3 Ways to Maximize Patient Care at Home

The Centers for Medicare & Medicaid Services (CMS) explain: “Our value-based programs are important because they’re helping us move toward paying providers based on the quality, rather than the quantity of care they give patients.” 

Successful value-based programs help realize the Institute for Healthcare Improvement’s (IHI) Triple Aim:

• Improving the patient experience of care
• Improving the health of populations
• Reducing the per capita cost of care 

Integrated Care Solutions (ICS) argues that coordinating and managing patient care throughout the care continuum must be a top priority to achieve the Triple Aim under alternative payment models. Optimizing patients’ and their care partners’ ability to manage their own care in their own home setting is a non-negotiable in developing successful care management processes. 

At ICS, we do just that. Our proven, proprietary high-tech, high-touch clinical model—focused on patient and care partner empowerment and a close collaboration between patient and community providers—allows us to achieve this monumental task on behalf of our provider partners. ICS works within the CMS models to guide physicians and health systems to successful outcomes in the transformation to value-based care. 

 “The future of care management is now in the present with the opportunities provided by CMS programs like ACOs, and even more compelling, Direct Contracting,” says ICS’ Dana Strauss, Vice President of Partner Engagement and a Doctor of Physical Therapy. “The direction now and moving forward is to develop processes and improved strategies informed by high-quality data and analytics and evidence-based practice guidelines that maximize days per year at home. Risk-bearing organizations that can successfully improve this key metric—days at home—are the ones that will be successful under these payment models.”

The Patient Care Management Problem
One of the biggest challenges across the care continuum, Strauss says, “is that doctors need support making evidence-based decisions, managing early- to mid-stage chronic diseases without needing to tap into the expertise of specialists.”

They also need to know:

• Their diagnosis is only the start of disease management. 
• They have the support of other clinicians who specialize in helping patients and care partners minimize disease progression and stay as healthy as possible. 
• Care extends beyond the walls of their office. Someone will be watching out for the patient and keeping them informed if something changes and a specialist is needed.

The value-based model requires participants like Accountable Care Organizations (ACOs) and Direct Contracting Entities (DCEs) to spend and use less than the total they’re allowed per beneficiary per month (PBPM) for every Medicare patient. Besides hospitalization costs and the cost of other inpatient settings (rehab facilities, skilled nursing facilities, etc), another significant cost is specialty care. Specialty care is vital for many patients, but well-supported primary care can do more to support chronic diseases, especially early stage. Specialists also do not commonly coordinate care with the primary care provider.  

When 85 percent of people over 65 have a chronic medical condition, specialty care costs quickly add up. Specialists should be utilized when primary care and the practice’s support systems can no longer meet the needs of a patient with a chronic disease, and clinical decision-making requires a higher level of specific expertise.

Strauss explains: “For example, let’s say a physician has a newly diagnosed type 2 diabetic patient on an oral hypoglycemic who comes for their annual wellness visit and bloodwork shows the patient’s hemoglobin A1C is 9. The physician knows blood sugar has not been kept under close control. Is the medication dose or type insufficient? Is the patient non-compliant with the diabetic diet? Or do they need insulin? The physician will have some time with the patient to make a hypothesis, but that is where their oversight ends. The doctor may provide instructions and a change in medication, requesting a return in one month. The patient is now essentially on their own, at risk of an adverse event with high blood sugar. Is an endocrinologist needed, or is a nurse who can closely follow the clinical course and better serve the patient to provide education, reinforcement, and oversight? ICS would advocate for close nurse care coordination as the first course of action.”

Some patients will have hospital admissions that are unavoidable, no matter what is done proactively. Physicians are often blind to these events. 

“It’s time to help physicians take control of their patient care,” said Brian Fuller, ICS’ CEO. “At ICS, our goal is to support the transition from a hospital or post-acute facility to the home setting and proactively manage patients’ clinical and support needs in the community. We want to give every patient and their care partners who have suffered a hospitalization every chance of remaining home and on the road to recovery.”

Below are ways to maximize patient care at home and reduce the overall costs of care. 

Partner with a Skilled Care Management Nursing Team Trained in Chronic Care Management
Keeping patients at home requires a team of skilled nurses who are experts in care management and care coordination. To support hospitalized patients, ensuring these teams facilitate successful transitions prevents errors and gaps in care. The term “discharge” is segueing out of the healthcare vernacular.  

“At ICS, we never discharge a patient,” Strauss says. “We transition them and support the primary care management of those patients. We know where they are in the care continuum.  We know who’s at risk, and that’s the great benefit of partnering with a company like ICS.  These transitions of care are blind spots for community physicians. ICS is their eyes and ears.” 

ICS also identifies patients within a population that is at risk of an adverse event. We know who frequently utilizes the ED, who has had multiple hospital stays, and those who don’t regularly see their physicians despite having chronic diseases. ICS can target the right patients to contact and identify the right frequency at which to contact and communicate with them.

In one case, an ICS multi-disciplinary team helped a patient with a history of mild dementia and bipolar disorder who was admitted to the hospital for sepsis and then a skilled nursing facility (SNF) for follow up care. The team advocated for the patient when her condition worsened at the SNF, and as a result, more tests were done. It was found that she was suffering from a urinary tract infection among other ailments. ICS met with the patient’s spouse to determine a safe, long-term living situation, helping to address the “big picture” and lead to the best possible long-term outcome.

Hospital readmission was prevented by addressing deteriorating health conditions with the SNF. Length-of-stay was carefully managed, preventing complications from extended stays that don’t improve patients’ long-term outcomes.

Monitoring Condition Changes in a SNF Prevents Unnecessary Readmission

Investing in a skilled team to work along that continuum will always benefit the patient and provider. 

Communication is Key
Value-based programs depend on communication—and it’s mandatory for successful patient care management. To ensure patients can safely and comfortably remain in the home, care teams must skillfully and patiently communicate with patients and care partners. They also see problems through to resolution. An excellent patient care team, for example, analyzes the living situation at the patient’s home and, in some cases, acts as the coordinator to make sure the house is up to standards. They may help contact contractors who modify homes to reduce adverse events like falls and maximize days per year at home. 

In one case, ICS coordinated community funding and support for constructing a wheelchair ramp so a patient could return safely home, avoiding an extended stay at a SNF. Without ICS interventions, the patient might have had a protracted stay in the SNF. ICS made sure an application was started for Medicaid. Better post-acute care coordination and communication led to this patient being discharged home safely in 24 days.

Reducing Unnecessary SNF Utilization Through Coordination with Community Resources

“Though maximizing patients’ time at home is the ultimate goal,” Strauss says, “when patients are hospitalized, we collaborate with the hospital case management staff to use high-quality providers along the continuum to ensure patients have smooth transitions. Also, we make sure medications are reconciled throughout. We diligently work to get them back home to a point of at least stabilizing their chronic condition and addressing any new needs that may have developed because of their injection back into the acute- and post-acute part of healthcare.”

Invest in Strong Care Management Technology 
The digital age of healthcare is offering more opportunities to better manage patients throughout the care continuum; however those products often do not exist “off-the-shelf.” With the right investment in a longitudinal care management platform, medical teams can instantly access patient information across settings of care from a single source. Such platforms allow uninterrupted handoffs through patient transitions that ultimately provide optimal outcomes for those in care and those providing care. 

ICS has a proprietary technology—Care+— that significantly improves patient management throughout the care continuum. The software was developed to ensure excellent patient experience wherever the patient receives care, and equip providers with insights and analytics needed to track outcomes and control costs.

Benefits of the Care+ software include: 

• Proprietary risk prediction 
• Real-time patient tracking and health status
• Dynamic, patient specific cross-continuum care plans

“ICS combines high-tech enterprise customized solutions that marry claims data, social determinants of health data, ADT feeds, and real-time data to inform care management opportunities,” Strauss said.

Being able to provide the right tools for the right outcomes is a crucial step in transforming healthcare to the value-based model.

ICS guides organizations through their transformation from fee-for-service to value-based care. We deliver the post-acute expertise and data-driven processes necessary to achieve quality care and financial success. If you are a provider in need of a partner with expertise in value-based care and proven results working with risk-bearing organizations, contact ICS today for a free consultation.
info@integratedcaresolutions.com
860-622-7645

Additional Resources on Patient Care Management
Direct Contracting: Moving the Risk from CMS to Providers
Direct Contracting: A Collaborative Relationship Between DCEs and SNFs
Post-Acute Care Solutions for Direct Contracting Entities
Discharge Planning: A Critical Component of the Continuum of Care

ICS helps organizations improve community care coordination and drive the transformation to value-based care. Learn more about how ICS delivers results for organizations by putting patients first. Call us today: 860-622-7645.