10 Things That We Know To Be True.

1) The patient comes first.
  1. Our primary purpose in medicine is to treat the patient. However, our current fragmented medical system provides fragmented patient care. SON alleviates the divide, refocusing our attention once again on the patient.
2) Doctors are difficult to contact.
  1. As hospitalists, we know first-hand how difficult it is to contact other physicians. Unless you have direct cell phone numbers, contacting the office and/or the paging system is always cumbersome. Time is of essence. SON solves this dilemma by enabling you to immediately locate the physician in our system and send them the message.
3) There is no existing universal standard patient discharge sign-out system.
  1. Although there may be silos of communication/sign-outs within organizations, there is no one standardized sign-out method across organizations.
  2. Current flawed communication at the time of discharge includes the following:
    1. No communication between the Discharging Physician and the Accepting Physician.
      1. Majority of cases
    2. Occasional communication between Discharging Physician and Accepting Physician
      1. At discharge from the hospital, only 3-20% of the time is there direct communication from hospitalist to Primary Care Physician (1).
    3. More than 50% of all preventable adverse events that occur soon after discharge can be traced to poor communication.
    4. Accepting Physician relying on the discharge summary to be available at the time of the patients evaluation.
      1. Just 12-33% of discharge summaries were available to the Primary Care Physician at the time of the first visit. (2)
      2. Only 25% of d/c summaries mentioned pending tests and only 13% mentioned all pending tests. (3)
4) The time is now.
  1. We are in the midst of a paradigm shift in payment from volume to value. In order to ensure quality care at a good value, cost must be contained and waste must be eliminated. By improving communication between providers we can avoid duplication of studies, lower liability due to the failure to follow up studies, and prevent readmissions.
  2. Health Leaders Media 2013 CEO industry survey reveals:
    1. 65% rate health information exchange as the top opportunity.
    2. 27% rate care coordination/ continuum of care as the single greatest challenge they face.
5) Hospitals and skilled nursing facilities are in the direct firing line of penalties if care coordination is not done well.
  1. Re-admission penalties are here.
  2. Medicare will levy $227 million in fines against hospitals in every state but one.
  3. 25-40% of patients coming from SNFs bounce back within 30 days.
  4. SNF’s are housing the med/surg patients of years past. Now that nursing home patients are sicker than ever, the need.
  5. For a good transition is even more critical.
  6. The 60 pages of nursing notes on transfer don't convey the one piece of information telling the provider why the patient is there; SON provides this opportunity.
  7. In order to avoid readmissions, hospitals, SNFs, and doctors must:
    1. Offer structured discharge planning.
    2. Have early involvement by the Primary Care Physician.
    3. Reconcile the hospital/SNF prescribed medications with previous medications.
    4. Offer early assessment of follow up needs and resources.
    5. Have available electronic discharge notifications and summaries for the Primary Care Physician.
6) SON will help ensure Primary Care Physicians capture the new Medicare transitional care codes 99495-6.
  1. The Centers for Medicare and Medicaid services (CMS) new overall strategy involves improving quality and reducing cost by investing in care coordination that could help reduce hospital readmission rates.
  2. CMS estimates it will pay 600 million for transitional care services in 2013, with the majority going to the Primary Care Physician.
  3. Currently there are 47.6 million Medicare beneficiaries with an estimated 9,100 individuals added to the program each day (4).
  4. CMS estimates Primary Care Physicians will receive on average 7% increase in Medicare payments due to the new coder. Code 99495-6:
    1. Communication (direct contact, telephone, electronic) with patient and/or caregiver within 2 business days post discharge.
    2. Face-to-face visit within 14 (99495 moderate complexity), or 7 calendar days (99496 severe complexity).
  5. SON offers Medicare Alert and Time sensitive notification to Primary Care Physician’s.
  6. Medicare patients have an extra alert.
  7. Allows for tracking of communication timeline.
  8. Via contact with the patient and office, we help ensure the patient is seen in timely manner to capture the time sensitive code.
7) Bad things can tend to happen during Transitions of Care (“TOC”).
  1. In its statement released in August, 2007, the Step Up to The Plate Alliance (SUTTP), convened by the American Board of Internal Medicine Foundation (ABIM), noted that transitions of care often involve interactions between unrelated parts of the health care delivery system, and that transitions occur “in the ‘white space’ between individuals and organizations that is neither owned nor claimed by anyone.”
  2. TOC refer to the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change. Specifically, they can occur:
    1. Within settings; e.g., primary care to specialty care, or intensive care unit (ICU) to ward.
    2. Between settings; e.g., hospital to sub-acute care, or ambulatory clinic to senior center.
    3. Across health states; e.g., curative care to palliative care or hospice, or personal residence to assisted living.
    4. Between providers; e.g., generalist to a specialist practitioner, or acute care provider to a palliative care specialist.
8) SON contributes to achieving the triple aim set forth by the Institute for Healthcare Improvement.
  1. Improving the patient experience (including quality and satisfaction)
  2. Reducing cost (by reducing readmissions/waste/duplications/liability)
  3. Improving the health of populations
9) Medical liability will be minimized.
  1. About 25% of all medical liability lawsuits arise from failure to follow up.
  2. SON will mitigate risk in the greatest hazard area known as the “the boundary of care”.
10) Shared Accountability is key
  1. The Discharging Physician is able to verify online that the information was received by the intended recipient.
  2. The Accepting Physician is accountable and must respond, as well as acknowledge the receipt of information in a timely manner.
    1. Multiple reminders are sent either via text/email/fax in addition to a live tech who may assist in transferring the message.
  3. In addition, the Discharging Physician may make themselves available to clarify or answer any questions that the Accepting Physician may have.
  4. The Accepting Physician would act upon the information received.