Innovative Healthcare Teams can help you achieve your goal of high quality, cost effective care for your patients in a Value Based Payment environment. Successful implementation of Team Based Care will not only improve communication, collaboration and coordination among your entire healthcare team, but it will also improve patient access along with overall patient and employee satisfaction. When Team Based Care is in place, the patient experience is expanded beyond the traditional physician-patient visit. Your team will be led by the physicians, but will be expanded to include mid-level providers, practice managers, nurses, clinical and non-clinical support staff and most importantly, your patients.
Team Based Care represents a pervasive operational change management strategy. Initially, it might seem overwhelming to know where to begin. In our experience, The Medicare Wellness Program—which includes Welcome to Medicare, Initial Annual Medicare Wellness, and Subsequent Annual Medicare Wellness visits, is an excellent introductory Team Based Care project. Although this program was initially approved by CMS a decade ago, the program has not been successfully implemented in the vast majority of practices and health systems. In fact, it is unusual for even the best performing practices to exceed an implementation rate of greater than 15% of eligible beneficiaries. Innovative Healthcare Teams can help you achieve success in implementing and sustaining a robust Medicare Wellness Program. Successful implementation of this program will lead to improved health outcomes of your patients through identification of care gaps, health risks and chronic conditions earlier in the course of the disease and enabling early, more effective management of clinical issues. Your clinical support staff performs the health risk assessment, which increases the efficiency of the service and represents a key component of Team Based Care for your patients. The physician or advanced practice provider also conducts part of each visit in order to address any issues gleaned from the assessment and to update the plan of care if indicated. In addition to doing the right thing for your patients, the practice receives a significant Medicare reimbursement for each of these visit types. Additionally, most commercial Medicare Replacement Plans offer additional incentives for performing these services and closing gaps in care.
A successful Transition of Care program is built upon a collaborative relationship and close communications between the outpatient primary care team and the hospital team. In certain situations, specialty practices such as cardiology, oncology, pulmonology or orthopedics accept the responsibility of being the patient’s outpatient primary team. A typical Transition of Care situation might be related to an exacerbation of a chronic condition. For example, a person who has chronic heart failure who becomes acutely short of breath and will often seek care at a hospital Emergency Department. This situation often results in an admission to the hospital and subsequent discharge from the hospital back to the patient’s home. The health care team must provide a safe and effective transition for the patient. If there is not a successful transition from the hospital setting to the home environment there is a significant risk to that patient of requiring readmission to the hospital. The most common root cause for readmission is related to an issue with medications. The patient’s primary care practice site clinical support team is responsible for accepting and managing patients as they transition from a hospital admission to home. A clinical staff member initiates the process with a telephone call to the patient, which is followed by an office visit and other follow-up care that may be clinically indicated. Innovative Healthcare Teams has a proven operational model for Transition of Care that benefits patients and significantly reduces avoidable readmissions to the hospital. This Team Based Care program can be applied to other clinical events such as Emergency Department visits, discharges from hospitals to extended care facilities or rehabilitation facilities, and between primary care and specialty outpatient care.
As with the Medicare Wellness Program, there is additional revenue available to the ambulatory practice for the Transition of Care program that will improve your overall financial performance as you improve clinical outcomes for your patients after a hospitalization. The Transition of Care program is the essential first step in managing avoidable hospital readmissions for which your hospital does not receive reimbursement.