Jamaica Hospital has recently implemented a Care Transitions Program, a momentous effort to provide proactive medical and social interventions to patients who pose a high risk for hospital readmission. The new program, which also boasts significant financial savings for the hospital, began in 2011 and is comprised of three distinct initiatives- The Intensive Multidisciplinary Primary Care Team (IMPACT) , the Community-Based Care Team (CBCT), and the Hospital Care Transitions Team (CTT).
IMPACT was established to provide long term, managed care to super-utilizers, patients who have repeated in-hospital stays. These patients are followed by a care team made up of a nurse practitioner, a social service case manager, and a community health worker, who work together to assist patients with scheduling their doctor appointments, filling their prescriptions, securing health related services such as home care, obtaining social services, and providing them with education and other health related assistance.
In a 2011 pilot, high utilizers of medical services, who had Neighborhood Health Plan (NHP) Medicaid were chosen to participate in the IMPACT program. A Care Transitions Team (CTT), which is comprised of a registered nurse and service coordinator who screens patients for either IMPACT or CBCT, used the hospital’s state-of-the art EPIC system to identify potential super-utilizers, patients who had several hospital admissions within a six month period, were diagnosed with one or more of the following disorders—pneumonia, congestive heart failure, diabetes, chronic obstructive pulmonary disease, or end stage renal disease, or myocardial infarction— and met additional health and socioeconomic criteria.
At the conclusion of the year, the patients didn’t experience hospital readmissions and were satisfied with their overall care. Additionally, a reduction in the utilization of services allowed the hospital to save $400,000. Prior to the implementation of IMPACT, these superutilizers would have cost the hospital $700,000, compared to the $300,000 spent during the year-long pilot.
The Community-Based Care teams, which are currently in development, are designed to reach patients who aren’t super-utilizers but are still at risk for hospital readmission because of their health status or other biopsychosocial factors. The teams will monitor 30-40 patients each for up to 29 days. Each team will work closely with the patient’s primary care physician to ensure coordination of health care needs for thirty days post discharge. Health care interventions, such as medication reconciliation, referrals to health care services, and management of medical services, will be provided in the home and/or the community to best meet the needs of the patient. After the completion of 30 days, patients may be referred to ongoing services in the community, to the IMPACT program, or ongoing monitoring by their primary physician.
“The idea behind our care transitions initiative is to provide interventions in the home to high risk individuals and to reduce the risk of preventable readmissions,” said Dr. Angelo Canedo, Vice President at MediSys Health Network. “Overall, our Care Transitions Program is aimed at cutting 30-day readmissions by at least 20%, which is also aligned with the government’s recent effort to decrease hospital readmissions, and to increase community based/ambulatory care.”
Under the Affordable Care Act, hospitals face financial penalties when a patient is readmitted within 30 days after their discharge. Medicare has also begun penalizing hospital for readmissions. Jamaica Hospital, which serves a population with a high risk for hospital readmissions, has a 25% hospital readmission rate, while the national average rate is 15%.
To ensure that the facility’s readmission goals are attainable, Jamaica Hospital is currently seeking a HEAL grant to develop additional care transition teams, which would allow the hospital to service more patients. Though the hospital is focusing on Medicare fee for service patients, the goal is to expand to other payers in the future. The development of these programs is just one step the hospital has taken to prepare itself for the future landscape of the healthcare industry. It’s though the collaboration and cooperation of all employees that these programs will be a great success.
In an effort to identify and implement ecological initiatives that have a positive impact on the environment and to create a cleaner and better world for our patients and the community, the MediSys Health Network recently developed “ecoMediSys.”
