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The American Journal of Managed Care October 2017
Low-Value Antibiotic Prescribing and Clinical Factors Influencing Patient Satisfaction
Adam L. Sharp, MD, MS; Ernest Shen, PhD; Michael H. Kanter, MD; Laura J. Berman, MPH; and Michael K. Gould, MD, MS
Countywide Physician Organization Learning Collaborative and Changes in Hospitalization Rates
Brent D. Fulton, PhD, MBA; Susan L. Ivey, MD, MHSA; Hector P. Rodriguez, PhD, MPH; and Stephen M. Shortell, PhD, MPH, MBA
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Alison Cuellar, PhD; Amelia M. Haviland, PhD; Seth Richards-Shubik, PhD; Anthony T. LoSasso, PhD; Alicia Atwood, MPH; Hilary Wolfendale, MA; Mona Shah, MS; and Kevin G. Volpp, MD, PhD
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Anne P. Ehlers, MD, MPH; Sara Khor, MS; Amy M. Cizik, PhD, MPH; Jean-Christophe A. Leveque, MD; Neal S. Shonnard, MD; Rod J. Oskouian, Jr, MD; David R. Flum, MD, MPH; and Danielle C. Lavallee, PharmD, PhD
Trends in Hospital–Physician Integration in Medical Oncology
Jeffrey D. Clough, MD, MBA; Michaela A. Dinan, PhD; and Kevin A. Schulman, MD
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Improving Care Transitions: Complex High-Utilizing Patient Experiences Guide Reform
Nancy Ambrose Gallagher, PhD, APRN-BC; Donna Fox, RN; Carrie Dawson, MS, RN; and Brent C. Williams, MD, MPH
Statewide Data Infrastructure Supports Population Health Management: Diabetes Case Study
Craig Jones, MD; Mary Kate Mohlman, PhD; David Jorgenson, MS; Karl Finison, MA; Katie McGee, MS; and Hans Kastensmith
Is Higher Patient Satisfaction Associated With Better Stroke Outcomes?
Xiao Xiang, PhD; Wendy Yi Xu, PhD, MS; and Randi E. Foraker, PhD, MA
A Health Plan's Investigation of Healthy Days and Chronic Conditions
Tristan Cordier, MPH; S. Lane Slabaugh, PharmD; Eric Havens, MA; Jonathan Pena, MS; Gil Haugh, MS; Vipin Gopal, PhD; Andrew Renda, MD; Mona Shah, PhD; and Matthew Zack, MD

Improving Care Transitions: Complex High-Utilizing Patient Experiences Guide Reform

Nancy Ambrose Gallagher, PhD, APRN-BC; Donna Fox, RN; Carrie Dawson, MS, RN; and Brent C. Williams, MD, MPH
The authors audited a series of complex patients’ records longitudinally across their institution’s existing care management programs to improve the coordinated functioning of these programs.

Objectives: Care management has been adopted by many health systems to improve care and decrease costs through coordination of care across levels. At our academic medical center, several care management programs were developed under separate management units, including an inpatient-based program for all patients and an outpatient-based program for complex, high-utilizing patients. To bridge administrative silos between programs, we examined longitudinal care experiences of hospitalized complex patients to identify process and communication gaps, drive organizational change, and improve care. 

Study Design: This descriptive study analyzed the care experiences of 17 high-utilizing patients within the authors’ health system.

Methods: Chart audits were conducted for 17 high-utilizing patients with 30-day hospital readmissions during 2013. Clinical and social characteristics were reviewed for patterns of care potentially driving readmissions. 

Results: Patients had heterogeneous social factors and medical, psychological, and cognitive conditions. Care management interventions apparently associated with improvements in health and reductions in hospitalization utilization included movement to supervised living, depression treatment, and achievement of sobriety. Monthly case management meetings were restructured to include inpatient, outpatient, ambulatory care, and emergency department care managers to improve communication and process. During 2014 and 2015, hospital readmission rates were overall unchanged compared with base year 2013 among a comparable cohort of high-utilizing patients. 

Conclusions: Joint review of clinical characteristics and longitudinal care experiences of high-utilizing, complex patients facilitated movement of historically siloed care management programs from their focus along administrative lines to a longitudinal, patient-centered focus. Decreasing readmission rates among complex patients may require direct linkages with social, mental health, and substance use services outside the healthcare system and improved discharge planning.

Am J Manag Care. 2017;23(10):e347-e352
Takeaway Points

To bridge administrative silos between care management programs, we examined longitudinal care experiences of hospitalized complex patients to identify process and communication gaps, drive organizational change, and improve care. 
  • Charts of 17 high-utilizing patients with heterogeneous medical and psychological conditions were reviewed for clinical and social characteristics and patterns of care potentially driving readmissions. 
  • Care management interventions apparently associated with improvements in health and reductions in hospitalization utilization included movement to supervised living, depression treatment, and achievement of sobriety. 
  • We are restructuring our monthly case management meetings to ensure simultaneous participation of case managers from inpatient, outpatient, ambulatory care, and emergency department service lines to eliminate communication and process gaps and better serve the wide range of clinical and social service needs of complex high-utilizing patients.
Thirty-day hospital readmission rates are high among individuals with complex medical and psychosocial needs.1,2 Although findings of randomized controlled trials (RCTs) have shown care transition interventions can reduce hospital readmissions in older adults3,4 and those with specific diagnoses,5,6 populations with multiple comorbidities and mental illness or substance abuse present special challenges. Some programs report success in improving services for this population,1,2,7,8 but we identified no RCTs showing reductions in readmission. The purpose of this paper is to describe the clinical characteristics and health service needs of readmitted patients with complex medical and psychosocial needs, with implications for linkages between inpatient and outpatient care management programs.

At our academic medical center, a number of care management programs focused on diseases or settings were developed to improve care transitions and reduce readmissions. Most evolved through separate administrative units without establishing communication or collaboration processes across units or levels of care. As these programs grew, one vexing gap in coordination occurred between inpatient and outpatient programs. This was highlighted in 2010 when changes to inpatient discharge planning were undertaken and renamed care management without coordinating with the outpatient care managers caring for many of the most complex patients. Therefore, we wished to build coordinated care management protocols between inpatient care management nurses and social workers and the outpatient care management social workers working with complex patients. This program, our Complex Care Management Program (CCMP), is primarily staffed by social workers due to patients’ behavioral and socioeconomic needs. To facilitate this process, we applied the Lean process from Toyota,9 which asserts that problems are best analyzed and addressed by the individuals closest to the data from the point of delivery. Specifically, we undertook a patient-level analysis of a cohort of complex patients with 30-day readmissions.

The Complex Care Management Program

The CCMP provides care management to individuals with significant challenges in several of 5 domains based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition classification system: major psychiatric conditions, behavioral and substance use disorders, active medical conditions, lack of social support, and inadequate physical resources (eg, precarious housing or food, limited transportation, or multiple socioeconomic barriers). At the time of this study in 2013, patients were enrolled in CCMP primarily through record review of Medicaid- and Medicare-enrolled and uninsured patients discharged from inpatient and emergency department (ED) services. A complex care manager conducted a phone assessment of each candidate patient, using questions covering the 5 domains with additional tailored follow-up questions, such as their understanding of and ability to obtain medications and keep appointments.10 Most received only this phone call, but during the study period, approximately 10% to 15% of patients assessed were identified as complex based on care managers’ qualitative judgment—usually indicating challenges in at least 3 of the 5 domains—and, if the patient was not known to CCMP care managers, were enrolled for ongoing care management. Incorporating key elements of successful care management programs for complex patients, CCMP care managers coordinate services for patients, accompany them to primary care and specialty appointments,7-9 visit them in inpatient settings,3,6,7,11 and help to identify and reduce socioeconomic barriers to treatment.12-16 The usual caseload of complex patients per care manager is 25 to 35 patients.9 The CCMP serves approximately 450 patients annually.


Setting and Sample

We conducted a descriptive longitudinal analysis of patient experiences of a consecutive cohort of complex patients across levels of care at our institution. Seventeen CCMP patients with 1 or more 30-day readmissions during the first 3 quarters of 2013 were audited, including all with 30-day readmissions in 2 (n = 7) or 3 (n = 1) of the first 3 quarters. In addition, 7 patients with at least 1 readmission from the third quarter (the most recent data available) and 1 patient from each of the previous 2 quarters were audited (n = 9). Most were readmitted multiple times during the study period.

A nurse practitioner experienced in working with similar populations but unassociated with the medical center analyzed the data, identifying patients’ clinical conditions, presenting complaints at each hospitalization, types of healthcare professionals caring for the patient, and services provided during and between hospitalizations. Clinical judgment was used to identify factors potentially influencing readmission. Factors were qualitatively organized in categories mirroring the 5 domains used as enrollment criteria for CCMP. 


Demographic and Socioeconomic Factors

Patients ranged in age from 18 to 61 years; 7 were women and 10 were men. All but 1 had income below the federal poverty line, and most had Medicaid or Medicare or were uninsured. All patients had 2 or more chronic medical problems, multiple socioeconomic barriers, and/or were nonadherent to treatment. Many used food assistance programs and had limited social support, strained family relationships, and transportation problems (sometimes complicated by assistive devices, such as walkers). Several patients lived in group homes; 8 had precarious housing situations (Table). Frequent housing changes complicated patient management and follow-up for medical and psychological conditions.

Medical and Functional Factors

The most common chronic medical diagnoses were diabetes, hypertension, angina, chronic obstructive pulmonary disease (COPD), end-stage renal disease, and congestive heart failure. Two patients died during the 6-month audit period as a result of medical complications. Inpatient admissions over the study period ranged from 2 to 5 per patient (mean = 3.3). Common admission diagnoses were alcohol or substance toxicity/withdrawal, respiratory disease (asthma/COPD), chest pain, and psychological conditions (depression, suicidality, and psychosis). With the exception of alcohol/substance use–related admissions, readmissions were often for a different diagnosis than the previous admission, and no simple pattern emerged. 

Psychological and Behavioral Factors

Sixteen patients had psychiatric or psychological conditions; 1 had cognitive impairment. The most common psychological condition was depression, followed by anxiety, schizophrenia, and bipolar disorder. These conditions sometimes complicated efforts to manage medical conditions. In 2 patients, hallucinations and psychiatric medication adjustments caused behavioral changes that complicated self-management and access to healthcare. In others, depression or anxiety interfered with the ability to manage their conditions but was not considered severe enough to justify intervention by county Community Mental Health psychiatric providers, resulting in treatment delay. In another case, a patient was eligible for a program in which his psychiatric medication was monitored; however, no medication monitoring was available for his medical condition and he was re-hospitalized for that condition. 

Eight patients had substance use disorders, with alcohol dependence being the most common. Most readmissions in this group were related to substance use. Two were lost to follow-up during the study period.

Care Coordination Gaps and Institutional Response

Patients accessed health, behavioral, and social services at the community level, as well as multiple levels within the health system, and communication gaps between these services further challenged their care. In some cases, these challenges appeared to be factors in readmission, either through missed communication or the inability to effectively treat the patient’s medical or psychological conditions. In addition to primary care, emergency, and inpatient services, most patients saw 1 or more medical specialists and used community services related to housing, transportation, food, medications, health insurance, or mental health. 

One important challenge was that the electronic health records (EHRs) used in the community, outpatient, and inpatient services were not accessible by other agencies or different levels in the health system. Although CCMP personnel had access to health system records, health system personnel did not have access to CCMP records and neither group had access to community service records, possibly contributing to missed communication between levels of care. In 2 patients transferred to skilled nursing facilities, for example, medications for chronic medical/psychiatric conditions were not given, leading to 1 readmission and 1 loss to follow-up. In others, late or incomplete communication about laboratory results, medication dosages, or specialty follow-up preceded readmission. In addition, no system existed to communicate patient hospitalizations to CCMP staff and inpatient care managers were not always aware of CCMP resources. 

Identifying and acting on these communication challenges offered an early way for the health system to respond and potentially reduce readmissions. Administrators and care managers from the inpatient and CCMP programs reviewed the care experiences and communication gaps described in the audit at meetings throughout 2014. Timely communication among the patient, CCMP, and healthcare personnel was identified as a critical need related to readmission and coordination of posthospital services and referrals. As a result, program reform shifted toward improving communication, and patient-specific care planning was initiated between the inpatient care managers and the CCMP case managers who coordinated posthospital services. 

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