Advancing Patient Care Coordination in the Post-Acute Setting

Innovative new care team model at Trinity Health Mid-Atlantic enhances and streamlines delivery of care in the post-acute setting while addressing challenges related to population health and social inequities of health care.

It is well documented in literature that patients are especially vulnerable for adverse events in the days and weeks following a hospital discharge. Patients with complex medical comorbidities and unmet social needs are at a particularly high risk for poor outcomes, including readmission to the hospital, during this transitional time. To mitigate this risk, Trinity Health Mid-Atlantic Clinically Integrated Network has developed interdisciplinary care teams to better support the patient and their caretakers to transition safely back to their community setting.

Toward the end of 2019, leaders of Trinity Health Mid-Atlantic’s Ambulatory Care Integration and Clinically Integrated Network teams realized that there was an opportunity to significantly enhance the patient experience and improve patient outcomes in the post-acute setting by overhauling their care coordination operating model. This included implementing strategic, coordinated assignments for the team members who provide follow-up support to patients in the days, weeks, months, and years after their discharge from an inpatient facility.

The goal of the new care team model was to fully operationalize post-acute, patient-centered care. Clinical and quality leaders looked holistically at the way the patient subset was managed following discharge and instituted a process to first identify key social determinants of health, asking questions such as:

• Are there medical or social complexities present?

• Is the patient safe at home and safe in their community?

• Is the patient at higher risk for certain medical conditions?

• Are there needs for specific medical services?

The new care teams that were developed include registered nurses, social workers, community health workers, health coaches, and behavioral health specialists, as well as a clinical pharmacist to support medication management. With the new model, patient assignments are evenly distributed throughout the service areas of Trinity Health Mid-Atlantic’s four acute-care hospitals, and alternative payment model contracts are aligned with physician practices. By design, the care team members refer patients to each other across the various disciplines. New, innovative ideas were also introduced, such as Lyft rides that can be provided to patients in need of transportation support.

Within the new model, the initial post-acute phone call to the patient always includes an introduction to the entire care team, wrapping the patient in the program while decreasing call fatigue, aiming for a more positive patient experience. The introduction also allows the patient to get to know their complete care team, so as different team members reach out, the patient is familiar and more receptive to the outreach.

Additionally, the care team model creates better coordinated care for the often medically and socially complex Medicare and Medicaid beneficiaries who are a part of Trinity Health Mid-Atlantic’s Accountable Care Organization, by providing resources to reduce emergency department visits and inpatient hospital stays.

Importantly, the costs associated with these wraparound services are part of the interdisciplinary investment that Trinity Health Mid-Atlantic has made in population health management and therefore are not charged to the patient, but rather incorporated into an enhanced model of care with their primary care and specialty physicians.

Off to a positive start

Trinity Health Mid-Atlantic’s new care team model program went live in the Spring of 2021 and quickly grew into a success.

The data below represents rates per 1,000. Performance is well under target (47 visits/1000 vs. the target of 58 visits/1000) as of the most recent data points available from October 2022. These results are a strong indicator of the new care team’s ability to appropriately manage care in the ambulatory- and community-based settings.

Preventable Hospitalizations, formerly referred to as ACSCs (Ambulatory Care Sensitive Condition Admissions), is defined as a Prevention Quality Indicator by ARHQ (PQI #90 Prevention Quality Overall Composite (ahrq.gov)).

In addition, since the inception of the care team model, via internally collected referral data, the team has identified a 55 percent increase in wraparound service referrals, including but not limited to: specialists, food programs, nutritional counseling, hospice, DME, and aging support services.

Trinity Health Mid-Atlantic employees are benefitting from the new care model as well. Since the program’s launch, staff members have reported a greater sense of camaraderie and team identity, because of the more strategic, organized, and effective approach to patient care. Internally and within the community, the new model has redefined and enhanced post-acute care at Trinity Health Mid-Atlantic, all focused on one patient.

Identifying and closing preventive care gaps

Trinity Health Mid-Atlantic’s new post-acute care teams support patients with resources specifically designed to identify and then close preventive care gaps for patients included within specific alternative payment, value-based contracts. The new model goes deeper into preventive care by not only focusing on the physical clinical needs of a patient, but also on mental health and social dynamics that can potentially promote or prevent a healthy outcome.

Here’s a hypothetical example of how the Trinity Health Mid-Atlantic care team model would identify and then close a patient’s preventive care cap:

1. A care team member performs routine post-acute outreach to the patient and identifies the need for a mammogram or colonoscopy.

2. The patient is scheduled for the outpatient test but needs transportation.

3. A referral is sent to the assigned social worker or community health worker on the team for transportation resources.

4. During conversation with the patient, the social/community health worker also identifies a behavioral health need for depression, and the patient is then referred to the behavioral health worker for appropriate care and follow-up support.

This simplified example demonstrates how each patient is cared for in a holistic manner within the new model.