solved Wellness, Coordinated Care, Caregiver Support, Acute Care Management] Describe how

Wellness, Coordinated Care, Caregiver Support, Acute Care Management] Describe how best to identify specific gaps and fill them in any of the following areas: Wellness, Coordinated Care, Caregiver Support, or Acute Care Management?.
Answer this question:
Acute Care Management, Readmissions, and Transitional Care
Readmissions are a costly reminder of our failure to provide adequate Acute Care Management. “Nearly one in five Medicare patients discharged from the hospital returns within 30 days and roughly 75 percent of those readmissions are considered preventable.” (Hodach, 2016) The problem arises not necessarily from a failure of the acute care team, but a failure in the ability of the system to manage patients from the primary care office, to the admission, then home, and back to the PCP.  Hodach, et, al, go on to say “In a broader sense, it can be attributed to systemic failures that begin in the hospital and continue in the fragmented healthcare settings that patients move through after discharge.” (Hodach, 2016) I would argue that it starts in the primary care setting and not in the hospital.
The identification of the gaps is not difficult. Most insurers have portals that can be accessed to identify “frequent flyer” readmits. Also, many hospital systems have Case Management teams that use tools to identify high risk patients. Our hospital, for example, uses a modified version of the Better Outcomes for Older Adults model.  (Earl, 2020) Many hospitals can also utilize their own EHRs, population health software, or Hospital Association data to develop these registries.
Filling this gap is where things get a little more tricky.  I believe that a strong transitional care team is absolutely imperative to achieving the goal of decreased readmissions. Our organization was able to decrease readmissions simply by incorporating the BOOST model and giving more attention to the patients that were identified with it, but when I took on this role, I wanted to take that further.
Our approach has been to utilize Lean management concepts (as detailed in the Hodach book) to approach the problem. Because transitions of care involve many areas of the in and outpatient world, our first meeting consisted of myself as administrative representative and “owner” of the A3 (what we call a lean process because of the size of paper you use to draw the process), hospitalist, floor nurses, case management, home health, in and out patient pharmacy, physical therapy, and population health.  We have had several meetings over the course of the year and eventually had to have several smaller A3s to work out process problems before coming back to the table.
We are nearing the end of the A3 – COVID has thrown a wrench in a lot of the planning – and have already implemented many of the processes. We hired a transitional care LPN who goes to morning huddle with nursing and case management every morning. She works with case management to identify the needs of the patients identified with BOOST to help coordinate follow up and transitional care. We also hired a home visit NP who attends and meets the highest risk patients in the hospital, then does a home visit. High risk patients get referred to our transitional care program and receive a phone call at 24 and 48 hours and a home visit within a week.  Moderate risk patients receive a phone call at 48 hours.  Low risk patients are touched only by the transitional care nurse, not case management, and are assessed to make sure that nothing was missed. We have developed three ring binders with colorful inserts containing information on the disease reason for admission as well as other contributing diseases, medications, and follow up appointments. We have also started utilizing our meds to beds program and are having the pharmacists look at new rx for potential cost issues. If these arise, they are looking at our 340 B program and having the transitional care nurse discuss options with the patient.
We drew our model from several sources, but the one I relied most heavily on was The Science of Successful Care Transition Management by the Healthcare Intelligence Network. (Healthcare Intelligence Network, 2017) We have not got all of the pieces in place at this time, but we hope to see a decrase in readmissions as well as increased patient satisfaction once it’s rolling. A big barrier has been COVID and nursing shortages. Our population health nurses have been pulled to more “critical” staffing. Also, meetings were on hold for a good part of last year.  All in all, though, I think this is a good step toward better population health and decreased readmissions. I hope to move farther with this in the future by addressing some of the “chronic ambulatory care sensitive conditions” and hire more team members to monitor and administer in home care. (Longman, 2015)
Works Cited
Earl, T. P. (2020). Making Healthcare Safer III: A Critical Alalysis of Existing and Emergent Patient Safety Practices. Rockville: Agency for Healthcare research and Quality (US).
Healthcare Intelligence Network. (2017). The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI. Sea Girt: The Healthcare Intelligence Network.
Hodach, R. M. (2016). Provider-Led Population Health Management. (M. Karen Ezekiel Handmaker, Ed.) Indianapolis, IN, USA: John Wiley & Sons, Inc.
Longman, J. M. (2015). Admissions for chronic ambulatory care sensitive conditions – a useful measure of potentially preventable admission? BMC Health Services Research. Sydney, Australia.
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Wellness: Gaps in Breast Cancer Screening
Yearly mammograms starting at age 40 have been shown, in randomized control trials and real-world screening data, to reduce mortality from breast cancer by 40%. However, recommendations for getting a mammogram differ between organizations.  For instance, the American College of Radiology, Society for Breast Imaging, National Comprehensive Cancer Network, and many others recommend annual mammograms at age 40. By contrast, the United States Preventive Services Task Force recommends biennial mammograms from ages 50 to 74. Many insurance plans base their coverage on USPSTF’s recommendations. These various policies make it confusing for women and providers and may contribute to gaps in care. Furthermore, the USPSTF’s recommendations are based on data from mostly white women. Black women have higher mortality rates from breast cancer compared to White women are more at risk for BRACA1 and BRACA2 mutations, and for triple negative cancers. Because Black women have a higher risk, they would benefit from earlier and annual mammograms. Low socioeconomic status can also compound disparity because of lack or access to care and no insurance.
A program in Chicago called Equal Hope helps women receive breast care at no cost. Their evidence based system to reduce disparities has the following steps:
1. Landscape Analysis-map out where people get their care, and find the gaps
2. Develop a Quality Scorecard-analyze what is highest quality of care to get best outcomes at lowest side effects. Use an easy to understand scorecard so providers and facilities see how they can improve.
3. Create a Big Tent-enroll providers and facilities to provide quality data-everybody in and nobody out
4. Assess How the Healthcare System Works in Real Life-What are the touch points, what are the barriers, and what helps patients get what they need
5. Listen and Learn From Patients
6. Design Evidenced Based Interventions
By determining which neighborhoods had the most need, pinpointing quality improvement issues within facilities (radiologist training, followup to imaging), public campaigns to communicate the need and provide free breast care for uninsured patients, and patient navigation were all implemented to decrease Chicago’s disparity. In fact they claim Chicago is now #1 in reducing breast cancer deaths among African Americans.
References:
Monticcilo, D. (2020) Current guidelines and gaps in breast cancer screening. Journal of American College of Radiology. https://doi.org/10.1016/j.jacr.2020.05.002 (Links to an external site.)
Equalhope.org
Improving Access and Quality of Breast Health Services in Chicago.https://equalhope.org/wp-content/uploads/2019/05/s…