The transition from the hospital to another facility or even home can be challenging for patients under the best of circumstances, but it’s often especially difficult for the elderly. Many of them have complex medical conditions and medication regimens that put them at higher risk of readmission. The Seniors Clinic at University of Colorado Hospital is part of an initiative to support its patients after discharge by marrying technology with old-fashioned communication.

The initiative is a joint effort between the clinic and Ambulatory Health Promotion (AHP) – a patient outreach program that is part of the University of Colorado School of Medicine’s Office of Value-Based Performance. The overall goal of AHP is to provide preventive care and chronic disease management to UCH patients through a variety of strategies.

The AHP-Seniors Clinic initiative aims to coordinate care for elderly patients discharged from UCH to go home or to a community provider. The foundation is the Epic electronic health record (EHR), which AHP uses to identify the patients, said Lisa Schilling, MD, MSPH, director of the program.

With that information, AHP staff make “interactive contact” with each patient within 48 business hours of their discharge to help set up clinic follow-up visits that happen within seven days of discharge for complex patients or 14 days for those with less-complex needs. They also identify patients’ current needs, and triage them to the Seniors Clinic team for further care coordination. Patients get their medications reviewed and reconciled by a pharmacist before their clinic visit.

Necessary steps

Patient contact, medication reconciliation and scheduling of a timely clinic visit are all necessary to bill the Centers for Medicare and Medicaid Services (CMS) for managing transitions of care, Schilling said. That provides an incentive for the real goal: establishing regular communication with patients and helping them avoid unnecessary readmissions and trips to the emergency department. That, in turn, benefits the patient and the hospital, which can receive penalties from CMS if its 30-day readmission rates for patients with specific conditions, such as heart failure, are too high.

The work has tightened the Seniors Clinic’s connections with hospitalized patients, said Medical Director Bennett Parnes, MD. Since the program launched in August 2014, it’s covered more than 500 discharges of Seniors Clinic patients. More recently, the clinic has used AHP information to sharpen its scrutiny of the roughly 30 percent of patients discharged to skilled nursing facilities (SNFs). They have long been higher-than-average readmission risks, Parnes said.

“They are often complicated patients,” Parnes said. “It’s a harder nut to crack to manage SNF patients who are discharged to home.”

The social network

The problem is fragmented communication between the hospital and the large number of SNFs scattered around the Denver metro area, the state and the region. To close those gaps, Kirbie Knutsen, LSW, social worker for the Seniors Clinic, uses AHP notifications in the Epic EHR to identify clinic patients discharged to a SNF and contacts the facility to make contact with a social worker or discharge planner. Knutsen reviews the patient’s needs, such as transportation, durable medical equipment, and home health care, and requests that the SNF fax her a copy of the discharge summary and medication list when the patient leaves the facility. At that point, Knutsen lets the patient’s clinic provider and the AHP team know that the patient has been discharged and can be scheduled for a follow-up visit.

Knutsen, who began the SNF project about two months ago, said that as of mid-May she had closed eight cases and was working on another seven. The biggest challenge, she said, was getting SNFs to call her back. “It’s not always their highest priority,” she said. “But I’m developing relationships with them. It will improve with time.”

There are additional incentives for SNFs to work closely with hospital providers like Knutsen. CMS has proposed a rule to withhold 2 percent of Medicare payments to SNFs. The facilities could earn the money back by keeping their 30-day hospital readmission rates at or below average.

The measure puts tightening coordination of care and preventing unnecessary readmissions “high on everyone’s list,” Parnes said.

Rx for care management

The AHP-Seniors Clinic project also brings clinical pharmacy into the transitions-of-care cycle. Data show the importance of that decision. In an analysis of the medication lists of nearly 300 Seniors Clinic patients discharged from UCH between August 2014 and August 2015, clinical pharmacists identified at least one “discrepancy” – a medication that should have been stopped but was left on the discharge summary, for example – in 78 percent of the cases, said Danielle Rhyne, PharmD.

That’s not surprising, Rhyne said. Most elderly patients take at least five medications, but the analysis put the average at 14. Those with chronic disease and complex medical conditions may take two dozen or more, Rhyne said.

“The more medications they are on, the more problems they can have,” she said. Medication-related issues such as low blood pressure or blood sugar, dizziness, and electrolyte imbalances can land a patient back in the hospital unnecessarily.

The medication management work has had a positive effect. The patients discharged from UCH during the August 2014-August 2015 period – average age 81 – had a 14.8 percent 30-day readmission rate compared with an overall readmission rate for UCH Medicare patients of 15.6 percent. From Dec. 1, 2015 to Feb. 29, 2016, the readmission rate for Seniors Clinic patients managed by the program fell to 10.6 percent.

Drug detectives

That kind of success requires commitment. Rhyne and pharmacy colleague Sunny Linnebur, PharmD, sort through patients’ medication lists and head off potential issues. They are in the Seniors Clinic five days a week, contacting patients identified by AHP. They ask them or their caregivers to retrieve their medication bottles and read them so they can reconcile the patients’ actual meds with those listed on the discharge summary from the hospital or SNF.

“We act as investigators,” Rhyne said.

She and Linnebur correct discrepancies, collect medication questions to ask the provider, and start notes in Epic to document any changes in dose, start and stop dates.

The work requires patience – the calls typically take 45 minutes, but they can run much longer – as well as precision. It’s important that patients take the medications as prescribed, but it’s also important to weed out those they don’t need.

“We try to identify medications that are of no benefit to patients,” Rhyne said. Benadryl and Advil, for example, are “no-no’s” for elderly patients because of their potentially harmful side effects.

The pharmacists also act as conduits to care whenever they can. If patients have trouble paying for medications, for example, they try to find low-cost options. If transportation is an issue, they assist with setting up mail-order accounts. They give patients on Warfarin the number for UCH’s Anticoagulation Clinic and route their medication notes to providers in specialty clinics to ensure they are aware of the medications their patients are taking.

The benefits of such efforts of the Seniors Clinic and AHP go beyond clinical confines, Parnes said.

“We’ve had extremely favorable reviews from patients,” he said. “Many have said they were surprised that we knew they had been in the hospital. Patient satisfaction has been huge.”

The outreach work continues. Schilling said AHP also receives daily data feeds from the Colorado Regional Health Information Organization (CORHIO) about UCH primary care patients discharged from other hospitals. Staff pull information from CORHIO PatientCare 360, a web-based portal that allows users to view medical records from Colorado hospitals. They view the available details of each hospitalization, including the discharge summary, enter the information into the Epic EHR, and start the outreach process. They also send the information to his or her primary care provider at UCH. In the future, Schilling said she hopes in the future to see data from CORHIO flow straight into Epic.

Similarly, Schilling envisions a system that automatically alerts AHP when a SNF discharges a UCH patient. That would free a social worker like Knutsen from having to make phone inquiries.

Overall, however, Schilling said the transitions-of-care progress made thus far is encouraging. “We are striving to optimize data exchanges and the use of data to drive more personalized, right-person, right-time team-based care that focuses on value rather than volume,” she said.