Over the last two years, Care Compass Network (CCN) has conducted several Medicaid Accelerated eXchange (MAX) Series in conjunction with local health systems to redesign the way care is delivered for the state’s most vulnerable patients. In earlier article “‘Mad’ MAX Comes to the Southern Tier“, we provide further detail on the process for the MAX Series.
Guthrie Cortland Medical Center (formerly Cortland Regional Medical Center) was one of four health systems that participated in the MAX Series with CCN. The action team there was made of staff from all facets of the hospital. However, it was observed that the most important information that was gathered was from those with their boots on the ground.
The action team started by adding to the daily census, which lists who is in each bed on each floor, an indicator as to who was a high utilizer. By doing this they could wrap care around them differently. The care team used the method of asking the ‘5 Whys’ to further understand the individual drivers of utilization. The whys peel away the layers to understand what, beyond the medical condition, has brought the person to the hospital. Through this questioning it was discovered that oftentimes caregiver anxiety was the root cause of the visit. Because Guthrie Cortland Medical Center already had a relationship with Hospicare, the community palliative care service, high utilizers were often linked to their agency.
A palliative care assessment was put into practice based on an existing evidence-based evaluation created by Dr. Amy Boutwell of Massachusetts General Hospital. Guthrie Cortland refined the tool enabling their RNs to administer it and hand it off to a physician to write the order for palliative care. The discharge team was also made aware that patients with positive assessments who have not been linked to palliative care should be given a referral.
The action team also decided to offer participation in the Care Transitions program to high utilizers. With this program the individual is follow up with via phone or a home visit within three days of discharge and throughout a 30-day period. The team understood that many times their patients would forgot extra help if they were given the choice. However, to get more people to participate with the Care Transitions program, they changed enrollment form an opt-in process, asking “would you like a follow up phone call” to an opt-out “I’m going to make a follow up phone call to get you the care you need.” This slight change in wording, enabled the team to enroll more individuals into the program giving them the opportunity to provide better care for their patients.
To build better relationships with community-based organizations (CBOs) the action team set up weekly meetings to discuss hospitalized high utilizers. They also worked to alter some of the hospital’s policies in order to make it easier for outside staff to be directly involved during warm handoffs with patient’s at the hospital. This policy change opened the door for teams to bring in additional CBOs, such as Cortland County Area Agency on Aging and staff from local skilled nursing facilities.
Overall, the action team from Guthrie Cortland learned from their MAX Series to start with a small, manageable patient cohort when trying to address the needs. This proved to be more successful in creating change than attempting to take on all the needs of all their patients at once. They also realized that data analysis should be kept to actionable insights so as not to overload the amount of information provided.