April 2022 Spotlight - Transitions' Team Approach to Care
An interview with Trish Benson, Chief Strategy Officer
Transitions Care recognizes the need for a team-based approach when caring for and treating our patients. In 2021, Transitions Care enhanced this approach with the implementation of Chronic Care Management (CCM), Remote Patient Monitoring (RPM), Transitional Care Management (TCM), Wound Care, and Podiatry. All of which aim to provide the highest quality care to all of our patients, develop trusted partnerships with other care providers, reduce costs for the healthcare system, and continue Transitions’ trend of innovation into the future.
One component to improve patient outcomes is a successful Chronic Care Management (CCM) program. CCM is a critical component of primary care that contributes to better outcomes and higher satisfaction for patients. CCM is the care coordination that is outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient. It can be delivered to people with many different types of health conditions. Transitions provides all CCM patients with a team of dedicated health care professionals who can help plan for better health and stay on track to reach better outcomes. Services, such as monthly check-ins and ready access to their care team, improve patient care coordination by facilitating clear communication and assisting with the management of care transitions, referrals, and follow-ups. In 2021, Transitions enrolled 21% of our home-based patients into the CCM program.
Transitions team-based approach includes LPNs and CNAs working together to help identify key elements for the providers on CCM eligible patients. These elements are reviewed by the provider with the patient to not only help to maintain a continuity of care but also enhance communication between the care team, patient, families, and provider.
The Remote Patient Monitoring (RPM) program uses digital devices to collect medical data and other metrics from our patients and securely transmit that information through our electronic health record. The management platform integrates with a number of approved RPM devices – such as bluetooth, cellular, and HealthKit – which transmit health data seamlessly to our system. The benefits for our patients include: Phone or in-app access to a health coach, health condition monitoring and intervention, and alerts and reminders via the RPM management app and on the RPM devices themselves.
Remote patient monitoring has demonstrated significant impact in reducing potentially avoidable ED utilization as well as a reduction in unnecessary hospital admissions and readmission. It enables ED diversion and earlier acute discharge, resulting in shorter lengths of stay and lower cost of care. RPM enables movement of appropriate levels of acute care and chronic care monitoring into the home, reducing the high costs of inpatient services.
RPM conveniently meets patients where they are, and where they want to be. It removes the burden of a hospital visit or stay, allowing patients to receive efficacious and safe care from the comfort of their own homes.
Transitional Care Management (TCM)
The goal of TCM is to ensure that there are no gaps in patient care by encouraging providers to thoroughly plan the patient’s course of care from the moment the patient gets discharged from a hospital or skilled nursing facility.
For patients suffering with chronic conditions, the transition from hospital to home is a priority. Once the patient is discharged from the care setting, the TCM nurse visits the patient within 24 hours. The nurse performs a care plan by continuously re-evaluating the patient’s condition and arranging a plan with the patient, the caregiver, and the primary care provider. The average care period is 2 months. The benefits of TCM therefore include reduced Medicare ED utilization and increased patient satisfaction due to weekly calls from their healthcare providers.
Transitions offers wound care, debridement, and podiatry services at home as well. This allows us to provide comprehensive care and coverage for our patients. Our providers assess, debride, create treatment plans, and will frequently follow up with patients until a wound is healed.
All of these services allow us to provide the highest quality of care to all of our patients, while allowing them to remain in the comfort of their home surrounded by loved ones. Transitions continues to innovate its care capabilities at all times, with the patient always at the forefront of our efforts. We look forward to the continued development of these capabilities as we move to be a provider of the future.