With one simple phone call, Cindy Miller shone a light on the challenges of improving a patient’s overall health – and how a team of collaborative providers can help.

Miller, a nurse and care manager with the A.F. Williams Family Medicine Clinic at University of Colorado Hospital, called a 74-year-old man as part of a transitions-of-care initiative aimed at ensuring that patients discharged from the hospital get the outpatient care and services they need to avoid unnecessary rehospitalizations and trips to the emergency department.

The man had a host of intertwined medical and social issues. He had suffered a seizure shortly after moving to Colorado from New Jersey to be closer to his children. He had Parkinson’s disease and diabetes. Miller saw on his discharge summary that he had at some point been prescribed antidepressant medications, but it wasn’t clear if he was taking them regularly.

Such combinations of ailments and issues too often lead to health crises that threaten patients’ lives and trigger costly ED visits and inpatient stays. So it was a good thing he had a follow-up appointment scheduled at A.F. Williams.

But there was, Miller found, a roadblock: The man’s son wasn’t available to give him a ride to the clinic. Rather than chalking that up to bad luck, Miller arranged a ride with the Seniors’ Resource Center, and the patient made it to the clinic.

That single act brought the patient into a system of coordinated care that addressed issues that might otherwise have sent him back to the hospital, including falling, possible adverse medication interactions, depression, and blood sugar control. Along with help from Miller and A.F. Williams providers – physicians, nurses, behavioral health specialists, clinical pharmacists, and social workers – the patient now receives home health care as well as assistance with everyday tasks from Jewish Family Service of Colorado.

The patient, who Miller says is doing much better and is taking an active hand in managing his health, illustrates a point steadily gaining prominence. If providers are to help patients maintain or improve their health, they often will need to address both their medical and social issues. And there are no hard-and-fast templates for that.

“Each call I make goes in its own direction,” Miller said. “There are things that prevent people from being healthy that have nothing to with their medical condition.”

(Don’t) hold the phone

Miller and fellow care managers at the hospital’s Boulder, Westminster and Lowry clinics now make regular follow-up calls to patients shortly after discharge to streamline their transitions to outpatient care. At A.F. Williams, which developed the model as part of an IHQSE (Institute for Healthcare Quality, Safety and Efficiency) pilot, the results have been especially noteworthy.

Between Jan. 1 and Aug. 31, 2015 – before the pilot – 25 percent of A.F. Williams patients discharged from UCH were readmitted within 30 days. In the three-month period after the pilot’s follow-up calls began Sept. 1, 2015, the readmission rate fell by nearly half. The percentage of patients who kept their follow-up “transitions of care” visits rose from 57 percent to 81 percent.

In addition, the follow-up calls headed off dozens of “near misses” illustrated by the elderly patient Miller contacted. The IHQSE data showed that fully one-fifth of calls to nearly 300 patients caught an issue that could have delayed care or caused harm, including disease symptoms, medication problems, lack of transportation, and so on.

The results aren’t surprising, said Katy Boyd-Trull, MD, a senior instructor in Family Medicine and member of the IHQSE team.

“Our department sees many patients in the outpatient setting who have been admitted as inpatients,” Boyd said. Prior to launching the project, however, the IHQSE transitions of care team identified “patients falling between the cracks. We had no system to capture them,” she added.

A typical problem occurs with newly diagnosed diabetes patients, Boyd said. They require disease education, as well as information about their medical supplies – needles, syringes, and insulin. But all of that could be derailed if, for example, their insurance doesn’t cover long-acting insulin. Without help from someone familiar with the health care system, patients in that situation are at risk of not getting the medication and ending up back in the ED, Boyd said.

30-day disconnect

Such seemingly simple issues contributed to a national 30-day hospital readmission rate for Medicare patients of more than 18 percent in 2012. That was for all causes; the percentage is much higher for patients with chronic conditions. For example, the rate for heart failure patients was 24 percent. The problem siphons billions of dollars from the system every year.

The Affordable Care Act targets the readmission problem, in part by implementing reimbursement for transition-of-care follow-up phone calls within two business days. Primary care providers also receive payment for face-to-face follow-up visits within seven to 14 days. Medicare, Cigna, Aetna, and Humana now reimburse for the care, Miller said.

The IHQSE pilot had the strong support of A.F. Williams Medical Director Cory Lyon, DO, as well as data analysts, Epic team members, and process-improvement coaches. The team created the structure necessary to take advantage of those opportunities. But Boyd said the initiative’s true mission is to meet needs that patients have openly expressed.

“We surveyed patients about what would help them the most,” Boyd said. “What we heard is that they need someone they can reach who will answer their questions. They want to know, ‘If there are issues, what are my options?’”

Miller serves in that point-person role, using a decade of experience as a nurse care manager to scan each patient’s medical chart for red flags that need extra attention. Some she can handle herself – she resolved a prior-authorization requirement for two medications with a quick call to the insurance company, for example. Many others she funnels to the appropriate provider to get quick resolution.

The medical and the mental

One of the thorniest overlaps is between medical care and behavioral health issues, notes Joanna Stratton, PhD. Stratton, an assistant clinical professor in Family Medicine who practices at A.F. Williams and an IHQSE team member, has spent one-half day a week the past five years visiting inpatients admitted to the Family Medicine service who also have a mental or behavioral health diagnosis that can exacerbate their condition. A patient’s trouble adhering to a medication regimen, for example, might be traced to depression or poor family support.

Stratton’s techniques, developed over the years, focus on helping patients and their loved ones identify short-term solutions that they not only think are important but also believe they can achieve. But even with A.F. Williams as a bridge to outpatient care, she’s had no illusions that her efforts have made a major dent in the broad range of problems.

“In seeing patients over multiple years, I’ve had the sense that the behavioral health issues of many patients don’t get resolved,” Stratton said.

The transitions of care project, with support from the Department of Family Medicine, has given her a much greater ability to reach them. Miller uses her follow-up calls to pick up on potential psychological or behavioral health issues that could affect a patient’s care after discharge and alerts Stratton’s team prior to a clinic visit.

Stratton said the most common issues she and her team help with are medication adherence, pain management, depression, sleep difficulties, and diet and exercise. Each has the potential to derail a patient’s medical recovery.

They look for clues of psychological disruption, such as excessive fatigue and sleeping, poor appetite, sadness, isolation and anxiety. They work with patients, often in collaboration with other A.F. Williams providers, to find paths to better health.

“We try to construct their post-hospital world,” Stratton said. “It’s the same interventions that we use in the hospital, but in a different setting.”

Meeting with patients promptly, understanding their unique circumstances, and guiding them toward resources that make sense for their lives can help them “avoid disconnecting from the system until they become acutely ill,” Stratton said.

The early data show the transitions-of-care initiative is making real progress with patients who need assistance, including the 30 percent or so that have both a medical and behavioral health diagnosis, Stratton added.

“Patients often get confused when they leave the hospital,” she said. “It’s a time of turbulence. Any intervention we can give them is great, but the process we are following is top-notch.”

Heading home?

With the early success of the IHQSE project, Boyd is now looking to spread the concept. She said she recognizes potential barriers. For example, the strategy requires clinics to invest in “protected time” for care managers to make calls. Miller said the roughly 65 patients she contacts each month for the transitions-of-care program take about 75 percent of her time. Boyd believes, however, clinics can pay for a person to do the job if they are scrupulous in meeting the phone call and follow-up visit requirements and billing for them.

In addition, Boyd is building the business case for home visits to high-risk patients from a multidisciplinary team. That’s a component of the model developed by CU School of Medicine internist and geriatrician Eric Coleman, MD, a nationally recognized transitions-of-care expert.

Patients at the highest risk of readmission are “a growing demographic,” Boyd said. “They often have no time to visit a primary care physician, so we need to target them and reach them in their homes.”

Miller, who followed Coleman’s model during a stint with a company that managed care for Medicare HMOs, believes home visits could make a significant difference in patients’ lives.

“Home visits were very beneficial,” she said. “We were able to use them for disease management, to reconcile medications, provide appointment information, and give patients a list of questions to ask at their primary care visits.”

The current approach has set the stage for the next steps, Boyd believes. “The IHQSE project was a great experience, and a great way to make a positive impact at the system level,” she said. “We’re very grateful that the numbers are showing what we expected would happen.”