Date Submitted: August 5, 2016
Story Submitted by: Keya Brooks, MBA MHA, Network Manager
Organization: ActiveHealth Management (AHM)
Location: High Point, NC
North Carolina State Health Plan Enhanced Transition of Care (TOC) Program
Description of Population Served:
ActiveHealth Management provides care management services, including transition of care services, to North Carolina State Health Plan members who are active, COBRA, or pre-65 retirees.
The population targeted for the Enhanced Transition of Care Program includes members that are considered high risk for avoidable readmission.
The North Carolina State Health Plan (Plan), in partnership with the North Carolina Hospital Association (NCHA) and ActiveHealth Management (AHM), has been receiving real-time admission and discharge feeds on Plan members admitted to participating facilities since March 2015.
As a result, AHM and the Plan have been able to provide Enhanced TOC services to identified members with the goal of improving member engagement, health care experience, efficient care, and ultimately, health outcomes. Additionally, strong relationships are being built with local hospitals across the state to integrate and coordinate care transition activities for identified Plan members.
Efforts to reduce avoidable readmissions remains a focal point among health care service partners because they too are looking to reduce costs and improve quality of care. Additionally, there are significant missed opportunities to engage with Plan members in care transition services since many are not fully knowledgeable about these benefits. Higher engagement in transition of care services leads to better outcomes for the member, the hospital and the Plan. Because there are numerous initiatives by multiple organizations to reduce avoidable readmissions, there are challenges in coordinating these services to ensure a seamless patient experience. The goals of the Plan’s Enhanced Transition of Care program are to increase member engagement, raise awareness of available resources, ensure a better member experience, coordinate services with hospitals, reduce readmissions, and ultimately, mitigate costs and improve health outcomes.
Strategies and Interventions Implemented:
Through the partnership with NCHA, AHM and the Plan implemented an Enhanced Transition of Care Program. The goal of this program is to utilize AHM’s Regional Care Managers (RCMs) whenever possible to visit with Plan members who are high risk for avoidable readmission. These visits occur while members are still in the hospital. The RCMs are responsible for the following during each member hospital visit:
- Present members with the NC Enhanced TOC Packet and explain how to best use the resources and information
- Answer any benefit and resource related questions from the member
- Schedule a time to touch base with the member post discharge to engage them in TOC services
- Coordinate member’s transition with the Inpatient (IP) Care Coordinator at
AHM also implemented a Medication Therapy Management (MTM) Program for those Plan members that have a high risk condition for readmission, are taking more than eight medications, have evidence of medication duplication, or have been identified by a nurse for a medication concern. The dedicated pharmacist engages with identified Plan members through one-on-one telephonic coaching, completes a comprehensive medication review, and establishes a personalized Medication Action Plan. The pharmacist also follows up with both the member’s primary care provider and the member as needed.
Through the Enhanced TOC Program, member engagement has increased to 95%. Feedback from both members as well as participating hospital staff has been very positive. While it is premature to measure direct impact on avoidable readmission rates, the Plan’s rates have remained low.
The most important lessons learned through this initiative include:
- Interacting with members and their caregivers face-to-face in the hospital significantly improved member engagement rates
- Coordinating TOC services with hospital care coordinators resulted in a seamless and positive experience for both the member and hospital staff
- Integrating workflows with hospitals complement discharge planning activities and prevent duplication of services
- Maximizing the impact of Regional Care Managers requires strategic placement and coordination with facilities having varied member volumes and central as well as satellite locations
- Quick and consistent follow up with members post discharge is essential to maintaining strong levels of engagement and effective clinical impact
- Unexpected, value-added outcomes include increased TOC staff knowledge and ability to serve members, strong collaboration with NCHA, and improving the accuracy and utility of the ADT file data.