Nurses Bridge Gap from Hospital to Home

When Medicare began reimbursing for transitional care management services Jan. 1, 2013, it assigned a specific financial value to a subset of services that nurses such as Adrienne Schultz, BSN, RN, have been providing for some time: care coordination, also known as care management.

Schultz and her team of care managers help patients navigate the often overwhelming world of healthcare both inside the hospital and out. Newly discharged patients have 24/7 phone access to their RN care managers, whose job it is to ensure patients have the consistent logistical and emotional support they need as well as continued clinical guidance from a source they trust.

“We help our patients manage side effects of treatment, educate them about their disease and the importance of compliance with treatment therapies, and ensure that all of their at-home care is easy and manageable,” said Schultz, director of care management at Cancer Treatment Centers of America at Midwestern Regional Medical Center, Zion, Ill.

“Care managers proactively contact patients when they know symptoms will be at their worst, and we serve as a guide when we anticipate they will struggle,” she said. “Our patients know us, know our voice and know that we know them and are aware of their medical history.”

Partnering with patients has long been central to nursing practice. But the importance of care coordination is catching on outside nursing circles. The significance of CMS’ recent decision to reimburse providers for transitional care management goes beyond hospitals’ bottom lines.

“This is the first time in history that Medicare has decided to directly and specifically reimburse a separate care coordination service,” said Eileen Shannon Carlson, JD, RN, associate director of government affairs at the American Nurses Association.

“RNs have been doing care coordination as part of their ongoing responsibilities in multiple settings for many, many years,” she said. “This recognizes their work formally.”

The Call for Transitional Care

One aspect of care coordination, transitional care management aims to keep patients healthy after hospital discharge. Currently, nearly one in five Medicare patients is readmitted to the hospital within 30 days, according to CMS.

By paying for transitional care coordination (and by imposing penalties withholding up to 1% of a hospital’s Medicare payments for high readmission rates), the agency hopes to better that statistic.

The effectiveness of care coordination provided by nurses is backed by a bounty of research, which the ANA outlined in last June’s 22-page The Value of Nursing Care Coordination report. When advanced practice nurses provided transitional care to patients with heart failure, survival increased significantly, readmissions shrank and savings per patient over 3 months averaged $4,845, according to the ANA white paper.

The Coalition for Evidence-Based Policy ranks the Transitional Care Model, designed by the University of Pennsylvania School of Nursing in Philadelphia, as meeting Congressional standards for top-tier evidence on its website promoting “social programs that work.” The nonpartisan coalition cited two randomized controlled trials that showed 30%-50% reductions in rehospitalizations and approximately $4,000-per-patient net savings.

The Transitional Care Model was lauded in the New York Times Jan. 23 in an online column endorsing evidence-based solutions to the country’s problems. In the column, David Bornstein, author of the book How to Change the World, “Anyone interested in decreasing Medicare costs should fight to get well-tested models like this added to the system.”

New CPT Codes

While Medicare’s policy on transitional care coordination is not a replica of the Transitional Care Model, it is a start.

Under the new option, included in the 2013 Physician Fee Schedule Final Rule, physicians, nurse practitioners, clinical nurse specialists, certified nurse midwives and physician assistants can bill for transitional care management services using one of two codes: CPT 99495 (worth 4.82 relative value units, or about $163) and CPT 99496 (6.79 relative value units, or about $230).

CPT 99495 involves medical decision-making of moderate complexity; CPT 99496, high complexity. Both require face-to-face visits with the billing provider within a week or two of hospital discharge, and both cover activities, such as patient education, medication management and coordination of necessary care and services, to ensure clinical staff bridge the gap between hospital and home.

“There is a list of different types of activities to basically make sure the patients are doing OK, that they understand their medications and that they’re getting the treatments, referrals and equipment they need through ongoing assessment over the phone. All of this care coordination is usually done by RNs,” said Carlson.

Although RNs cannot bill Medicare directly for transitional care management or any other service, facilities will be paid directly for the work for the first time. As usual, other payers are expected to follow Medicare’s lead. Carlson anticipates the newfound willingness to pay for this type of care coordination will create increased demand for transitional care coordinators, RNs especially, in healthcare settings.

“I have heard from physicians who have been doing this work themselves who will now hire nurses to do it,” she said. “Some social workers do care coordination, but the types of services that these codes contemplate require a certain knowledge of medication and physical assessment that, in my view, would require an RN.”

On the Job

That’s the case at Cancer Treatment Centers of America, where Schultz said the clinical background of an RN is crucial to understanding and anticipating the needs of patients receiving treatment for advanced-stage and complex cancer.

“The complex needs of our patients require clinical training in medical care,” said Schultz. “For example, Cancer Treatment Centers of America is a leader in advancing the use of hyperthermic intraperitoneal chemoprofusion, an advanced surgical procedure for patients with cancer in the abdominal cavity. To offer this to our patients, it is vital that we have care managers trained in surgical care, as there is a lot of pre- and postoperative care required. As the hospital expands services and innovative therapies, we need to ensure that we have care managers on staff to support those services.”

RN Care Coordinators

At the Atlantic Accountable Care Organization (ACO), Morristown, NJ, a joint venture of the northern-New Jersey-based Atlantic Health System and Valley Health System, an RN care coordinator determines discharged patients’ needs for community resources and helps link them to appropriate community and hospital-based programs, according to Donna Naturale, DNP, APN, RN.

Patients deemed at high-risk are followed by complex care coordinators like Naturale: master’s- and doctoral-prepared nurses who keep abreast of patient progress through hospital discharge, to sub-acute and long-term care skilled nursing facilities, to home. Once home, the organization’s safe transitions program kicks in, offering phone education and support to the patient, and communication back to the physician, for the next 30 days.

The Atlantic ACO has offered transitional care since it formed last April as the second largest ACO in the country, according to Trish O’Keefe, MSN, RN, CNA, chief nursing officer at Morristown Medical Center, Morristown, N.J. “While CMS’ announcement clearly did not prompt our approach, we regard it as welcome recognition that this kind of coordination will help promote high quality, cost-effective care,” she said.

Hospitals aren’t the only settings hiring transitional care coordinators. Hudson Health Plan, a nonprofit managed care organization based in Tarrytown, N.Y., employs multidisciplinary transitional care coordination teams made up of nurses, social workers, pharmacists and assistants to keep communication lines open among healthcare providers.

“We are doing a clinical focus study on transitional care for New York State. We send hospital census reports to primary care providers so they know who has been hospitalized, who has been discharged. who has been to the emergency room,” explained Margaret (Peggy) Leonard, FNP, MS, RN-BC, senior vice president of clinical services at Hudson. “We are also working with a pilot set of institutions, getting discharge plans, speaking to the patient and making sure the primary care provider gets a copy of the discharge plan.”

Bright Outlook for Nurses

Sources interviewed by ADVANCE all agreed the future of transitional care management is bright, as administrators, regulators and clinicians seek effective ways to heal the ills of patients-and healthcare.

“Care coordination for nurses is only going to grow in the future,” said Carlson. “The bottom line is that hospitals are expensive, and patients are getting sicker there. This is part of the movement to allow patients to recover in their own homes where they’re more comfortable.”

“The future of nursing is transitional care,” added Leonard, a member of the National Quality Forum’s steering committee on care coordination, the Center for Medicare & Medicaid Services’ technical expert panel on hospital readmission within 30 days, and the National Transitions of Care Coalition’s public policy taskforce.

“Nurses have the technical and people skills to bring a transition team together and lead it,” she concluded. “With more emphasis on care management, nursing’s time has come.”

Jolynn Tumolo

is a freelance writer.

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