Out­pa­tient providers need to con­sider bet­ter care tran­si­tions, too

Modern Healthcare - - BEST PRACTICES - By El­iz­a­beth Whit­man

Care tran­si­tions are of­ten de­picted as a pa­tient’s move out of the hospi­tal and to the next des­ti­na­tion, such as a post-acute care fa­cil­ity or back home. Far less at­ten­tion is paid to other tran­si­tions in health­care that qui­etly shape a pa­tient’s health out­comes.

The 22 out­pa­tient clin­ics in the Mon­te­fiore Med­i­cal Group in New York’s Bronx and Westch­ester coun­ties have fo­cused on seem­ingly sim­ple, of­ten over­looked care tran­si­tions. In the past two or three years, “we’ve re­ally hard­wired this process,” said Namita Azad, the group’s trans­for­ma­tion man­ager.

They fo­cus on four tran­si­tions: emer­gency room or in­pa­tient set­tings to out­pa­tient providers, pe­di­atric to adult, re­fer­rals be­tween dis­ci­plines, and the ad­di­tion of new pa­tients.

Paving the path for a teenager to go from see­ing a pe­di­a­tri­cian to see­ing an adult prac­ti­tioner, or to en­sure that a pa­tient who is re­ferred from a pri­ma­rycare provider to a spe­cial­ist, has re­quired care­ful com­mu­ni­ca­tion and a mul­ti­dis­ci­plinary ap­proach. Clin­ics, which in­clude pe­di­atric care, in­ter­nal medicine and fam­ily medicine, also have a so­cial worker, psy­chol­o­gist or psy­chi­a­trist, and a re­fer­ral co­or­di­na­tor

“For the most part, we’re touch­ing the en­tire lifes­pan for our pa­tients,” Azad said. “We’re taking care of the whole pa­tient.” Their suc­cesses reg­is­ter in im­proved vis­i­tor vol­ume and re­ten­tion, as well as im­prove­ments in clin­i­cal met­rics, such as de­pres­sion screen­ing, she added.

The pro­por­tion of pa­tients screened for de­pres­sion used to be in the 60% range, Azad said. Now it’s about 90%. Azad at­trib­uted that aware­ness di­rectly to hav­ing be­hav­ioral health staff in the same lo­ca­tion with pri­mary-care providers

Build­ing this in­fra­struc­ture has not merely en­sured con­ti­nu­ity of care. It has also al­lowed Mon­te­fiore’s out­pa­tient providers to branch out and talk to pa­tients about non­med­i­cal is­sues that af­fect health, such as en­vi­ron­men­tal or so­cio-eco­nomic stres­sors.

The stan­dard time for a pa­tient to switch from see­ing a pe­di­a­tri­cian to a physi­cian who sees adults, such as a fam­ily doc­tor, is around age 17. But at Mon­te­fiore, providers start the con­ver­sa­tion years be­fore, around the age of 13 or 14. The pe­di­a­tri­cian will start to have con­fi­den­tial vis­its with the teenager to help wean them from their par­ents (or, per­haps, wean par­ents from their chil­dren).

“You talk to the pa­tient and you say, ‘Lis­ten, you’re of a cer­tain age now, and to bet­ter take care of all your health needs, there’s a bet­ter-suited pro­fes­sional within this build­ing you’ll go to in the fu­ture,’ ” Azad ex­plained. When the time comes to switch doc­tors, the hand­off is some­times lit­eral. The pe­di­a­tri­cians “phys­i­cally walk that pa­tient to the in­ter­nal medicine provider,” she said. That way, pa­tients feel they can trust their new doc­tor.

When a pa­tient is dis­charged from the emer­gency de­part­ment, the use of the same elec­tronic health record sys­tem in the ED and at out­pa­tient clin­ics—the Mon­te­fiore sys­tem uses one from Epic Sys­tems Corp.—smooths the tran­si­tion. It’s hard-wired to en­sure that some­one reaches out to pa­tients within 48 hours to make sure they have ev­ery­thing needed and to sched­ule a fol­low-up visit with a pri­mary-care provider within a week to 10 days. Azad said their suc­cess rate of reach­ing pa­tients within two days was at least 95%.

The clin­ics also closely track pa­tients when providers re­fer them to clin­i­cal spe­cial­ists or other re­sources, such as a com­mu­nity-based or­ga­ni­za­tion. If a pa­tient is re­ferred to a spe­cial­ist, such as a car­di­ol­o­gist or a health ed­u­ca­tor, the re­fer­ral is marked in the EHR. Re­fer­ral co­or­di­na­tors fol­low up with and help pa­tients with chal­lenges they en­counter nav­i­gat­ing the health­care sys­tem.

De­vel­op­ing these tran­si­tional best prac­tices now is crit­i­cal. Tran­si­tions will be­come only more im­por­tant in the out­pa­tient realm, ac­cord­ing to Dr. Noel Brown, di­rec­tor of per­for­mance and qual­ity im­prove­ment at Mon­te­fiore Med­i­cal Group. The growth of value-based pay­ment pro­grams that aim to re­duce un­nec­es­sary hospi­tal read­mis­sions has in­creased the in­cen­tive to keep pa­tients out of the hospi­tal and put more pres­sure on the out­pa­tient realm.

“We’re see­ing a shift where re­sources need to be al­lo­cated to the out­pa­tient en­vi­ron­ment, more so than in the past,” Brown said. “We’re be­ing asked to ad­dress more is­sues.”

The at­ten­tion to care tran­si­tions is part of a sys­temwide shift to pro­vide pa­tient-cen­tered care. The Mon­te­fiore Med­i­cal Group is cer­ti­fied by the Na­tional Com­mit­tee for Qual­ity As­sur­ance as a pa­tient-cen­tered med­i­cal home, a des­ig­na­tion both Brown and Azad said has been vi­tal in align­ing pay­ments with Mon­te­fiore’s pa­tient­cen­tered services.

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