Avoidable inpatient utilization is costly and studies have found that approximately one-fifth of New York state’s hospital admissions could be avoided. Our client is held accountable for their role in decreasing potentially avoidable admissions through the Medicaid/Medicare Quality Incentive (PCR, HPC, PQI). In the current state of healthcare delivery the care transitions process is fragmented, leaving a greater opportunity for errors and adverse events. Currently proxy data performance is showing declines in hospital admissions and readmissions over time; however, we still require significant improvement to reach desired targets.
Our Onsite Care Management team plays an important role in supporting and managing members at risk for preventable hospitalizations. A discharge from a hospital setting is a critical transition point in a member’s care. Incomplete handoffs and poor care coordination can lead to adverse events for members, and an avoidable re-hospitalization. Our Onsite Care Managers (OCM) are strategically placed at key sponsor hospitals, working directly with the care team to coordinate a safe discharge. The aim of this protocol describes the Onsite Care Management program and the process for management of members at risk for avoidable hospitalizations. This program is designed with four main objectives.
- Timely identification of members at risk: members are identified via predictive modeling, emergent admissions census, and through hospital referrals of members with multiple chronic conditions (HTN,CHF, COPD/Asthma, DM) recently hospitalized; OCM have access to Hospital EMR
- Linkage to primary and specialist care
- Consistently obtain key outpatient appointments for members who present to the ED or inpatient setting, at a clinically appropriate time, focusing strongly on primary and specialist care appointments
- Linkage to care management and community-based services
- Identify gaps in care and engage members who qualify for and would benefit from existing care management programs, including hospital-based, CBOs, and internal HF programs
- Short-term transitions management and discharge planning to enhance coordination of care during hospital visit and to promote successful transfer to outpatient services
- Goal is to provide targeted short-term care management services for members at risk of unsuccessful transition to community-based care