Identify two to six factors that are information that describes the problem that is included in the case study. For example, what type of data was collected? Was there an event that create

HIMSS Davies Award Case Study Transitions of Care 1

The Evolution of a Transitions of Care Program

Jefferson Health

Primary Contact Information:

• Tina Sokolowski- Vice President Population Health Services

• [email protected]

• 215-350-4724

Clinical Project Lead:

• Laura Gontz- Director Care Coordination

• [email protected]

• 267-671-7642

IT Project Lead:

• Kyle Cibak – Director Actuarial Informatics

• [email protected]

• 215-955-1559

Executive Summary

Since the passage of the Affordable Care Act in 2010, healthcare has

undergone a paradigm shift from a volume-based fee-for-service to an

outcomes-based payment model. For Jefferson Health and other providers

employing a continuum of care model (a cohesive care system that guides

and tracks patients over time through a comprehensive array of services

spanning all levels of care), this transformation has placed an outsized focus on

improving an integral part of the patient journey: the transition from one

service level of care to the next. Strategic communication is a key driver in

effectual and proficient patient care across the healthcare continuum,

particularly in transitions of care, with numerous studies demonstrating that

effective communication increases patient safety, saves costs, and reduces

duplicative work. And so, in autumn 2018, Jefferson Health launched a

multidisciplinary effort to develop a comprehensive transitions of care program

that would be both replicable and sustainable, address communication

challenges, and mitigate fragmentation through the patients’ acute care

journey. Emphasis was also placed on establishing goals to ensure our program

fostered accountability and collaboration in a multidisciplinary service deli very

structure that provides the right care, to the right patients, at the right time—to

treat each person holistically. While initial improvements in outcomes for

patients with ambulatory sensitive conditions were impacted by the COVID-19

pandemic, the team is confident that the comprehensive transitions of care

program will rapidly return to pre-pandemic levels of success. The health system

now has tools to identify patients discharged from all locations in a timely

HIMSS Davies Award Case Study Transitions of Care 2

manner without our nurse team sifting through spreadsheets and risk scores to

locate them. Custom templates were developed in our EHR to guide our staff in

consistent evidence-based scripted calls during our transition of care

connection. Disease-specific questions and care plans were built to direct our

attention to a patients’ ambulatory sensitive conditions which included self –

management plans, and barriers to follow up care. As members of

comprehensive primary care (CPC+), we are tasked with attempting to

contact 75% of patients transitioned out of an inpatient, or post-acute setting.

As a result of our efforts, our patient population is successfully engaged 78% of

the time and we have seen a significant reduction in our Hospital Readmissions

Reduction Program (HRRP) year over year with a savings of 18%.

Lessons learned include:

A high-quality transition is achieved when all patient referrals and transitions

meet the six Institute of Medicine aims of high-quality health care. From this

perspective, referrals and transitions should be:

• Timely: Patients receive needed transitions and consultative services

without unnecessary delays.

• Safe: Referrals and transitions are planned and managed to prevent

harm to patients from medical or administrative errors. Care

coordination has been defined as “the deliberate organization of

patient care activities between two or more participants involved in a

patient’s care to facilitate the appropriate delivery of health care

services.”

• Effective: Referrals and transitions are based on scientific knowledge

and executed well to maximize their benefit.

• Patient-centered: Referrals and transitions are responsive to patient and

family needs and preferences.

• Efficient: Referrals and transitions are limited to those that are likely to

benefit patients and avoid unnecessary duplication of services.

• Equitable: The availability and quality of referrals and transitions does

not vary by the personal characteristics of patients.

The journey through our transition of care program has shown there are

numerous steps to success as well as a great many patient outcomes to

measure. Initial focus was on identification of patients to outreach. We quickly

learned that it is the quality of the outreach and defining a successful outreach

that adds impact.

HIMSS Davies Award Case Study Transitions of Care 3

Define the Clinical Problem and Pre-Implementation Performance Transitions of care have become an important target for the Triple Aim of

improving care quality and the patient care experience, improving the health

of our population, and reducing cost. Most research to date has focused on

hospital-to-home care transitions, and numerous studies have shown major

gaps in care during these transitions. For instance, communication across sites

happens infrequently, follow-up needs are not consistently identified, and few

patients have timely outpatient follow-up care after hospital discharge. More

recent studies have shown that most patients do not meaningfully benefit from

early outpatient follow-up. Transitional care resources would be best allocated

toward ensuring that highest risk patients receive follow-up within 7 days.

Given Jefferson Health’s robust annual patient volumes (approximately 127,000

admissions and 517,000 ED visits), the evolution from a fee-for-service to an

outcomes-based payment model put in stark relief the need to close any gaps

that may exist in transitional care across the health system. One area of

increased focus was the identification and prevention of readmissions for

ambulatory sensitive conditions. These readmissions are frequently related to

the index admission discharge and represent a poor outcome for the patient.

CMS also imposes heavy fines on hospitals who perform poorly in this area.

Additionally, as insurers develop utilization management (UM) policies that

deny payment for these services, these readmissions also have a negative

fiscal impact on the health system’s bottom line. Performance for 30-day

readmission rate of ambulatory sensitive conditions was 11.88% in 2018 prior to

implementation. Our readmission rate goal for our commercial population is

10.2 to achieve top quartile.

Prior to developing a comprehensive transitions of care system, Jefferson did

not have a consistent method of identifying these patients, nor did we have

templates that allowed our team to address the specific needs of these

extraordinarily complex patients. Our EHR limited the discharges we could see

to inpatients from our hospital system, excluding those patients who were being

discharged from outside hospitals. As a result, the health system lacked insight

into what was happening in these situations. In 2020, we reached or attempted

to reach only 72% of our patient attributed to primary care. Although we

attempted to reach 72%, only about 30% of patients followed up with a

physician within 7 days, due to factors such as lack of transportation, lack of

patient awareness to importance of follow up, and appointment availability.

Design and Implementation Model Practices and Governance

One of the major goals of Jefferson’s Population Health department has been to

unite teams and services under one common reporting structure. We needed to

HIMSS Davies Award Case Study Transitions of Care 4

share what we learned, replicate what worked in our division, and listen to new

enterprise teams who suggested changes.

In spring 2021, Jefferson Population Health brought together a team of healthcare

professionals to form three temporary action groups all centered on transitions of care

and preparation for the excess days in acute care measure. Analytics was able to provide

us with our baseline EDAC scores for the subset of patients wi th a Jefferson primary care

provider. Using this information, we set out to quickly make actionable changes to

improve our performance. Our (TAG) deliverables were to improve technology to monitor

and optimize transition of care workflows, identify barriers, adjust processes and leverage

digital health to expand capacity. We transitioned our team to leverage two new risk

adjustment models in support of transitions of care activities. The population health team

worked directly with our Jefferson hospitals inpatient care management team to create a

standard of care and communication across the care continuum based on highest risk

and utilization of patients. The Director of Care Coordination and her team of early

adopters offered ongoing support to new teams, employees, and service lines, which

allowed for growth and system integration. In January 2019, a standard Epic playbook for

transitions of care and care coordination documentation was built and distributed for

education. This playbook was also updated with changes and upgrades.

With this new enhanced process in place, it was our aim to increase the

proportion of our patients with a follow up appointment within 7 days and

further decrease our significant readmission costs.

HIMSS Davies Award Case Study Transitions of Care 5

Clinical Transformation enabled through Information and Technology

Jefferson’s transitions of care program utilizes a three-phased approach: Risk,

Screening, and Transitioning.

In the Risk phase, EPIC at Jefferson utilizes a two-step risk stratification process

that incorporates (1) an algorithm-based method, which uses data such as

demographics, utilization, co-morbid conditions, and other metrics; and (2)

care team perception of risk to segment the population into three risk tiers

(High, Medium, Low).

The algorithm-based method utilizes the metrics shown in the screenshot below

to calculate a General Risk Score. These metrics include demographic

information such as age and insurance type, utilization including a hospital

admission or ED visit within Thomas Jefferson University Hospitals, Inc. (TJUH), the

existence of co-morbid conditions including COPD, Diabetes, CHF, Liver

Disease, Depression, CAD, Hypertension, and chronic kidney disease, and other

metrics that have been shown to increase readmission risk such as substance

abuse and dementia. Risk scores are automatically and continuously

calculated as soon as information is entered and/or changes in a patient’s

record (i.e., new hospital admission to TJUH).

The risk tiers are determined based on the following points:

•0 – 3 points: Low Risk

•4 – 5 points: Medium Risk

•6 – 9 points: High Risk

HIMSS Davies Award Case Study Transitions of Care 6

The second step of the Risk phase includes the ability to refine the risk score

based on a practitioner and/or care team’s information or clinical intuition.

EPIC at Jefferson utilizes a Smart Phase to allow both the Primary Care Provider

and the RN Care Coordinator to change a patient’s risk score.

Jefferson Hospital Center City Division also calculates a LACE+ score on all

inpatient and observation discharges. Like the general risk score, this score is

based on demographics, utilization, co-morbid conditions, and other metrics.

Jefferson chose to utilize the LACE+ score due to its power to predict death or

urgent readmission post hospital discharge.

Patients from Jefferson affiliated hospitals with a LACE+ score of 59 and above

are placed on the registered nurse care coordinator caseload. Lower risk

patients with a Lace+ score below 59 are placed on the caseload of a

transitions of care focused health coach. These health coaches are certified

medical assistants with training in TOC, appointment scheduling, primary care

quality, and social determinants of health.

HIMSS Davies Award Case Study Transitions of Care 7

To identify the patients with a Jefferson primary care provider appropriate for

the transitions of care outreach, the analytics team developed a report of all

available acute or post-acute discharges. This reporting combined Epic-

sourced discharge information with admission, discharge, and transfer (ADT)

notifications provided through Jefferson’s participation in the regional health

information exchange. Each discharge was then assigned to the appropriate

care team member based on the patient’s primary care provider and risk

score. The assignment of discharges is automatically sent directly to the team

for outgoing calls, via a daily morning email.

HIMSS Davies Award Case Study Transitions of Care 8

The Screening phase focuses on the review of key information related to an

individual’s health situation to identify the need for health and social services.

The care coordinator’s objective in screening is to determine if a client would

benefit from such services. In such situations, a care coordinator or care

coordination assistant reviews the medical record—to the extent possible—

relevant to the “Four Domains”: Social Support, Chronic Disease and Self-

Management, Mental Health, and Health Trajectory.

The Transitioning phase focuses on moving a patient across the health services

continuum safely. To maintain continuity of care, this phase’s activities entail

the complete execution of the patient’s level of care transition through

communication with key individuals at the next level of care or setting, the

patient, caregiver, and members of the healthcare team. Care transition

contacts are excellent opportunities to assess patients for greater needs and

help through care coordination services. Now, it is standard practice for staff

from Jefferson’s Care Coordination team to reach out to the patient within two

business days of discharge from an acute or post-acute setting. Services

provided in this stage include but are not limited to

• Summarizing what happened during an episode of care

• Assisting in securing durable medical equipment (e.g., glucose meter, scale,

walker)

• Assisting in scheduling transportation services (if needed)

• Conducting a medication review

• Conducting an in-home needs assessment

• Coordinating/scheduling follow up appointments within 7 days of discharge

(Primary Care, Specialist, Ambulatory services)

Four key focus areas of review and teach back for the patient and/or patient’s

support system include:

• Medication changes and adherence

• Patient self-evaluation tools for signs and symptoms

• Stressing the importance of provider follow up

• Discussion on how and when to communicate changes/issues with your

primary care provider

HIMSS Davies Award Case Study Transitions of Care 9

In October 2021, we implemented the use of Epic MyChart Care Companion to

electronically contact our lowest risk patients post discharge for individuals who have

a chart account. This change was implemented so that the existing team could reach

more patients and provide a greater focus on the “rising risk” patient population. As

an example, a series of questions would appear as follows:

When patients answer these questions and screen positive for needing

assistance, a best practice advisory alerts the nurse. This patient will then

receive a direct phone call to assist them in their need.

HIMSS Davies Award Case Study Transitions of Care 10

Improving Adherence to the Standard of Care

Throughout the evolution of Jefferson’s transition of care program, two key

areas of focus were (1) the team’s ability to contact patients and (2) for the

team to make a reasonable effort to do so.

Currently, it is our policy to make two attempts to contact the patients post

discharge. For high-risk patients, this is primarily done by a phone call.

However, patients can indicate their preferred method of communication.

Each practice’s outreach attempts and successes are tracked and distributed

monthly. We use this data to look for issues with workload, documentation, or

report errors. Monthly distribution makes it possible to identify issues quick ly and

easily.

Today, with enhanced reporting capabilities that show not only the number of

calls made but also the percentage of those calls that are successful , our

analytics team monitors:

• Successful TOC Percentage (Based on the CPC+ Definition)

• Successful Patient Contacts (As a Percent of All Acute Events)

• Successful Patients Contacts (As a Percent of Successful TOCs)

HIMSS Davies Award Case Study Transitions of Care 11

Improving Patient Outcomes

Transition of care interactions and seven-day follow–up visits with a primary

care provider or specialist position have been shown to decrease hospital

readmissions and increase positive patient outcomes. Our patient population is

successfully engaged 78% of the time. During our initial TOC contact and 7-day

follow up visit, we frequently uncover issues or “good catches” that could

correlate to poor patient outcomes.

While it is difficult to link these actions to reduced readmission rates in the time

of a global pandemic, we achieved a decrease in 30-day readmissions from

9.7% in FYQ3 2018 to 8.4% currently. Additionally, we have seen a significant

reduction in our hospital HRRP penalty year over year. This is primarily due to

the increased complexity of the ambulatory sensitive patients served and not a

decrease in average readmissions. The team is dedicated to delivering safe

transitions of care and are always looking for the latest processes and data to

deliver excellent care to our patients. We will continue to monitor these

HIMSS Davies Award Case Study Transitions of Care 12

initiatives as well as the new excess days in acute care measures to ensure we

are providing a valuable service to our patient population.

Total Population

ASC

HIMSS Davies Award Case Study Transitions of Care 13

Accountability and Driving Resilient Care Redesign

To increase the transparency in our performance throughout the transition of

care continuum, a dashboard was developed using the Qlik visualization

software. This dashboard summarizes near real-time Epic information and allows

population health leadership to be able to monitor performance from patient

outreach to successful contact and eventual follow up visit. This data is initially

presented in aggregate with the ability to drill down to the individual patient

level in support of identifying areas of further process improvement. Clinicians

can use this data to identify high utilizers and increase surveillance of those

individuals. Our population health nurse practitioners can be deployed to see

high utilizers in home to offer real-time interventions. Having this information

readily available has not only provided insight into the outcomes of our current

process, but also allowed us to rapidly evaluate the impact of workflow

changes. This ability has given our team the ability to adapt at the speed of

business, ensuring we are optimizing our processes to care for the patients we

serve.

HIMSS Davies Award Case Study Transitions of Care 14

HIMSS Davies Award Case Study Template 15

HIMSS Global Conference Audience Guidance (This will not be published)

Topic Guidance: Check three which apply to this case study

Clinical Informatics and Clinician Engagement

Clinically Integrated Supply Chain

Consumer/Patient Engagement and

Digital/Connected Health

Consumerization of Health

Culture of Care and Care Coordination

Data Science/Analytics/Clinical and Business

Intelligence

Disruptive Care Models

Grand Societal Challenges

Health Informatics Education

Health Information Exchange

Interoperability

Data Integration, and Standards

Healthcare Applications and Technologies

Enabling Care Delivery

Healthy Aging and Technology

Improving Quality Outcomes

Innovation, Entrepreneurship, and Venture

Investment

Leadership, Governance, and Strategic Planning

Population Health Management and Public Health

Precision Medicine and Genomics

Process Improvement, Workflow, and Change

Management

Social, and Behavioral Determinants of Health

Telehealth

User Experience (UX)

Usability

User-Centered Design