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On-site nurses reduce readmissions, overall LOS
Program saves health plan millions
By placing on-site nurse case managers in hospitals and post-acute facilities, Presbyterian Health Plan of New Mexico has saved more than $1 million in just 10 months, according to Paula Casey, MSN, RN, ONC, CCM, clinical director for inpatient and recovery services at the Albuquerque-based health plan.
The savings come from reducing readmission rates and from an overall reduction of length of stay for patients on the health plan's list of the top 15 diagnoses that result in readmissions, Casey adds.
Case managers in the health plan's Nurse Care Coordinator program have home offices and work on-site at hospitals, skilled nursing facilities, and a rehabilitation facility in the Albuquerque area. The health plan case managers determine that members' needs are being met and address any gaps in care. They follow up by telephone after the patients are discharged to review discharge plans and needs.
As of January 2010, the 30-day readmission rate for Medicare Advantage members was 13%, far below the national average of 19.6% as reported by The New England Journal of Medicine, and the overall 30-day readmission rate for patients with all types in insurance was 6.8%. "My perspective is that a readmission is a failure of the discharge plan. When we saw the data on Medicare readmissions within 30 days, we knew we needed to do something better. Our readmissions rates are fairly low, but we still had opportunities for improvement," Casey says.
The health plan analyzed readmission data from all product lines Medicare Managed Care, Medicaid Managed Care, and commercial products and determined that its readmission diagnoses compared closely to Medicare's diagnoses. Medicare has announced that hospitals will be penalized for readmissions of patients with heart failure, pneumonia, and heart attack within 30 days after discharge. The health plan found that in addition to the three diagnoses cited by Medicare, a significant number of readmissions were occurring among patients with pancreatitis, dehydration, and septicemia.
The health plan's inpatient care coordination team looked at their own data, conducted a literature search, and identified steps they could take to reduce readmission rates. The team narrowed down the top 15 diagnoses that resulted in readmissions and identified patients with those diagnoses who were hospitalized. When patients with any of those diagnoses are hospitalized, a nurse case manager visits them in the hospital shortly after admission and again just before discharge whenever possible. With patients who have a very short length of stay, the case manager might make just one visit before discharge. When patients are from outside the Albuquerque metro area, the interventions take place by telephone.
During the first visit, the case manager talks about the role about the health plan in the discharge process and makes sure the patient understands his or her insurance benefits. On the pre-discharge visit, the case manager reviews the discharge plan with the hospital discharge planner and intervenes, if necessary, to make sure the discharge plan is appropriate. "We encounter situations where the patient is being transferred to a rehab facility, but there is no way that he or she can tolerate the required three hours of therapy a day, and instances where the patient is scheduled to go home the next day but hasn't yet walked to the bathroom," Casey says.
If a patient is being transferred to a post-acute provider, the health plan makes sure that the facility receives the discharge information and the orders for the patient. The case managers attend the care conferences at the skilled nursing facilities and observe the patients while they are in rehabilitation to make note of their progress.
During the post-discharge telephone calls, the case managers go over the discharge plan again and make sure that all of the supplies and post-acute visits and services have been set up. They ask patients to bring all of their medicine bottles to the telephone. The case managers go over what medications are in the home and what has been prescribed to make sure there are no duplications. They make sure that patients understand their medication regimen. They intervene if there are any gaps in care. For example, one patient failed to get her prescription filled after discharge, which put her for risk at severe complications. The patient told the case manager that she had no transportation to the drug store. The case manager got the prescription faxed to a drug store that delivered.
Most of the time, patients receive their post-discharge phone calls from the nurse care coordinators they see in the facility. The exception is if patients are enrolled or are candidates for a disease management program. In that case, the disease management health coach team makes the calls.
"When a patient gets out of the hospital or a post-acute facility, it's a wonderful opportunity to capture them at a time that they are aware of their chronic condition and motivated to change," Casey says.