Quality and patient experience indicators will undoubtedly be at the center of future reimbursement. Medicare continues to drive the agenda for quality of care, extending this concept well beyond the definition of quality of a current episode, and moving it rapidly into a broader definition of complication avoidance and acute event prevention. Three projects, which can be collectively executed in 120-180 days, will position any hospital provider organization for success in this new world.
1. Reinvent Preoperative Processes for Comprehensive Risk Management
In the case of scheduled procedures, providers often have some time to understand procedure and patient specific risks. Historically preoperative risk plans have focused on anesthesia related risks, and while some providers have been moved beyond that approach, few address the full spectrum of risks. Comprehensive risk assessment and management must include social, psychological, and comprehensive clinical risks due to multiple conditions in order to better manage comprehensive quality outcomes. Another consideration is that the process of patient stratification has to be designed so that risk identification and plan creation is executed in an economically feasible way. Lastly, preoperative care plans have to be designed for execution success, focused on the realities of patients and care givers, rather than look like a do-it-yourself project comprised of stacks of papers and brochures supplemented by verbal instructions. The pathway to reinventing preoperative processes is:
A) Create a clear, fresh vision for preoperative services that is anchored in comprehensive risk management beyond pure anesthesia and procedure clinical risks.
B) Create a tiered process, linked to a clear risk stratification process, to manage patients with the best process given the situation (example: self-service, phone call, in-person assessment with built in escalation and consult escalation). Make proper use of protocols and standing orders to implement best practices, and reduce clinical resource use on administrative tasks to allow focus on risk management.
C) Re-think all communication processes regarding preoperative care plans by making them consumer (patients and care givers) friendly.
D) Streamline and mistake proof (Poke Yoke) clinical communication and EMR use to minimize administrative time spent and maximize time allocation to clinical work and comprehensive (BPS) risk management.
E) Implement a measurement and improvement strategy that provides feedback to fine tune process details and risk stratification.
2. Redefine Case Management
Case Management has gone through several evolutionary changes regarding its purpose over the last decade, with respective reporting and staffing changes. With value based reimbursement, Case Management now needs to be a focus area of care delivery, finally giving it the comprehensive importance is has always needed. While the focus in the fee for service world was often administrative, be it documentation review or authorization management, it has recently expanded into level of care decision support. The new frontier of Case Management is, just as Pre-Operative Services, the engagement in comprehensive risk management, including, but by no means limited to, risk associated with the current hospital stay. To create a solid Case Management Model the following should be considered:
A) Off-load administrative tasks to a centralized support center to enable clinical resources to fully engage in risk management.
B) Utilize real time, HL-7 based decision support systems to identify areas of risk for patients currently in house, in order to manage them immediately and in order of priority.
C) Establish cross functional case management teams, spanning case managers, nurses, social workers, physicians, CDI staff and the centralized support center.
D) Begin the case management / care management process at Pre Op or, if not applicable, at time of admission.
E) Enroll eligible patients into long term care programs, such as Chronic Care Management prior to discharge to extend the care management process into later stages of the episode, but ultimately, well beyond.
3. Implement Care Management Utilizing the CMS CCM Program as the Launch Platform
While efficient and effective care delivery are a must do to survive in a value based world, total cost measures will also play a substantial role. Programs to prevent acute care episodes, or limit the severity of acute care episodes, are a must do for providers. These types of programs present a challenge to many providers as comprehensive programs of this nature have not been developed in the past to be economically feasible and scalable, they have often focused only on the most severely brittle population. In the future, managing the next tier of patients is crucial, and now feasible. This is particularly true when considering social determinants in the risk profile of a population, as social determinants are ultimately key drivers of risk. The solution:
A) Engage eligible Medicare patients in a CCM program. With the creation of the CCM CPT code, CMS created a program that allows providing care management to the Senior population.
B) Engage the social environment of the patient. Once patients leave the acute care setting, most often non-clinical care givers such as family and friends represent the key support infrastructure providing the majority of the post-acute care support. Engaging this community, be it through traditional means or the use of consumer friendly technologies can deliver substantial results at no cost to the provider. For more information regarding CCM visit us at www.healthsignalpartners.com.