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How can you prepare for an ACO world?
Various strategies outlined
Some hospitals have been focusing more on care transition issues in anticipation of the advent of accountable care organizations (ACOs) or just because it's a way to improve both quality and efficiency in health care.
One health network in Arizona has implemented several projects and programs that lead to health care transition improvements, especially among high-risk populations.
"We use navigators who are community outreach workers to enroll people in a diabetes disease management program and to create a registry," says Donna Zazworsky, RN, MS, CCM, FAAN, vice president for community health and continuum care at Carondelet Health Network, a four-hospital system in Tucson, AZ.
"We identify the highest risk patients, and navigators get them into services," she explains. "They make sure they have their annual exams and have access to dietitians and educators in the doctor's office."
Navigators, who are nonclinical and must be supported by a nurse or other member of the clinical staff, also call patients who miss appointments and schedule and coordinate patients' contact with the care team. They help manage patient data, act as peer contacts who bridge language and cultural barriers, and assist patient interaction with the diabetes care team.
"It's all part of our patient-centered health care effort," Zazworsky says.
Here are some other areas in which the health network is focusing more on care transitions:
Pay close attention to heart failure patients. "Heart failure is one of those major areas that hospitals need to target because there won't be payment for readmissions if people are readmitted within 30 days," Zazworsky says.
"You will see a lot of transitional programs where nurses, with the help of cardiologists and health managers, identify patients they pick up from inpatient care and follow them to the home," she explains. "They make sure they make their physician appointments, get their medications reconciled and filled, and provide some home visits and phone call follow-up."
Some transitional care nurses will even meet a patient in the doctor's office. This follow-up continues for 60 days and provides needed support to patients who are asked to do considerable daily monitoring, including checking their weight, symptoms, and taking a complicated medication regimen.
"Patients often have difficulty with that," Zazworsky says. "They're high risk, vulnerable, and may not have a family support system."
Transitional care nurses attend the patient's meetings with other providers and help patients understand their care instructions, she adds.
Hold other providers accountable. When the hospital discharges a patient to his or her home and refers the case to a home health agency, the hospital has an expectation that the home health agency will do what it can to prevent readmission.
"We expect our patients to be seen within 24 to 48 hours post-discharge," Zazworsky says. "We expect a feedback loop."
The days of working in a silo where the patient no longer is the hospital's patient upon discharge are ending, she notes.
ACOs will give hospitals and other providers economic incentives to be accountable for their patients throughout the entire care continuum, she says.
This means that hospitals will pay more attention to the home health agencies, nursing facilities, and other providers to whom they refer patients. And they'll develop preferred provider lists based on the community providers' quality and readmission data, Zazworsky suggests.
"We say to providers, 'If you want to be on our preferred provider list then these are our expectations,'" she adds.
Develop post-hospitalization clinics. The key is to have patients visit their providers in a timely fashion after discharge.
"We work with a federally qualified health center that has a wonderful program for transitional care," Zazworsky says. "We make sure they are seen by a provider and have a discharge planning nurse."
The discharge nurse works with the newly discharged patient to make certain the community doctor visits take place, medication prescriptions are filled, and care instructions are followed.
Post-discharge clinics might have physicians, nurse practitioners, and/or physician assistants who are available to see any patient who is discharged from the hospital and who has a problem with getting in to see a primary care doctor for timely follow-up, Zazworsky says.
"With some physician practices, patients might wait two weeks to get in to see the doctor, and they could end up in the hospital again," she explains. "So the post-discharge clinic provides the initial visit, does medication reconciliation, and assesses whether the patient's self-management and care coordination are adequate."
Expanding access through telemedicine. Carondelet Health Network has a telecardiology program that expands the reach of rural hospitals.
"A patient might come into a rural critical access hospital with congestive heart failure, unstable atrial fibrillation, or soft chest pain," Zazworsky says.
The rural hospital's emergency department physician can examine the patient and then initiate a telecardiology visit with a cardiologist at the urban hospital. The cardiologist helps the local physician decide whether to keep the patient at the rural hospital or ship to the urban center, she explains.
"You're delivering lower-cost care in a critical access hospital rather than paying for helicopter flights and hospitalization in an urban setting," she adds.
The health system's telemedicine program also includes teleneurology, telestroke, and tele-education in which professionals can be trained at any location, Zazworsky says.
Donna Zazworsky, RN, MS, CCM, FAAN, Vice President for Community Health and Continuum Care, Carondelet Health Network, 1601 W. St. Mary's Road, Tucson, AZ. Email: firstname.lastname@example.org.