Preventing Rehospitalizations through Comprehensive Care Management

Whenever a surprise blizzard or other weather emergency threatens to paralyze New York City, VNSNY’s value-based care management team moved into high gear. “We had 900 patients under value-based care arrangements at the time, and our staff phoned each of them to make sure they had all their medications and sufficient food in the house,” recalls Marki Flannery, VNSNY’s President and Chief Executive Officer, of the blizzard of March 2017. Several patients reported they were nearly out of essential medications, and the VNSNY team was able to get same-day resupplies delivered to them—preventing what could have been medical emergencies requiring trips to the hospital.

The blizzard outreach is just one example of the attention VNSNY gives to patients admitted to our care under value-based models. These models benefit VNSNY’s referring providers as well. “Hospitals, sub-acute facilities, and physicians taking on population risk may take a financial hit if their patients get readmitted,” Flannery explains. “As the agency caring for these patients following discharge, we’re committed to seeing that doesn’t happen.” These patients fall into two categories—those in Medicare bundled payment models, which cover all medical expenses incurred during the 90 days following hospitalization, and those in private insurance case rate arrangements, where the coverage period is typically 60 days.

VNSNY’s care management has already reduced hospital readmission rates by 5 to 10% for its case rate patient population.

Since its expansion to other managed care plan populations early this year, adds Flannery, VNSNY’s care management approach has already reduced hospital readmission rates by 5 to 10 percent for its case rate patient population.

Evidence-Based Protocols as Part of Care Management

To keep recovery of discharged patients on track and prevent readmissions, VNSNY’s care management team employs an array of evidence-based protocols, starting with a comprehensive evaluation that includes screenings for depression and anxiety, analysis of nutritional status and medication adherence, and an assessment of rehospitalization risk.

Once a patient’s formal home care episode is completed—usually after three to four weeks—the team continues to check in with each patient for the rest of the value-based period, monitoring key health parameters, confirming that medical equipment is in place and medications are being taken appropriately, making sure doctor’s appointments are made and kept, as well as addressing dietary, behavioral, and social need issues, and intervening directly if a problem arises.

“Each value-based patient is assigned a care manager who coordinates the activities of the care team members,” notes Rose Madden-Baer, Senior Vice President, Population Health and Clinical Support Services, who directs the program for VNSNY. “We may arrange for the patient to get an in-home visit from a nurse, social worker, or nutritionist as needed, and we will also contact the patient’s physician if certain warning signs occur.”

If a patient in a value-based arrangement shows up at an area emergency room or hospital admitting facility, the care management team gets an automatic alert, enabling VNSNY team members to reach out with alternative health services options that may prevent a hospital admission.

Giving Patients Tools to Maintain Health After the Care Period Ends

Besides taking all possible steps to prevent hospital admissions during the value-based care period, VNSNY’s care management team also educates patients and connects them with resources to help keep them healthy once VNSNY is no longer supervising their care. “For example, we teach our patients and their family caregivers how to identify potential crises early on, so they can manage the problem with their doctor rather than go to the emergency room,” says Joan Cassano, Vice President, Clinical Operations Improvement and Care Coordination. “We take our job very seriously—and that includes giving our clients the tools to stay out of the hospital once we are no longer caring for them directly in their home.”