Imagine hearing this at a conference: “Success resulted in decreased revenue for our healthcare system.” My first thought: am I going to learn about rewarding intelligent failure in this session? Well, not at all.
At a recent nurse executive conference, we heard how leaders at Southwestern Vermont Health Care recognized the need to prepare for a payment system other than fee-for-service and took a bold step. They created a Transitional Care Program based on the Mary Naylor Model and staffed it with advanced practitioners.
Transition Care Nurses partner with primary care providers to help high-risk patients navigate between care settings. This path may traverse the ED, a hospital stay, to rehab and back home. Along the way, the Transition Care Nurse assures that critical information moves with the patient. This saves time for primary care providers, hospitalists, and other key caregivers. The Transition Care Nurses also provide:
- patient/family education,
- medication reconciliation,
- home visits within two days of discharge, and,
- an assessment of the unmet needs of the patient and their caregivers.
- The goal is to improve the patient’s quality of life in their own setting.
Advanced practice clinicians’ expertise in navigating across systems and in physician communication make them ideal for this role. They implement solutions for critical gaps in care, engage community resources where appropriate, and “meet the patient where they are.” This improves case management and prevents hospital readmissions.
Southwestern Vermont Medical Center’s results have been impressive. Within two years, they have:
- achieved the state of Vermont’s lowest operating expense per adjusted admission. (Reducing that cost 10% from $9476 to $8557),
- seen a 42% reduction in hospital admissions and 30% reduction in ED visits for the patients in the program, and,
- achieved the lowest 30-day all-cause readmission rate in Vermont.
With an 86% penetration rate across the state, Vermont is saving significant healthcare dollars. Participating providers have not seen an increase in payments. This is despite improved patient outcomes and decreased costs.
As much as we know that reimbursements are declining, it is hard to see success as reduced volume and revenue. That is, however, success for our communities, states, and nation. Patient population management demands new measures of what defines success.
Our challenge is to embrace a future where success is not measured on growing revenues and volume, but on keeping patients out of hospitals. We must reduce our costs while not reducing quality, satisfaction, or care outcomes. Those are concepts we talk about frequently. Creating and implementing a model around it, as Southwestern Vermont Health Care has shown, is a bold step into the future.
