissions Overall IP 30-Day admission % >28 Days % 15 to 28 Days % 8 to 14 Days8337.5% 1 to 7 Days % Referred: Unable to Contact3937.7% Referred: Declined9222.2% March – August 2012


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