Transition of care calls for primary care quarterback

Imagine you have a patient who was recently hospitalized because of a stroke. After weeks in the hospital, with rehabilitation, she is being discharged on a Friday afternoon. She lives alone, but her son comes to the hospital to take her home. The physical therapist’s notes state that the patient can only safely maneuver four steps. Her son works full time and has a wife and children of his own.

It becomes clear that this patient may have issues with taking medications on time, and getting around her home safely. But who should be at the discharge planning meeting-the hospital physician, her primary care physician? Does her son know all he needs to know to ensure her care? Who is accountable for following up with the patient?

Mona Sweeney, RN, assistant director of accreditation services-primary care for the Accreditation Association of Ambulatory Health Care (AAAHC), says that at a recent discharge planning meeting, she was surprised that no one was asking the patient, or her family, critical questions about her life outside of the hospital.

“A number of hospital discharges happen on Fridays or on the weekends, and no one asked how many stairs were in the house-there were 15,” Sweeney says. “We need practitioners to look at the whole piece, and not just doing a good job at what they do. This includes an assessment of family and home situations.”

There are a number of programs being developed that aim to address transition of care issues, many coupling primary care and Patient-Centered Medical Homes (PCMH). And though research suggests that medical communities can provide the most comprehensive care to those moving from one healthcare situation to another, many of these programs have limited funding.

“The system does not incentivize physicians,” says Sweeney, adding that AAAHC has accredited 371 satellites as PCMHs, which branch out to include several more individual sites. “It is very difficult for a small practice to be a team. If they are hiring people, they need to be working at the top of their degree. Many of these practices are overwhelmed with patients, overwhelmed with paperwork. But a big piece of successful transition of care is the medical home, which helps address and sustain patients to prevent readmissions.”

The Centers for Medicare and Medicaid Services estimated that it will pay $600 million to practices after implementing five new codes that support care coordination in 2013. For 2015, new codes reimbursing practitioners for non face-to-face visits and telemedicine have been approved. But experts agree that it is difficult to track and bill for meetings with other physicians, and conversations with caregivers.

Also, getting physicians from different disciplines, nurses, health coaches, family and patients all on one page seems like a colossal task for an already busy primary care physician.

“We put a lot of emphasis on relationships, which may sound soft. But that’s the piece that leads the other pieces. Patients become partners in their own care and doctors are in charge of knowing the neighborhood,” Sweeney says.

Challenges for primary care
Practitioners are being urged to become more patient-centered, which has been proven to help patients transition between providers. Many models encourage primary care and family physicians to be “quarterbacks” in patient care, but how practical is it for busy practices to implement this idea?
“In general terms of transition of care, it doesn’t always include primary care. Sometimes there are elderly patients who are bouncing between sites.

Doctors are left out when patients are bounced between specialists,” says Harbrecht. “With PPO [Preferred Provider Organization] plans, patients can be bounced around a lot, and primary care doctors can be out of the loop. Someone needs to be the coordinator, the quarterback for the patient. Without it, it is more likely to lose focus in patient care.”

Lattimer says that cost barriers such as adopting new technologies and hiring additional advanced-level nurses and practitioners are also issues that face small practices. However, in some communities there are other resources that practices can utilize to communicate with patients better, she says.

Though it is hard to estimate how much it costs to launch a PCMH,  the American Academy of Family Physicians estimates that it can cost up to $100,000 per full-time physician, including technology costs. In order for the model to work, practices are going to have to find affordable ways to coordinate care.

“A lot of what we see with primary care physicians is that they are trying to identify health coaches and care coordinators within their community to provide support. These people can understand resources beyond hospitals and specialists,” Lattimer says. “In rural areas there is a tremendous challenge because community resources could be very limited and physicians just don’t have the same choices. But many of those doctors use non-medical home entities to help coordinate transition of care coordination with patients.”

Is technology the solution?
The implementation of electronic health records (EHRs) and more acceptance of telemedicine are often viewed as a big step in care coordination, but there are still glaring technology difficulties. Interoperability between EHR systems inhibits solo practitioners from easily communicating, with can slow up transition of care.

“It is very challenging because practitioners are not on the same EHRs, and are often very busy in their own offices, the payment system doesn’t reward for it at all and attempts at communication is not always mutual, Harbrecht says.

Unfortunately, technology can sometimes do more to slow the transition of care process. Half of the patient records primary care physicians send to specialists never reach them, according to statistics published in the Journal of the American Medical Association. The study also found that 48% of hospital discharge letters contain incorrect information about patients’ medical history.

Lattimer says that there are still security issues surrounding the management of patients via video and telephone. In addition, one of the requirements for primary care practices to be reimbursed for non-face-to-face care is that they have a nurse practitioner or physician assistant on staff. This may be a challenge for a solo practitioner.

“There is still a lot of concern when you talk about telemedicine and the patient-centered medical record switching several hands and remaining confidential,” Lattimer says. “I am a strong believer in technology as a tool and a resource, but it is not an end all answer.”

Which patients need the most transition of care help?
Elderly patients aren’t the only ones dealing with transition of care issues. In fact, our experts encourage practitioners to stop looking at transition of care as an old age problem.

According to the Center for Healthcare Quality and Payment Reform, preventable readmissions occur because of surgical site infections; patients and caregivers not receiving clear instructions about medications and lifestyle adjustments; and recurring chronic conditions.

“Anyone who has a transition of care is affected by the challenges of care coordination,” says Marjie Grazi Harbrecht, MD, chief executive officer of HealthTeamWorks, a long-term support organization for practices and organizations adopting patient-centered care.

Cheri Lattimer, executive director of the National Transition of Care Coalition (NTOCC), agrees that any patient moving from one medical setting to another, or facing significant rehabilitation, needs a transition of care plan. “It is more dangerous in poor transition of care with someone who is 20 years old with a knee replacement, than a 40-year-old who has better care options,” she says.

Patients with mental disabilities, multiple handicaps, complex chronic or reoccurring medical problems, and who don’t speak English often have the most issues with care coordination between providers.

“It’s not about procedures or ailments. Specific populations are at a higher risk of being out of the loop-seniors, pediatrics, homeless, and the under-insured or those with no insurance,” Lattimer says.

Make transition of care work for your practice
At the end of the day, implementing a plan to make transition of care coordination a priority in your practice is more about what patients need and not what is easiest for practitioners.

“If we focus on the patients and what the patients need, as opposed to each individual entity or practitioner and their needs, we can have greater success,” Harbrecht says. “The biggest things are engaging and empowering the patient. Second is making sure there is a quarterback with medical knowledge to fight for the patient. Lastly, communication between all the entities providing care.”

After evaluating transition of care models for years across different populations, from rural to big cities, NTOCC has identified seven key interventions that all models have in common:

• Medications management

• Transition planning

• Patient and family engagement/education

• Information transfer

• Follow-up care

• Healthcare provider engagement

• Shared accountability across providers and organizations

with more information about how to fit these interventions into your practice. Lattimer notes that models that implemented these seven key interventions showed better engagement and adherence and were better able to use technology to communicate with­ ­patients.
Ultimately, any strategy must include a strong communication component. Lattimer says that providers need to understand the language they use among each other is not the same language they can use with patients. When patients feel they aren’t being heard, or don’t understand what needs to be done, the risk rises for ­readmission.

“There needs to be more than written instructions. Everybody can raise the bar and attempt to approve. Providers can’t point fingers at patients because there is a lot of room for all of us to improve,” Lattimer says.