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.
Our Lady of Lourdes Memorial Hospital participated in the MAX Series with two different departments, Inpatient Care and the Emergency Department. Inpatient Care focused their action plans on creating a transitional team to bridge the gap between inpatient services and outpatient services, improving warm handoffs and identifying support services to loop in community-based organizations (CBOs).
“The inpatient team at Lourdes were go-getters,” shares Rachael Haller, Regional Lead and MAX Series Facilitator at Care Compass Network. “A lot of the team had a rapport from working together already and that was a real advantage.”
The Lourdes inpatient action team leveraged the already established 30-day readmission team to start meeting at regular intervals about their high utilizers. The group also developed a process map for warm handoffs and coordinated a high utilizer plan with Lourdes Primary Care to help bridge the communication gap.
To better work with CBOs the team worked to develop a standard care plan that could be shared with any organization. A service resource list was created that includes health insurance providers, the Department of Social Services, and other valuable external outpatient resources which is available for care providers when needed.
Improved discharge instructions were created for patients that were diagnosed with COPD and heart failure. “Because their symptoms are changing, patients were unsure of when it was appropriate to go to the hospital and when it wasn’t,” Haller explains. The action team started to utilize Zone tools for these patients. This tool helps identify situations that would require hospitalization and ones that require a consult with their primary care to work through symptoms, eliminating unnecessary hospitalizations.
In a continual effort to empower patients in the management of their symptoms, the inpatient action team worked to establish relationships with Palliative Care services to provide support. Due to the large volume of patients identified, ensuring that everyone could take advantage of this resource became a challenge. The action team continued to strengthen the process, working within the barriers that existed. “There was a concerted effort to get the people would benefit from the program in to speak with someone to see if it changed the utilization pattern,” recalls Haller.
After examining high utilizer data, the team found that people were coming to the hospital for dialysis, though they were unable to provide the treatment. The action team worked on establishing and strengthen relationships with the dialysis centers during the course of the workshop. The team created consistent messaging for both parties to share with those patients with end stage renal disease, redirecting them from seeking dialysis at the hospital to the appropriate place that could provide care for them.
Prior to the start of the program, 84 unique high utilizers were identified to have been discharged a combined total of 151 times. Ninety days after the close of the MAX workshop, those same 84 unique high utilizers had a decrease in their admittance rate of 55%, the MAX goal set for the team was a 10% reduction within 6-months post workshop conclusion . The NYS Department of Health, through the Delivery System Reform Incentive Payment (DSRIP) program, has tasked 25 Performing Provider Systems (PPSs) with a statewide goal to reduce avoidable hospital use by 25% over a five-year period. The introduction of the MAX Series workshop is helping hospital systems and PPSs across the state to potentially reach or possibly surpass that goal by the close of DSRIP in 2020.