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Care Management’s Best Practices

By Kindred Healthcare

What are care management’s best practices at this early stage in its existence? This question was answered by William Mills, MD, Chief Medical Officer for Kindred at Home and Vice President of Medical Affairs for Kindred’s new Division of Care Management, during a break-out session at Kindred’s Fifth Annual Clinical Impact Symposium.

There’s no doubt that readmissions to acute care hospitals are costing the healthcare system a lot of money, and the patients who cost the system the most might fit a profile like this:

  • 85 years old
  • Living in independent senior living
  • End-stage congestive heart failure as well as myriad other chronic conditions, such as COPD, diabetes and mild dementia
  • Life expectancy of less than 24 months
  • Family members dispersed across the country

Patients like this typically see anywhere from two to ten doctors regularly. They have no home support, so when a crisis arises, 911 is called and the patient is taken to the emergency room, which leads to a hospital stay eight out of ten times, Dr. Mills said. Rehabilitation and a long-term care stay follow, then home care and then the cycle recurs.

For patients like this, wouldn’t it make more sense to deliver care in the home setting?

That’s where care management comes in – and it’s already being delivered, largely in pilots, such as one in Nevada that targeted patients ready for discharge from an acute care hospital, who met criteria for admission to a skilled nursing facility but who, quite simply, wanted to go home.

These patients, Dr. Mills pointed out, were at risk for readmission. There were 57 patients referred, and 45 enrolled. Average age was 83. They received home-based primary care visits supplemented by support with RN coaching via telephone. They called it the Transitional Care Program. And the average number of days on the program was 35.

So what were the results?

  • Number of readmissions to the hospital within 30 days : 4 – two were medical and two related to behavioral health
  • Rate of readmissions: 8.8 percent (compared to 31 percent in the general population)
  • Projected savings: over $2 million saved in readmissions alone
  • Total cost would’ve been $450,000 if the pilot patients  had gone to nursing home versus  $192,600 for the Transitional Care Program for just this small 45-patient pilot

Dr. Mills knows about pilot projects such as the one in Nevada because it’s his business to know what programs like this are doing, what’s working and what’s not. Five years ago, he founded Western Reserve Senior Care, a multi-specialty visiting medical provider group whose core business is the comprehensive care management of homebound seniors. Today, the practice provides care in six northeast Ohio counties and has gained recognition for its high-quality, evidence-based medical care that has resulted in published outcomes.

By Kindred Healthcare