July 26: (2/2) Transitional Care Medicine
What a great week at Banner Good Samaritan. I had the opportunity to host another Town Hall - with a crowd of more than 70 people. Lots of energy. We talked about our vision and again a challenge to everybody to contribute and get engaged in your unit’s Improvement activities ... So many Possibilities.
Today, I wanted to highlight two great physician leaders and their teams that have clearly differentiated Banner Good Samaritan in their journey to becoming a national leader as a teaching hospital in a new academic medical center distinguished by its ability to deliver high value based care across the continuum.
Ken S. Ota, DO, is a great Physician leader creating Possibilities in the Transitionalist Program at Banner Good Sam. (A separate post by Dr. Stacie Pinderhughes preceeds).
Steve Narang, MD, is the chief executive officer at Banner Good Samaritan Medical Center.
Transitional Care Medicine
By Ken S. Ota, DO, Medical Director, Transitional Care Medicine, Banner Good Samaritan
One of the most daunting tasks in health care today is managing the care of patients that have recently been discharged from the hospital.
The patients are typically over the age of 65, chronically ill with at least three to four medical co-morbidities, inundated with a long list of prescription medications, have multiple outpatient physicians that do not directly communicate with each other, have poor health literacy, and are frequently burdened by distressing symptoms.
With the increased survival of our aging population, health care providers are faced with the challenge of figuring out how to accommodate their care in a cost-effective manner without jeopardizing their safety or quality of care.
In an attempt to meet the demand of chronically ill patients at high risk for 30-day rehospitalization, the Transitional Care Medicine (TCM) program was initiated at Banner Good Samaritan in 2011 with the purpose of optimizing post-hospitalization care management for these frail patients. Many clinical and administrative issues often go awry during the transition period from hospital to community (home, skilled nursing facility, acute rehabilitation center, etc.).
To ensure a frictionless transition, we implemented a strategy that involves direct communication between patients and provider, same-day evaluation of complaint at the patient’s home or in the TCM clinic and access to various treatment modalities in the outpatient setting.
The TCM program has demonstrated the ability to reduce Emergency department (ED) visits and 30-day rehospitalizations. Our biggest impact has been observed in the heart failure population, where the current rate of 30-day rehospitalizations is less than 10 percent – 60 percent less than the national Medicare average.
I am reminded of an 80-year-old female with frequent ED visits and admissions for various cardiopulmonary disorders. In both 2010 and 2011 she accumulated more than $100,000 in hospitalization costs. She was referred to the TCM program at the end of 2011. She had congestive heart failure, chronic obstructive pulmonary disease (COPD), profound debility, coronary artery disease, diabetes mellitus type 2, suspected early dementia, and several other co-morbidities.
The patient was so debilitated that she was unable to move from her recliner. She called 911 for any concerning symptom because she was physically unable to go to her primary care physician’s office.
Through rapport-building and regular home visits, she stopped calling 911. Those calls became diverted to the TCM provider at the time – me. As expected, she had numerous episodes of decompensation of her heart failure and COPD. During the time I took care of her, she developed pneumonia and had a few bouts of cellulitis – all issues she would have been hospitalized for had she been transferred to the hospital.
Essentially, this patient received “hospital-at-home” type care through TCM. Her acute illnesses were treated and her symptoms were managed. I eventually advised the patient that she needed home hospice as her debility was worsening. She died peacefully in late 2012 in an in-patient hospice unit.
As a Physician Transitionalist, I have visited patients in their homes throughout Phoenix. Some of the house calls have taken me to areas that have opened my eyes to the dismal living conditions of many of our patients.
It is not uncommon to encounter hoarding, bed bugs, reuse of insulin needles to save money, intoxicated patients, lack of air-conditioning, illicit drugs, lack of caregiver support, destitution or homelessness.
In early 2013, the TCM program hired a nurse practitioner and a social worker to implement a multi-disciplined care model that has clearly enhanced the power of this program. We commonly see that patients’ psychosocial issues hinder progress with their medical care.
Having a skilled and experienced social worker that is aware of the various community resources to assist these patients with their basic primary needs for living is an inarguable necessity. By empowering our patients to take better care of their health, our social worker has very quickly become a key asset to the program. In a time where hospital readmissions and quality of care is being heavily scrutinized, it behooves health care systems to invest in programs that can help improve the psycho-social conditions of the patients we serve.
The foundation of TCM is to do what is right for the patient. Yet we are also measured by how well we are able to keep readmission rates at a reasonably low level. We have found when we respond to patients in a timely fashion, they utilize the hospital system less. We aim to be available (physically) around-the-clock if they need to be seen.
All patients enrolled have the direct phone number of each TCM provider. In some cases still, we have patients that present to the ED without contacting a TCM provider. IT has developed an alert system which automatically notifies each TCM provider when an enrolled patient presents to any Banner emergency department. The ED physician seeing the patient is also notified that the patient is enrolled in TCM and is prompted to contact the TCM team to come up with a care plan that would potentially avoid the need for rehospitalization.
Since its inception in early March of 2013, the alert system has fired 49 times and only five of the alerts resulted in hospital admission. (This system has not yet been formally studied).
To date, we have enrolled more than 250 patients into the program and the multidisciplinary care provided is systematic and effective. We continue to strengthen our transitional care network within BGSMC and into post-acute facilities. We continue to build relationships with outside medical providers to enable a cohesive care process for our patients. TCM, though still in its infancy within the health care system, is very quickly being recognized as a necessary service line by the hospital community both from quality of care and fiscal standpoints. We are excited to see emerging TCM programs throughout the nation and look forward to being a part of the transitional care movement!
Patient-centered care is the unwavering core of TCM philosophy. We are here to help – use us.