Care Management Best Practices for Improving Patient Outcomes

1. Improving Patient Care

How to Improve Patient Intake

According to the last survey conducted by the U.S. Department of Health & Human Services, there were over 125 million outpatient department visits in a single year to U.S. hospitals. With such high patient volume, every healthcare organization should take a thorough review of its patient intake processes and identify areas for improvement. Here are a few best practices your organization should keep in mind when considering ways to improve your processes.

Patient Engagement

Another vital area of care management is patient engagement. Let’s take a look at three reasons why you should include patient engagement in your care management plan.

Enhancing Coordination of Care

While caregivers are largely responsible for care coordination, problems can arise if patients are not fully engaged and educated. A few potential problems with patients include:

• Not understanding why they are being referred for something
• Unclear on how to schedule appointments
• Not understanding why it’s important to complete each stage of treatment
• Unsure of what to do after completing a particular stage

Eliminate Duplication

If patients are asked to complete a particular service more than once, this could delay their treatment. In addition, it will also waste a patient’s money and a provider’s time and increase the potential risk of an investigation of fraud. To identify potential duplication, caregivers must ask patients whether they have already received a particular service when discussing treatment plans.

Help Patients More Effectively Manage Health Conditions

As Partners Healthcare notes:

“Evidence has shown that patients engaged in their health demonstrate improvements in their ability to self-manage their care, better outcomes and experiences in hospitals, and lower costs of care.”

Providers can help patients manage their own conditions by supporting them in the following ways:

• Give them more control
• Offer education and support
• Consider health literacy
• Focus on moderation

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Care Management Program

Care management programs have become a vital part of helping organizations improving the quality of care while reducing costs. They have become especially important as organizations have moved from fee-for-service to value-based payment models.

As you evaluate your care management program, consider these best practices.

1. Define Program Scope — Don't try to tackle too many initiatives at once. A program will perform best when projects are aimed toward specific populations and/or specific needs within the community.
   
   
2. Engage Stakeholders — Stakeholder support can be critical to your program’s success. Be sure to involve appropriate stakeholders in the development and execution of the program.
   
   
3. Establish Objectives and Timelines —To determine success with your program, outline objectives and timelines to achieve them.
   
   
4. Measure and Evaluate Performance — With the established objectives stated earlier, you can measure and evaluate the performance of your care management efforts.
   
   
5. Secure Financial Support — When working to secure financial support for the program, have a plan for how that money will be used. Developing a budget or calculating estimated costs can be helpful as well.
   
   
6. Learn from Experiences — Particularly if your organization has multiple care management programs, ensure that program leaders are sharing updates with one another. This may include status updates, new initiatives, successes, failures, and lessons learned.
   
   

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Management of Patient Care

There’s no easy solution for improving medication adherence and management. However, there are a few areas you can focus on that have a practical application and maximize the return on time invested.

Unnecessary Emergency Room Visits

There are countless instances of patients going to the emergency room (ER) for non-emergency issues. Here are a few ways your organization can work to prevent unnecessary visits to the ER.

1. Create a campaign — Whether it’s a catchy phrase or ensuring there are signs in the ER, patient waiting rooms, etc., patients should be told repeatedly that in most instances they should call their doctor before heading to the ER. Clinicians should reinforce this to patients upon discharge from every encounter.
   
   
2. Create handouts — A handout can provide valuable information in directing patients where they should go under certain circumstances, e.g., when to call the doctor, when to use urgent care or access telehealth, or when to call to the ER or call 911.
   
   
3. Provide condition-specific information to people — The more specific information you can provide patients, the better. One example of this is as follows: “If your child’s fever is up to 104 degrees and he/she is calm/playful, call your pediatrician. If it’s 105 degrees and/or your child is lethargic, take him/her to the ER.”
   
   
4. Promote use of personal health triage applications — Technology advancements also offer the opportunity to provide younger patients (typically under 40) the ability to check an application. By guiding patients through a series of questions, they can determine whether a visit to the ER is necessary.
   
   
5. Offer telehealth as alternative — Telehealth is another alternative growing in popularity. Patients can access a physician without leaving their home and determine if an ER visit is really needed.
   
   
6. Target certain patients with one-on-one education — For “high-fliers” — patients who have been in the ER more than four times in 12 months — provide personalized education about when they should or should not go to the ER.

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Gaps in Care

Gaps in care occur for many reasons. Often, when relationships between patients, providers, and payers develop problems, issues can then arise that allow patients to fall through the cracks of the system.

To avoid such scenarios, organizations should have actionable data at their fingertips. Here are a few steps to strengthen data collection and maximize its effectiveness.

1. Audit Your Data — It’s important to know what data you are collecting, who is collecting it, where it’s being stored, and how it’s accessed. Once you have this information together, evaluate if there are any opportunities to eliminate redundancy, consolidate data collection efforts, and identify opportunities to combine data sets.
   
   
2. Educate on Data Collection Purposes — While data collection can often feel like a burden for staff and patients, it’s crucial to educate both on why it is so important for patient care. For your staff, explain how the data is being used and why it’s needed for determining appropriate treatment, patient safety, and compliance. For patients, explain why accurate personal information is necessary for ensuring accurate diagnosis and treatment.
   
   
3. Act on What You Collect — Data collection is great, but if you don’t do something with it, it’s worthless. Failing to assess data and act on what it tells you could lead to your missing out on valuable insight for improvements.
   
   
4. Enhance Data Integration Across Entities — Finally, another key part in using data and avoiding potential gaps in care is ensuring that data is integrated between entities that share the responsibility for patient care. If data is missing or incorrect across systems, it will increase the likelihood of problems in ensuring optimal delivery of care.
   
   

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2. How to Transform Care Transitions

Care Transitions

Poorly coordinated care transitions waste billions of wasted annually. Poor transitions can also lead to poor health outcomes.

Care transitions are considered so important that there is a dedicated government initiative — the Community-based Care Transitions Program (CCTP) — that sets goals for improving care transitions for hospitals and other settings.

Let’s take a look at six recommendations for organizations to strengthen transitions:

1. Develop policies and procedures — Produce policies and procedures that establish protocol and standards to address every transition. All staff responsible for transitions should receive training on these rules. Wherever possible, require staff follow standards for care transitions by using technology.
   
   
2. Create a care transitions task force — A task force can help ensure that efforts for ongoing improvements are not overlooked. The task force can review data on care transitions, identify areas for improvement, make recommendations on changes, and verify whether changes were implemented successfully.
   
   
3. Understand root causes of ineffective care transitions — While there are many factors that can contribute to ineffective care transitions, there are a few core causes you should be aware of: communication, patient education, and accountability. Reviewing how your organization approaches each of these should help you uncover potential issues with care transitions.
   
   
4. Learn from others — Much can be learned from how other healthcare organizations successfully improved transitions. Read stories like these for inspiration: University of California, San Francisco and Cincinnati Children's Hospital Medical Center.
   
   
5. Tap into technology — Several information technology companies have launched solutions intended to help improve care transitions. A few examples include TrekIT Health, edoclist, and Kolkin Sign Out Software.
   
   
6. Incorporate resources — There are numerous resources available online designed to strengthen care transition process. These include Whole-Person Transitional Care Planning, Discharge Process Checklist, and Next Step in Care.

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Patient Care Coordination

Care coordination and care management are two important patient support services. To understand how coordination affects management, let’s look at the definitions of each concept.

1. Develop Standards and Systems — It’s vital that all teams within a care network use the same forms, checklists, and resource guides and that there are set communication standards in place. Communication should be the same between community physicians, long-term care providers, DME providers, and other community resources to ensure consistent information.
   
   
2. Deliver Comprehensive Training — In addition to training care coordinators in areas like completing workflows and using the right resources, forms, and data systems, they should also be able to identify social determinants of health, build trust with patients, and be culturally sensitive and aware of how cultural differences impact a patient’s desire to use clinical resources or follow care instructions.
   
   
3. Prioritize Communication — Clear communication is critical to getting patients to go where they need to, when they need to so care delivery remains on schedule. Care coordinators should ensure that patients and their families are clear about why they are being referred to a specialist and how to follow post-acute care instructions. They should also be good listeners and build relationships with patients, their families, and community providers.
   
   
4. Ensure Access to Integrated Technologies — Through the use of electronic health record (EHR) and integrated systems, care coordinators and population health managers will have greater access to the tools they need to receive and share patient information and coordinate services.

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Care Management Process

As you design your care management process, there are a few best practices to keep in mind.

1. Create and follow care plans — For the sake of consistent treatment, care plans must at least detail medical needs, histories, patient goals, and interventions. More extensive plans should be developed for patients with complicated conditions and those taking multiple medications. High-risk patients should receive more urgent attention and extensive care planning before being discharged from the hospital. Finally, care managers should ensure that patients with complex needs receive the resources and support that they need.
   
   
2. Assign patients to primary care managers — Designating care managers to specific patients helps create more optimal conditions for patients to follow their care plans. In addition to having access to any patient information, such as labs, discharge summaries, medication lists, and x-rays, the relationship that care managers develop with patients is even more important. Close relationships allow them to impact care more than primary care physicians, particularly when it comes to time available to help patients.
   
   
3. Account for psychosocial factors — This particular area should not be ignored but can be missed without the appropriate plan in place. A care plan should address personal situations for patients, such as, one’s financial situation, support system, nutritional habits, and cultural background. Each of these can affect a patient’s ability to follow a care plan and, ultimately, their health outcome.
   
   
4. Rely upon motivational interviewing techniques — This best practice ensures that the focus is on patients rather than physicians. It allows providers to ask exploratory questions of patients rather than simply talking at patients. These questions help patients understand their care and encourage self-efficacy. Empathetic methods also allow care managers to talk about more sensitive topics, such as medication adherence.
   
   Each of these best practices allows care managers to pull together the full picture of a patient, going beyond symptoms and medications. An effective care management process allows the provider to actively work with patients and make a difference in their treatment.

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Hospital Workflow

To improve patient outcomes, there’s no better area to focus on than hospital workflows. Benefits of an improved workflow include:

• Reduced likelihood of staff errors and oversights
• Elimination of unnecessary redundancies that stifle the delivery of timely, efficient care
• Improved compliance with critical safety rules and regulations
• Keeping patients on the most sensible and effective treatment path.

To enhance your organization’s workflow, consider these four recommendations:

Improving Care Transitions

In a report by The Joint Commission on transitions of care, a study is referenced which estimates that 80% of serious medical errors involve miscommunication during hand-offs between medical providers.

Knowing that patient safety is at risk due to these errors, chief medical information officers (CMIOs) must make decisions based on data. Here are four statistics in particular that relate to improving care transitions.

1. Readmissions — According to JAMA Internal Medicine, during a review of 1,000 general medicine patients readmitted within 30 days of discharge to 12 U.S. academic medical centers between April 2012 and March 2013, 269 were potentially preventable.
   
   
2. Medication Errors — According to “Patient Safety and Quality: An Evidence-Based Handbook for Nurses,” more than 40% of medication errors are believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients.
   
   
3. Patient Falls — From the Agency for Healthcare Research and Quality (AHRQ):
   
   

   “Falls often lead to devastating consequences; in fact, they represent the leading cause of injury-related death in those 65 and older. Hospital-based falls can be particularly problematic, with an estimated 30% resulting in serious injury.”

4. Discharge — An AHRQ Patient Safety Primer report states:
   
   

   “… nearly 40% of patients are discharged with test results pending, and a comparable proportion are discharged with a plan to complete the diagnostic workup as an outpatient, placing patients at risk unless timely and complete follow-up is ensured.”

These are just a few revealing statistics that show the importance of CMIOs assessing the data captured by their organizations to determine what changes should be made to improve care transitions.

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4. The Hospital Discharge Process

Seamless Discharge Planning Process

As we touched on earlier in this guide, the discharge planning process plays a key role in overall care management.

The idea of a seamless discharge planning process is simply when patients are effectively and safely transitioned from the hospital to their home. However, when seamless care does not happen, effects can include falls, adverse drug events, worsening conditions, or new, avoidable conditions.

A few effective ways to ensure a seamless discharge include:

• Plan discharge at admission
• Create integrated care teams
• Place one person in charge of care coordination
• Create personalized plans for each patient
• Don’t rush the discharge process
• Address each patient’s cultural needs

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Hospital Discharge Summary

So, what should be included in a hospital discharge summary? To start, let’s look at how this report from Advances in Patient Safety describes it:

“Hospital discharge summaries serve as the primary documents communicating a patient's care plan to the post-hospital care team. Often, the discharge summary is the only form of communication that accompanies the patient to the next setting of care. High-quality discharge summaries are generally thought to be essential for promoting patient safety during transitions between care settings, particularly during the initial post-hospital period.”

Here are the key components that should be included in a hospital discharge summary:

In addition to these essentials, a set of standards that came out of the Transitions of Care Consensus Conference (TOCCC) includes these elements:

• Emergency plan and contact number and person
• Treatment and diagnostic plan
• Prognosis and goals of care
• Advance directives, power of attorney, consent
• Planned interventions, durable medical equipment, wound care, etc.
• Assessment of caregiver status
• Patients and/or their family/caregivers receive, understand, and be encouraged to participate in the development of the transition record, taking into consideration the patient's health literacy, insurance status, and cultural sensitivity.

It’s also important that post-discharge summaries are readily available for primary care physicians. Hospitals should consider ways they can improve the timeliness and availability of their summaries.

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The Role of Patient Discharge

While patient discharge is an end to a patient's time in the hospital, it should not conclude care management, especially because poor discharge planning could lead to risks with patient safety and readmission.

For example, a classic study found that nearly 20% of patients experience adverse events within three weeks of discharge. As reducing readmissions becomes more important in care management, consider these four strategies to improve patient discharge.

Hospital Discharge Planning Tools

An important part of strengthening discharge planning may include using the right tools. With so many resources available, we gathered five that we found interesting.

1. IDEAL Discharge Planning
2. Hospital Discharge Planning Worksheet
3. Private-Sector Hospital Discharge Tools
4. Discharge Planning Checklist for Patients and Caregivers
5. Guide for Families and Caregivers

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