Executive Summary
As we all are aware, it is planned to reduce hospital payment based on the readmission of patients to the hospital setting (mcare.gov, 2010). The hospital may very well lose an average of $500 per readmission. The Care Transition Program is meant to decrease readmissions and provide patients with a better quality of care. Many diagnoses will have a greater tendency to lose money due to readmission and would benefit from this program. However, the plan would be to start the program with CHF patients and expand from there. The program will improve quality and control costs for this group of patients and have expected a decrease in readmission rate by 2% to start. On the quality side, the expectation would include better Core Measurement scores. This, of course, will also increase reimbursement by up to 4% based on scores.
When patients seek medical care, they may end up using a variety of settings. One episode of illness may stretch over the inpatient setting as well as outpatient. Often, we find that patients and their families become responsible for maneuvering their way through this system of care, providing for good transitions between each. As the patient and or caregiver becomes more elderly, it becomes more and more difficult to do this adequately and readmissions begin to occur. A Care Transition Program gives the patient and or caregivers tools and resources to manage this system. Research shows that patients that use a program similar to this have fewer readmissions and shorter lengths of stay when they are admitted. The goals of the program would be to improve self-management skills, improve knowledge skills, improve medication management skills, and improve confidence levels in managing their disease states.
Building this program will not only improve quality, and decrease cost and readmission but will align the program with National protocols. It will move us toward meeting all of the new restrictions in payment head-on and will provide us with a base to build in other types of patients. An example of that would be the complex patient who requires large numbers of settings and is prone to readmission. These are the patients that this program will work the best for. In providing this program, we hope to provide a service that will meet the needs of many patients and caregivers attempting to handle all of this on their own.
The program will provide them with information to help them clue into early signs of problems with their disease so they can follow up and prevent a more severe exacerbation. It will teach them how to handle their medications and give them an organized system of management(John Muir Hospital, 2008). It will provide a home visit to assure an understanding of initial instructions and follow through and it will provide them with record necessities to provide well-organized information at follow-up visits with their physician and for new inpatient admissions to the hospital.
As stated, our initial population will be Congestive Heart Failure patients. A Transition Case Manager would be responsible for carrying out the program at a higher rate of approximately $59,000 a year. This Case manager would be responsible for taking an active role throughout the transition of the patient, assisting in assuring that the patient and or family are taking an active role in prevention during the program. The initial visit by this Case manager will take place within 48 hours of admission to the Acute Care Unit. She/He will then be responsible for progressing the patient and family through the program, getting them ready for the transitions ahead. This Case Manager will make one visit to the home post-discharge and will transition the patient to the outpatient caregivers which may be home health, hospice, or physician. She will keep records on the patient to allow for a smooth transition, should the patient return. She will assure that the patient and or caregiver can manage the program at home, including records needed for continued care.
There are no programs like this in the local area. There are beginning to be some available in the Oklahoma City area, however, they are not mature at this time. Many programs would like to transition to a program like this but have not yet attempted the process. I believe that this is a program that will give us the lead in Congestive Heart Failure followed by other complex diseases. It can be marketed in many ways including in-house physicians, community groups, and senior citizens groups to name a few. We can only improve our ability to stay in front of the market by providing this program and moving forward quickly to expand.
With the aging of the Baby Boomer generation so goes the increase of Congestive Heart Failure. Medicare changes in reimbursement and the RAC have placed all Congestive Heart Failure patients in need of such a program. There is also the possibility that local health insurance will want to include their patients with this diagnosis based on the decrease in readmission and cost of care. This program will be a physician and patient satisfier and physicians will want to subscribe their patients and patients and families will want to self subscribe. We also become customers as we will reduce our cost of caring for these patients and increase the number of beds available by not readmitting them. The overall ROI for this program is 31.4, specifics noted in the appendix.
References
Centers for Medicare and Medicaid, (2010) Web.
John Muir Hospital, (2010) Web.