Best Practices: Readmission Reduction Strategy

Our ACO, the McLaren High Performance Network, LLC. (MHPN), recently shared its success during the 2019 performance year, achieving a total savings of $37 million and shared savings of over $17 million. Despite these results being in the top ten nationally, we still have an opportunity to improve our clinical and financial performance in our shared savings contracts with CMS (ACO and Bundle Payments) as well as our shared savings contracts with commercial payors (Medicare Advantage).

One area in need of improvement is our 30-day All-Cause Readmission rate. The average cost of a hospital readmission is $14,000. 

What is MPP/MHPN doing to help reduce readmissions:

• MPP staff currently attends each McLaren hospital’s readmission reduction committee meeting and collaborates with the inpatient case management teams to improve the coordination of care a patient receives throughout their transition from acute care to ambulatory care. 
• Our ambulatory care managers (CMs) provide initial outreach to each patient within 2 business days of discharge. Each patient is risk stratified and offered enrollment in our chronic care management (CCM) program.
• A new addition to our care management services includes Telecare Coordination -virtual visits which allow our CMs and patients to have a “face to face visit” via a telehealth platform. MPP will loan a free iPad to those patients who need them to enable these virtual connections.

• Two key components to reducing a patient’s risk of readmission are completing a transition of care (TOC) visit within 7-days of an acute discharge (IP/ED/SNF) and managing our high Emergency Department (ED) Utilizers (frequent flyers).
• In collaboration with physicians on our Quality and Clinical Integration and ACO Utilization Management Committees, along with input from our Regional Steering Committees, we have developed Best Practices for TOC and Best Practices for ED Utilization (see attached). These documents are intended to provide proven strategies utilized by current MPP/MHPN providers to improve the clinical care that we provide to our patients.

Best Practices: Transition of Care (TOC) Visits

1. Utilize MPP Transition of Care documentation or notifications from your local hospitalist group to initiate need for TOC appointment.
2. Establish open access scheduling with appointments for TOC visits each week.
3. Review and sign the Care Manager’s notes (from the required initial patient contact within 48 hours of discharge) enabling you to bill the Transitional Care Management (TCM) codes and generate higher revenue.
   1. 99495 - TOC visit within 14 days = 2.11 wrvu’s, Medicare reimbursement $187
   2. 99496 - TOC visit within 7 days = 3.05 wrvu’s, Medicare reimbursement $247
   3. Non-TCM codes:
      1. 99213 = 0.97 wrvu’s, Medicare reimbursement $76
      2. 99214 = 1.5 wrvu’s, Medicare reimbursement $110
      3. 99215 = 2.11 wrvu’s, Medicare reimbursement $148
4. Refer your patients with chronic medical conditions for enrollment into MPP chronic care management program or McLaren’s Palliative Care program.
   
5. Perform medication reconciliation with patient and/or care giver to ensure patient is taking the correct medications at the correct dosages.
6. Instruct patients to bring pill bottles and discharge medication lists to the appointment.
7. Coordinate follow-up appointments with specialists, as appropriate.
8. Often the patient does not know the specific specialist physician that saw them in the hospital.
9. Sign Homecare orders as soon as possible to prevent delay in start of care.

Best Practices: High Emergency Department Utilization

1. Provide 24/7 access to a clinical decision maker.
   1. Avoid verbiage stating, “if this is an emergency, please hang up and call 911 or go to the nearest emergency room”.
   2. Encourage patient to speak with clinical decision maker before seeking care.
2. Provide outreach to patients who have had an urgent care visit or emergency department visit and schedule follow-up appointment as appropriate.
3. Communicate appropriate use of after-hours care.
   1. Utilize patient education - Urgent vs Emergent document.
4. Provide high-risk patients your cell phone number to contact you directly before seeking care, offer a same day appointment (or next day appointment if it is after hours) if appropriate or direct them to the most appropriate next level of care.
5. Ensure open access schedule to accommodate same day/urgent care visits.
6. Appropriate triage of patients upon call to clinic, avoid staff sending patient to ER unless agreed upon criteria met.
7. For patients identified as “high-ED utilizers”:
   1. Complete SDOH screen (Social Determinants of Health)
   2. Refer to MPP/MHPN Care Management
   3. Develop personalized treatment/action plan with the patient.