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Care Coordination and Right Level of Care
Increasing Capacity of Acute Care Beds
Work Stream Team Members
Pull Patients Out of Hospital Maintain Patients at Home Support ED Through Put
Leah Wegner Dawn Doe Becky Trella
Titilola Britto MD Lisa Roome Tara Gagner
Tarek Karaman MD Sharon Henry Steve Wojnicki
Pat O’Dea Tina Kimps Joanne Verburgt
Sarah Becker Cheryl Meyer Lynn Sisler
Sherri Aufderheide Sheila Thiel Ron Lawton MD
Martha Donnan Kris Kelm
Karen Marcelo
Goals• To protect stable, but vulnerable patients, from unnecessary exposure to pathogens by
safely shifting their hospital care to their home. This will reduce the use of emergency department and inpatient/observation beds, keeping them for the sickest patients.
• Increase hospital capacity• Reduce hospital length of stay (LOS)• Reduce readmissions• Reduce total cost of care• Increase patient satisfaction• Increase care coordination between acute and post acute
Key Deliverables • Integrated team consisting of inpatient care management, ambulatory care
management, emergency room, home health, hospice, skilled nursing facility program, respiratory therapy and DME developed a risk profile stratifying patients into appropriate discharge disposition level
• Utilized current programs to full potential without duplicating services• All patients including Emergency Room, Observation and Inpatient will be placed in
appropriate discharge disposition level• Care Management, Post Acute Liaison and Physician in collaboration will determine
discharge disposition level • Developed pathways/guidelines for each disposition level• Key changes to current programs
• Add APC for high acuity patient to supplement home health episode • Home Hospital program to decompress emergency room or hospital beds
It Begins with Discharge Planning
• CMS waiver allows care management to partner differently with Post Acute than in the past• Choice of SNF/Home Health waived• 3 midnight stay for SNF waived• F2F encounter can be virtual• NP, PA able to certify/order/follow in community for home health • Inpatient therapy eval NOT needed for home health• Inpatient therapy evaluation may not be needed for SNF
• Discharge planning begins in first 24 hours of hospital stay
• OFTs/Hospital Rounds continue remotely to expediate patient transitions to next level of care
• All patients (emergency room, inpatient, observation) will be classified into 6 categories which will determine resources provided
• D/C Planning team, Post Acute Liaison, ED Care Manager in collaboration with physician will make recommendation regarding Levels of Care 1-6
Services by Discharge Disposition Level Level 1
• Ambulatory Care Transition Program
• PCP
Level 2 • Home Health
• Post Acute Virtual Health• Ambulatory Care Transition
Program
Level 3 • Recovery at Home
• Home Health• Post Acute Virtual Health• Ambulatory Care Transition
Program• Advanced Practice Clinician
Level 4• Skilled nursing facility
placement
Level 5 • Home Hospital
• Advanced Practice Clinician
• Home Health• Post Acute Virtual Health• Respiratory Therapy
Level 6• Hospice
Identification of Patient Level of CareLevel 1 – discharged home with self care, can be followed by PCP in the communityLevel 2 – co-morbidities, change in medical treatment, patient stable able to be discharged and managed in the home with home healthLevel 3 – co-morbidities, acuity requires changing medical treatment and medical management in the home – adding APC to support home healthLevel 4 – requiring skilled level of care at facility setting, complex Social Determinants of Health (SDOH) affecting ability to go homeLevel 5 – discharge to Home Hospital ProgramLevel 6 – discharge to Hospice, end of life care
Level 1 – Ambulatory Care Management• Care Transitions: 30/90 Day Post Hospital Follow-up
30 day post hospital follow-up for ACO patients (high/moderate readmission risk) 90 day BPCIA bundles post discharge follow up to 90 days NEW:
• ALL COVID-19 positive patients discharging from AA hospital (all payers, all risk)
• Clinically-presumed COVID-19 Positive (not tested): Stratified patients by risk level – high-moderate-low High Risk – Ambulatory Care Management follow-up for minimum of two weeks supplemented by
symptom management technology such as Get Well Loop/Epic Care Companion Moderate Risk – Ambulatory Care Management check in once, supplemented by symptom management
technology such as Get Well Loop/Epic Care Companion Low Risk – Follow up with symptom management technology such as Get Well Loop/Epic Care
Companion with Ambulatory Care Management follow up for escalated symptoms.
Level 1 – Ambulatory Care Management• COVID Test Result Notification: Positive and Negative Results
Completed backlog of ambulatory results from mobile testing sites
Handling any NEW COVID-19 lab result notification for all patients NOT currently IP• Calling ALL positive tested to complete patient education, and negative tests that have not been
viewed in mychart/live well.• Current process is to document in telephone encounter• Future state to document in the results notes section in Epic
Level 2 – Home Health• Home Health
• In-Person Care First• Post Acute Virtual Health
• Telephone Calls• Automated Outreach• Remote Monitoring• Video Visits
• In Partnership with the Care Transition Program
Care at Home First
Our goal is to provide safe care in the home first. This in-home care will be augmented with Virtual Health as appropriate as driven by
patient choice, care plan and team member safety.
Evaluating Patient Triage Level
• Close to baseline function & meeting discharge goals• Patient has strong support network• Reaching independence with care plan or self monitoringLow
• Multiple comorbidities but has established/stable care plan• Inconsistent caregiver support and/or cognitive issues• Requires Action Plan cues• Non-active participant in care plan
Medium
• New dx/acute condition• High readmission, fall or safety risk• Lack of caregiver support• New medication teaching
High
1
2
3
Post Acute Virtual Health• Began in home health for high risk patients• Has expanded to Outpatient Rehab, Hospice, DME, IV, PAN SNF,
Physicians at Home and Home Based Palliative Care during the COVID-19 Pandemic to keep our patients and our staff safe
Home Health Determined per Triage Level
Automated Outreach Calls Available for all Home Health patients
Telephone Calls/Assessment Low & Medium triage HIGH Impact and Easily Accessible
Video Visits and Remote Monitoring
Focused on our highest risk patients
Level 3 – Recovery at Home • Home Health with an additional APC
visit/oversight• ECIN referral to Home Based Palliative Care• Mark the referral – “COVID-19 follow-up”• Patient will be followed by APC a minimum of
14 days post diagnosis
Level 4 – Skilled Nursing Facility Placement • Skilled Nursing Facility can be used to avoid hospitalization or
rehospitalization • Patient must meet criteria for Skilled Nursing Facility • Skilled Nursing Facility acceptance during pandemic
• Identify one SNF per region • SNF availability will be changing daily
• Current status (positive patients, PUI)• PPE• Current staffing • Directions from county department of health• ED to SNF for COVID-19 patient would not meet criteria
Level 5 – Home Hospital• Same day or next day Home Health with an additional APC
visit/oversight• Respiratory Therapy• Post Acute Virtual Health
• Telephone Calls• Automated Outreach Calss• Remote Monitoring• Video Visits
• Supports ED throughput during COVID-19
Level 5 – Home Hospital Supports ED Throughput• Current pandemic is causing undue stress on
emergency departments• Identified discharge disposition specific to COVID-19
population• Discharge disposition is driven by PA02 and clinical
stability• Recovery at Home Program and Home Hospital
programs developed in response to COVID-19 discharge needs
Clinical IndicatorFollow Up Care by Post-Acute Division: Current State Referral Process
Planned State for ED order sets implementation 4/20/2020
TRIGGER
Exertional SpO2 >=95% and no COVID high-risk factors
AMBULATORY CARE MANAGEMENT: Discharge home; Ambulatory CM to place/monitor pt on Symptom checker App (GetWellLoop or Epic Care Companion)
Epic Hospitals & AMG: Suspect COVID pts identified for Epic user patient populations (AMG and Epic hosp patients). Ambulatory care management follow up program active and initiated.
Cerner ED Hosp patients:GAP identified for Cerner Hospital Suspect COVID ED patients. Referral Process stated to fill gap.
Epic Hospitals: Pop Health Ambulatory CM has report/workflow active. Low risk pts placed on SymptomChecker App.
Cerner Hospitals: Provider/ED Care Manager can enter referral to Ambulatory CM via Microsoft Forms Link (as of 4/13/20)
Epic Hospitals: ED physician smart text order includes all levels of care
Cerner Hospitals: Provider/ED Care Manager can enter referral to Ambulatory CM via Microsoft Forms Link
surge 1-5
Exertional SpO2 >=95% and COVID high-risk factors
AMBULATORY CARE MANAGEMENT Discharge home with next day ambulatory care management phone call repeated x2, more if needed, arrangements for virtual provider visit, HH or recovery at home program if patient symptoms not well controlled.
All AAH Hospitals: COVID + patients DC'ed hospital setting populate on Care Transitions Nurse Program Report for Nurse Follow UpEpic Hospitals and AMG: Suspect COVID pts identified for Epic user patient populations (AMG and Epic hosp patients). Ambulatory care management follow up program active and initiated. Cerner ED Hosp patients: GAP identified for Cerner Hospital Suspect COVID ED patients. Referral Process stated to fill gap.
Epic Hospitals/AMG: Pop Health Ambulatory CM has report/workflow active.Cerner Hospitals: Provider/ED Care Manager can enter referral to Ambulatory CM via Microsoft Forms Link (as of 4/13/20)
Epic Hospitals: ED physician smart text order
Cerner Hospitals: Provider/ED Care Manager can enter referral to Ambulatory CM via Microsoft Forms Link
surge 1-5
Exertional SpO2 >=95% and COVID high-risk factors,
patient has limited support, mild cognitive impairment,
skilled nursing or rehab needs, able to follow up
with PCP
HOME HEALTH nursing visits and telephonic follow- up, HH coordinate orders with PCP or consult palliative APC for support if needed
ED physicians and hospitalist can place service to home care and will need to complete face to face orders in the EMR
Service to home health order, Care Connection Hopsitals will still have to enter the ECIN referral in order to send the HH for intake at AAHH.
No change to existing Epic or Cerner Hospital workflows surge 1-5
HOSPITAL COVID FOLLOW UP CARE
Exertional SpO2 93-94% or Exertional SpO2 >=95% with COVID high-risk factors and patient has limited support, mild cognitive impairment
and unable to follow up with PCP
RECOVERY AT HOME Discharge home with next day APC virtual visit and home health visits as needed, repeat daily visits as needed. In-person home visit if patient unable to have virtual visit.
New Program - ED or Acute Care Discharges
Care Manager to enter below orders into ECIN: Recovery at Home - Home Health Recovery at Home - APC team
Epic Hospitals: ED physician smart text order,Epic orders to flow straight through to HH and APC team, Cerner Hospitals: orders to be transcribed into ECIN during day time hours by ED care managers
Surge 3-5
Exertional SpO2 90-92%, no COVID high-risk factors and otherwise clinically stable
HOME HOSPITAL PROGRAM Discharge home with 2L NC and home pulse ox remote monitoring. Same day or next day APC virtual visit and HH nurse visit, repeat until medically cleared
New Program - ED Only, Implementation date tentatively 4/16/2020 - 4/20/2020. Patients to be discharged into program 6 am - 3pm to assure APC can provide outreach same day as discharge. If pt discharged after 3 pm no outreach will occur until 8 am next morning.
ED physician to write orders "Care Manager to arrange for in home APC visit, home health nursing, discharge with 2L NC Oxygen and home pulse ox remote monitoring." ED Care Manager to call Home Health (1-800 564-2025) and Advocate Physician at Home/Palliative (630-571-8990) with urgent Home Hospital referral and enter into 3 referrals into ECIN: Home Hospital - Home Health, Home Hospital -DME, Home Hospital - APC team. Note 4 hour TAT for O2 delivery to ED and home.
Epic Hospitals: ED physician smart text order, Epic orders to flow straight through to HH, DME and APC team as urgent Cerner Hospitals: orders to be transcribed into ECIN by ED care manager. ED Care Manager to call Home Health (1-800 564-2025 ) and Advocate Physician at Home/Palliative (630-571-8990) with urgent Home Hospital referral, note 4hr TAT for O2 delivery.
Surge 3-5
HOSPITAL COVID FOLLOW UP CARE
Level 5 Criteria and Timeline• Patient must have internet access to be eligible for the
program• Plans will be implemented and align with hospital surge needs• Implementation of programs are dependent on staff and
resource availability (PPE, 02, concentrators) • Implementation will be staggered and prioritized by hospitals
with high volume Covid-19 patients beginning at Advocate Christ Medical Center
Level 6 – Hospice • Goals of Care conversation occurs with provider• CM/SW contact Hospice Liaison with referral d/t choice waiver and
patient has no preference• Hospice liaison determines patient meets criteria for General
Inpatient Level of Hospice or Routine Level of Hospice• Hospice liaison, provider, and patient select the most appropriate
setting to provide hospice services for COVID-19 and non-COVID-19 patients
• Hospice in the hospital if unstable to transfer• SNF/ALF• Home• Hospice facility
• Hospice liaison coordinates referral to Advocate Aurora Hospice (in conjunction with CM/SW depending on destination)
Contact InformationDawn Doe, Vice President Post Acute Value Based [email protected]
630-935-5174
Kris Kelm, Vice President Integrated Care [email protected]
