Improving Transitional Care Management

The federal government is exploring initiatives that will significantly alter financial liability associated with TCM. This paper will discuss the background of this initiative, a potential alternative to improve efficiency and mitigate this financial impact, and the benefits of that alternative.

Transitional Care Management (TCM) describes the oversight and coordination of healthcare services for patients transitioning from an inpatient setting.

Background:

The costs associated with transitional care management have been steadily rising; however, patient results have remained about the same.

Over the last few years the Centers for Medicare & Medicaid Services (CMMS) have been leading an initiative to both reduce TCM costs and improve patient outcomes. The most significant initiative is called the Bundled Payments for Care Improvement (BPCI). As of October 1, 2017, the BPCI initiative has 1191 participants in Phase 2, comprised 252 Awardees and 939 Episode Initiators.

The specific medical conditions to be evaluated are called Episodes of Care. There are many different episodes but most involve surgery performed either by orthopedic or cardiac participants.

Under this approach, participants are paid a fixed amount for the procedure and the recovery. The financial liability associated with the recovery period (normally 90 days) presents a new challenge. As a result, many medical groups have been evaluating better ways to manage the recovery period costs.

Traditionally doctors require patients to come back into the office for periodic visits. Additionally, they may ask nurses to actually visit patients in their home or temporary residence. Participants are also exploring various telemedicine and comprehensive assistance for family caregivers.

To date, finding a consistently effective solution for BPCI has proven elusive.

Home Care LINK Alternative:

Perhaps it is time to consider an “outside the box” alternative.

Is there a way to use reporting from non-medical individuals to reduce financial liability and improve recovery outcomes?

It could be as simple as the patient self-reporting using a structured process. For the more complicated episodes, it may require caregiver support such as family members, volunteers or even paid caregivers.

During the recovery period, these non-medical individuals will see the patient far more frequently than the professionals. They see the patient on a day-to-day basis, and can report changes in condition in a timelier manner than the infrequent professional visits.

As you might suspect, professionals have concerns about collecting this type of information.

• Can they rely on this type of information? – Harvard Medical School recently reviewed the preliminary data from a home caregiver pilot program¹. In that pilot, caregivers were tasked to report any “changes in condition” with their care recipients. The HMS review pointed out many successful outcomes, including “relatively few false positives”.
• All we need is more information! – Currently with all the various care home software, medical professionals can be easily overwhelmed with information. It is becoming increasingly difficult to keep track of volume and isolate those pieces that truly impact patient recovery.
• How do we prove this will reduce costs and improve patients’ outcomes?  – The easy answer is a controlled pilot study. Medical professionals are familiar with these types of comparisons. Why not add an “outside the box” comparative study?

Home Care LINK  (HCL) has developed an approach for every caregiver to record changed condition observations. These observations are automatically sent to our cloud based home care software following each observation. These time-phased reports are immediately available for each patient.

Home care LINK also has a feature called “medication reminders”. This feature focuses on loading a simple pill box/organizer and monitoring a patient’s usage. Results are recorded and sent.

Each HCL observation can be prioritized as normal or critical. If a critical observation is made, automatic alerts are sent (text or email) to whomever the case manager has designated.

Essentially HCL is a telemedicine variation that is simpler and much less expensive.

For Transitional Care Management, Home Care LINK care home software permits professional case managers to customize the specific conditions to be monitored for each patient. The reporting caregiver then records their observations based on those conditions on this home care management software.

Benefits:

• Observation windows are more comprehensive
• Timeliness is significantly improved.
• Alerts and Reports are customized to each patient.
• Costs may be significantly reduced.
  • No requirement to technically integrate into the existing EMR system.
  • In many cases the patient’s family pays for the caregivers and the HCL service.
  • The data collection device is an inexpensive Android tablet.
• The potential to improve efficiency and reduce financial liability is significant.
• By reducing patient recovery issues, hospital ratings may rise.

Of course there are no guarantees, but isn’t this alternative worthy of studying?

_______________________

1. “Preliminary Data on a Care Coordination Program for Home Care Recipients”, The American Geriatrics Society Journal, August 2016.