New ‘Virtual Care Center’ Choreographs Post-Discharge Care

As hospitals around the country work hard at winnowing down readmission rates, a new grant from the Greater Rochester Health Foundation (Health Foundation) will give URMC’s Strong Memorial Hospital the chance to try a fresh approach: A “virtual care center.”

Representing a nearly $600,000  investment over three years by the Health Foundation, the center zooms in on the precarious 30-day post-hospital period, virtually shepherding some of Rochester’s most vulnerable patients as they move into community- or home-care settings.

“By micromanaging this transition period for a set of patients, investigators hope to avert U-turn readmissions that squander community resources, threaten emergency room access, and drive up care costs,” said principal investigator Marc Berliant, M.D., chief of URMC’s General Medicine division.

Turning the Tide for Readmissions

Readmissions are costly for everyone involved.

“For patients, it’s unnerving. They miss work, they worry. There are more medical bills,” Berliant (pictured below) said. “In some cases, it can even cause them to doubt their care team’s decision-making.”

Avoidable readmissions are also expensive for hospitals, robbing them of revenue, reputation, and market share. By Oct. 2014, the Centers for Medicaid & Medicare Services (CMS) will be withholding up to 3 percent of URMC’s total overall reimbursement payments, and only dispersing the money back to us if we keep readmission rates low.

The Health Foundation grant lets Strong take a hard, close look at the first month-long window after a patient is discharged. Berliant says this 30-day period is fraught with so many challenges, some physicians argue it qualifies as a distinct disease state all on its own.

“Numerous medications, slow-moving recuperation, and the sheer anxiety on suddenly managing care on their own can make patients susceptible to relapses that land them back in the hospital,” Berliant said.

Though some readmissions are expected, even planned, as the natural course of treatment, some are considered avoidable—often rooted in problems like poor communication, poor health literacy, medication mix-ups (it’s not infrequent that patients leave with 20 or more prescriptions), insufficient patient social supports, and more.

“Together, these readmissions aggravate America’s rising health care costs,” said John Urban, president and CEO of the Health Foundation. “We are pleased to invest in a program designed to curtail these avoidable admissions. A 2009 study showed that one in five Medicare beneficiaries winds up re-hospitalized within 30 days of their discharge—to the tune of $17 billion annually. The same year, in Monroe County, a Finger Lakes Health Systems Agency report estimated that 11 percent of all hospital admissions locally were preventable readmissions.”

According to Berliant, despite dogged pursuits of best practices—even bundles of practices—aimed at safer discharge transitions, “no one intervention, or set or interventions, can be credited with much success.”

He speaks from experience. Since the first quarter of 2011, Berliant has led Strong Memorial’s “Safe Transitions” project, the hospital’s first large-scale attempt at systematically improving the discharge experience to curb readmission rates. Signature elements of the now- two-year-old program involve flagging “high-risk” patients (predisposed to readmission later on), providing them with “check-in” phone calls at home, and getting a fast follow-up appointment on the books with their PCP. While the program has markedly improved care quality and specific facets of the discharge process (smoothing out information transfers between providers, or enriching patient education, for instance), readmission rates haven’t budged.

But Berliant says the new grant goes further, marking URMC’s most vigilant effort to date to intervene and assist patients prone to problematic recoveries.

A ‘Virtual’ Unit?

Starting this coming October, Berliant, together with collaborators URMC Pharmacy Director Curt Haas, Pharm.D., and President and CEO of Visiting Nurse Service Victoria Hines, will launch a “virtual care center” (VCC) model on two of Strong Memorial’s onsite general medicine units. At intake, a full-time VCC leader (with a social work background) will notify qualifying high-risk, chronically ill patients that they are being simultaneously “admitted” to a VCC that, invisibly, hustles to engineer a smooth transition to out-of-hospital care or self-care.

So what’s happening behind the scenes? For starters, meticulous management of medications by the VCC’s dedicated, part-time pharmacist. That means reconciling which prescriptions are active and which should be discontinued, making sure all items get filled, paid for, and picked up—and that the patient knows how and when to take them.

Also, during the hospital stay, the VCC leader actively registers the patient for URMC’s patient portal, MyChart, showing them how to leverage it to monitor upcoming appointments, caregiver messages, and more.

The VCC team (pictured at left) will also: (1) work closely with social workers to pre-empt potential stumbling blocks (e.g., trouble securing transportation to and from follow-up appointments); (2) hand-select supplemental transition coaching and telehealth programs administered by Visiting Nurse Service; and (3) conduct one- and three-week-post-discharge “rounding” meetings—multidisciplinary huddles that ensure fluid, frequent communication between outpatient care managers (from the patients’ medical home) and the hospital’s cast of health care professionals.

Besides pulling down readmission rates—the pilot targets a 20 percent reduction over three years for the enrolled population—other objectives are embedded as well. These include reducing emergency department visits, observational stays, and susceptibility to poor outcomes; improving access to medications after discharge; and measurably improving patients’ engagement in and satisfaction with their own recovery experiences.

Grant collaborators include URMC’s Center for Primary Care, social work team, and Strong Internal Medicine clinic, as well as the financial support and commitment of MVP and Excellus, who will share claims data, as necessary, to validate progress.

Berliant says similar virtual care models have been trialed in the United Kingdom and Canada, but results are still being analyzed. If Rochester’s VCC pilot indeed moves the needle—saving costs and sparing readmissions—it could be a beacon program for other communities.

“If this works, it would be one of the first interventions to show how tight, proactive care management programs can succeed—generating the kinds of cost savings and illness avoidance needed to be self-sustaining and pay for themselves.” 

Rebecca Jones | 8/7/2013