Tuesday, August 6, 2013
Patients with multiple chronic conditions often receive fragmented care because of the complexity of their relationship with the health delivery system: they see multiple clinicians in a variety of care settings, require frequent “hand-offs” between providers, and take numerous medications daily. This makes it difficult for both patients and their providers to track their care in total, and to successfully navigate the transition from hospital to home after an acute exacerbation of chronic illness.
To address such issues, Community Care of North Carolina initiated a statewide, population-based transitional care program for Medicaid recipients in 2008. An examination of the effectiveness of the program in reducing readmissions for patients with complex, chronic conditions during the first year following a hospital discharge has been published in the August issue of Health Affairs.
Investigators from CCNC and Darren A. DeWalt, MD, MPH, associate professor in the University of North Carolina School of Medicine, examined time to hospital readmission and one-year readmission rates for patients with multiple chronic conditions, comparing those who received transitional care with clinically similar patients who received usual care in the period July 2010-June 2011. Risk-adjusted readmission rates were approximately 20 percent lower for Medicaid beneficiaries who received transitional care support. Twelve-month readmission rates were consistently lower for participants within each level of clinical severity examined. In addition, the transitional care participants were less likely than others to experience multiple readmissions. In total, one readmission was averted for every six patients with complex chronic illnesses who received transitional care.
“The analysis demonstrates that North Carolina has successfully developed a robust and effective transitional care program for Medicaid recipients,” says C. Annette DuBard MD, MPH, senior vice president for informatics and evaluation at CCNC. “Care management that is locally coordinated between the hospital and home and focuses on the patient’s reengagement with his or her primary care medical home can greatly reduce long-term readmission rates, particularly for patients with the greatest illness burden.”
A total of 21,375 Medicaid recipients with complex chronic conditions and a hospital discharge in the period July 2010-June 2011 met the study’s inclusion criteria. Of those, 13,476 received a transitional care assessment or intervention by a program care manager. The study included patients discharged from 120 different hospitals, enrolled in 1,325 primary care medical homes, and residents of 99 of NC’s 100 counties. The patients in the transitional care group received a wide range of transitional care services depending on the individual needs of the patient, ranging from brief assessment, a hospital bedside visit prior to discharge, service coordination, medication reconciliation, a home visit by a nurse care manager, or a comprehensive medication review by a clinical pharmacist.
When the program was launched in 2008, it was thought to be the largest and most widespread transitional care program investigated to date. The core tenets of CCNC’s transitional care model are comprehensive medication management, face-to-face self-management education for patients and families and timely outpatient follow-up with a medical home that has been fully informed about the hospitalization and any clinical or social issues that complicate the patient’s care. Each of CCNC’s 14 regional networks developed relationships with local hospitals, established processes for real-time identification of Medicaid patient admissions, used the CCNC Informatics Center to access patient claims history and decision support, and directed care management resources toward patients with multiple chronic conditions and indications of clinical or social instability.
The CCNC transitional care program has continued to expand since the conclusion of this study and is now providing transitional care support to more than 2,000 patients with complex chronic illness every month. Efficiencies have been achieved through improvements in staffing and workflow, refined processes for identifying and prioritizing the patients most likely to benefit from transitional care, and increasing the use of electronic data exchange. Fifty-seven hospitals, which are responsible for more than two-thirds of NC Medicaid discharges, are currently participating in the exchange of admission, discharge, and transfer data with CCNC to produce real-time care team notification. As most hospitals, health systems, and payers in the United States focus on reducing unnecessary hospital admissions and readmissions, the CCNC model of care delivery may prove useful as an example that works on a large scale.