Title: The Care Transitions Program  

Organization Name: CareFirst BlueCross BlueShield  

Innovation type: Care Transitions  

What They’re Doing: Providing additional support to high risk patients as they transition out of the inpatient hospital setting. 

Clinical Innovation: Program staff rapidly triages patients with the greatest needs, especially members who have had lengthy hospital stays, have multiple chronic or complex diseases, are of advanced age, suffer psychosocial issues (i.e., depression and cognitive impairments), face linguistic or cultural issues, or have inadequate social (family) support. The program focuses on coordinating the care of the whole person, not just the specific disease. The Hospital Transition Coordinator (HTC) will conduct a real time review of available patient information (EMR, chart) and will develop a brief clinical summary including relevant clinical and demographic information such as current address and phone number. The HTC meets with selected patients prior to discharge and introduces themselves and their role. During the meeting they evaluate potential triggers that could lead to preventable hospitalizations, and engage the member in participation of a post-hospital follow up to ensure care is coordinated and needs are met. Key topics for evaluation include adequacy of support once discharged, knowledge of who to call if problems arise after discharge and coordination of care.   Patient who need case management, alternative care, pharmaceutical support or home based care services, are actively engaged in a care plan with a Patient Centered Medical Home and offered real time health care connections.

Staff contacts the patients post-discharge within 24-48 hours to re-assess their needs and care plan. If the patient has additional questions related to medications, staff connects them with a pharmacist who evaluates the medication plan and may also coordinate with the patient’s primary care physician.

Supportive Financing Mechanism: Some of the hospitals hope to participate in the state’s admission/readmission program​.  

Evaluation Type: Quasi-Experimental

Evaluation Plan: CareFirst is conducting an evaluation to compare the readmission rates for their patient populations in each hospital before and after the implementation of the program. They plan on analyzing the data on the basis of condition, zip code and other basic demographic information. They will also conduct a patient satisfaction survey. 

Patient Health and Cost Outcomes: Since hospitalizations serve to predict future high care cost, CareFirst has hired and trained over 50 skilled nurses, known as Hospital Transition Coordinators (HTCs), to assess patients in all of the local hospitals within the CareFirst region.  These nurses assess each patient upon admission in real time and gain insight when meeting the patient and their family in the hospital.  Admissions are categorized as follows:

• Advanced Illness/Palliative Care:  Catastrophic conditions, end stage disease, end of life. The member has intensive needs and is typically in Band 1 of the Illness Burden pyramid.
• Catastrophic Events
• Multi-morbidity Conditions:  An acute episode with worsening condition and/or multiple chronic conditions. The member has significant ongoing needs, multiple providers of care and/or multiple services post-discharge. Most of these members fall into Band 1 or possibly Band 2 of the Illness Burden pyramid.​
• Short-term Conditions: Acute episodes

For those patients triaged into the advanced, catastrophic or multi-morbidity health strata, the HTC nurse collaborates with the hospital staff to develop the post discharge plan and establishes a connection between the patient and a Case Manager in the appropriate specialty. Case Managers now fall into one of five specialties which include:​

• ​Oncology/hospice/palliative care
  
• Pediatric/special needs/pediatric oncology
• Trauma/rehabilitation
• Complex medical
• High-risk obstetrics

For those with multiple chronic conditions, simultaneously with admission, the HTC nurse notifies the patient’s PCP. In the event that the patient has long-term needs or requires community based care, the HTC nurse will refer the member to a Local Care Coordinator (LCC) who works with the patient’s PCP.

In the course of developing and monitoring a patient’s care, we have learned the critical role that adherence to medication and medication reconciliation have on a member’s health.  We know that a high risk multi-chronic population may take ten or more different medications. These drugs are often prescribed by multiple specialists and hospital based providers. This situation can lead to confusion and duplication, adverse drug interactions and higher levels of patient non-compliance.  The outcome from these scenarios often is another hospital admission.  In fact, one of the top causes of hospital readmission is issues with medication post-discharge. By including a pharmacist in the team, direct interaction with these patients regarding their individual medications and circumstances can occur.​

The following graphic displays the connections made for hospitalized patients during the first five months of 2012.

Publications:  none

Target Population: CareFirst members who are or recently have been hospitalized (About 12,000 per month). Date of Implementation: The pilot of the program began in May 2011 at two local hospitals. Full operation of the program occurred in January 2012, with fully trained nurses onsite at 27 high volume hospitals and telephonically in 20 other hospitals within its’ service area. 

Multimedia: Pending

Contact: Karen Everett, RN, Director Care Transitions Program karen.everett@carefirst.com, 410-605-2631.​