The Space Between: How Partners is Improving Care Transitions
Health care doesn’t happen as a singular event; rather it’s a series of interactions ranging from the most acute phase to routine follow-up care. With so many levels of care throughout the patient’s journey, it’s important to assure that the care transition process is well-coordinated. For example, a patient may receive open heart surgery, then transition to a rehabilitation center, and then finally to home-based services.
Collaboration with naviHealth has provided us with a new tool for managing care transitions. It helps us set goals for patients’ length of stay, and educates and prepares patients about what to expect during the next step of their treatment.
The naviHealth program started as a pilot at the North Shore Medical Center (NSMC) in April of 2015. The program focused on patients enrolled in the Center for Population Health high risk care management program, known as the Integrated Care Management Program (iCMP) as well as patients in our Accountable Care Organization (ACO).
When a patient is ready to be transferred from one facility to another, whether it is the hospital to a rehabilitation center or from a rehabilitation center to their home, one approach is to use a Transitions Navigator. The Transitions Navigator, similar to an Inpatient Case Manager, is embedded in the care team to act as a liaison between the patient, family members and the interdisciplinary clinical team. Both Transitions Navigators and Inpatient Case Managers focus on details that can overwhelm patients like scheduling follow-up appointments, connecting with physicians for medication reconciliation, or helping to enroll patients in iCMP.
A key element of success at NSMC was having access to naviHealth’s online tool called LiveSafe. The tool works by taking our patients data and comparing it against a large database of real patient outcomes. Despite a small set of questions manually entered about the patient’s current status, it’s a quick process to get results. “It’s really broken down into 3 categories: basic mobility, daily activities, and applied cognition,” says Michael Vestal, the Transitions Navigator at NSMC for patients discharging to Skilled Nursing Facilities (SNFs). “And with those three scores the tool gives us an overall score that guides us on what we consider next.”
By comparing the current patient to subsets of patients with similar conditions and backgrounds, the LiveSafe tool can produce a reasonably accurate estimation for how long the patient should stay at their current level of care. This estimation is not only important because it gives patients a realistic timeframe for their stay, but because it allows the team to evaluate rehabilitation facilities outcomes. According to Laurie Isidro, naviHealth Project Manager at NSMC, she can now compare facility outcomes in ways she never could before.
Normally, facilities can only be evaluated on average length of stay —an unfair measure considering some patients have more complex needs and will require more time to achieve their goals. “However, by knowing how long the stay should take versus how long the stay actually is, as well as if the patient was readmitted, we get a much more accurate picture of quality patient outcomes,” says Isidro. For example, one patient might have an expected length of stay of 15 days in facility one, with 5% variance. But at facility two, another patient has an expected length of stay of 12 days but is varying at 40%. “These metrics, when aggregated, allow us to evaluate which facilities are providing better quality, efficient care, and which have some opportunity for improvement.”
Using this tool, the naviHealth program at NSMC has been able to significantly reduce the number of days (Days/1000) patients stay in SNFs by 33%, compared to an 18% reduction for the Partners network. This is primarily driven by two advances, a reduction in SNF length of stay overall and redirecting some discharges home that otherwise would have gone to a SNF.
The Partners naviHealth program is now expanding to Massachusetts General Hospital, Newton-Wellesley Hospital, Emerson Hospital, and Cooley Dickinson Hospital. “All around, this program improved care,” says Charles Pu, MD, Medical Director for Care Transitions and Continuum at Partners.
The addition of the naviHealth Program at NSMC has optimized patient care transitions, reduced unnecessary post-acute utilization, and decreased the likelihood of readmission. “Not only do patients receive higher quality care that is more coordinated, it’s also cost effective,” says Pu. “We look forward to implementing this across the Partners network so more patients and their families can benefit from this resource.”