Overview

The Northwestern Medicine Group Transitional Care clinic (NMG-TC) seeks to reduce preventable re-hospitalization by implementing a model of intensive case management and integrated behavioral/medical healthcare to help patients discharged from the emergency department make adjustments necessary for the ongoing self-management through primary care at community partner clinics.

Organization Name

Northwestern Medicine Group Transitional Care Clinic

Organization Type

• Academic Hospital
• Academic Medical Center
• Community health system

National/Policy Context

• Around the United States, healthcare systems have been reacting to new payment incentives based on reduced hospital use (e.g. early readmission penalties, bundled payments, and accountable care savings incentives).
• Efforts to reduce repeat hospital use has lead many systems to invest in more specialized post-acute transitional care, resulting in new clinical and care coordination approaches.

Local/Organizational Context

• NMG-TC cares for patients referred by hospital clinicians due to lack of access to regular follow-up and primary care. It addresses acute and chronic medical issues and also mobilizes social services and supports for patients as needed.
• Overall healthcare costs can be decreased by providing more care in less-resourced specialties. Chicago’s declining mental health system made referral to system psychologists difficult, and the combination of untreated major mental illnesses and patient unwillingness to visit separate psychiatry clinics called for a new mode of community care to satisfy mental health needs.

Patient Population Served and Payor Information

• The patient population is 51.7% Hispanic, 41.4% Hispanic, and 18.5% White.
• 51.3% of patients are uninsured, 26.4% are covered by Medicaid, 15.4% have private insurance, and 6.8% have Medicare.

Research + Planning

• At the beginning of the project, all services were staffed by a general internist and social worker. As the number of patients grew, NMG-TC hired more staff to become more independent and self-functioning.
  • 2012: Added a pharmD and internal medicine resident, which allowed for increased patient education, medication reconciliation, and access to affordable drugs.
  • 2013: Added a part-time psychologist, helping to satisfy the need for behavioral health services overwhelming the social worker.
  • 2013: Added an advanced practice provider with community health experience.
  • 2015: Added an experienced physician assistant, expanding patient appointment availability and access.
  • 2016: Added a second part-time psychologist.

Tech Involved

• Electronic medical record

Team Members Involved

• Health Coach
• Physicians
• Psychologist
• RNs
• Social Worker

Workflow Steps

• When a patient visits NMG-TC for a specialty care appointment, they are matched with a long-term primary care provider (PCP) at an affiliated Federally Qualified Health Center (FQHC).
• The patient receives the following services/resources prior to their appointment with their new PCP:
  • An initial appointment within two weeks of the last NMG-TC visit
  • Directions and a map to the new location
  • A compilation of medical records
  • A simplified sustainable medication regimen
  • Care coordination for future services
• Patients with more behavioral health needs often require a “soft launch”, returning to NMG-TC after meeting their PCP to report how it went and to receive additional support.
• Patients with more severe health problems continue to receive long-term specialty care at the NMG-TC medical center.

Budget Details

• Cost of salaries for staff members newly hired for this service line

Where We Are

• NMG-TC was implemented in 2011 through Northwestern University, and data collected for this study ran from December 2011 through June 2016.
• The data collection portion of the project is completed, though current research is being conducted related to NMG-TC’s work (see Future Outcomes).

Outcomes

• 90-day rehospitalization rate: 28.5% of patients were re-hospitalized within 90 days of the original NMG-TC visit, demonstrating success in decreasing rehospitalization occurrences and therefore costs.
• Cost per hospitalization: 10.0% of patients were re-hospitalized within 90 days of the original NMG-TC visit and totalled charges less than the average visit, while 18.5% of patients were re-hospitalized within 90 days of the original NMG-TC visit and totalled charges more than the average visit.

Future Outcomes

• An ongoing randomized trial compares outcomes of NMG-TC referred patients to a randomly non-referred group of matched post-acute care patients where care discharge can consist solely of providing patients with a low-cost clinic’s contact information. The results of this study will reveal the generalizability of the intervention and which patients benefit most from more intensive, long-term case management interventions.

Benefits

• NMG-TC solidified a broad network of clinicians willing to provide phone consults or expanded access to patients in need of urgent care, improving specialty care access.
  • The clinic built individual relationships with providers at multiple FQHC locations, enabling efficient handoffs of the most complex patients.
• The intervention created a larger infrastructure for networking, teaching and co-managing patient relationships with community mental health and rehabilitation service providers.

Unique Challenges

• Reliable records for out-of-system hospital use were unattainable for NMG-TC patients.
• Inpatient visits were unable to be classified reliably as emergent or elective encounters.
  • It is likely that some inpatient use was not ‘preventable’ and should have been disregarded in evaluating NMG-TC effectiveness.
• Case management is seen as a costly ‘high touch’ intervention, and there has been no research conducted on the cost-effectiveness of transitional care clinics like NMG-TC.

Glossary

Feinglass J, Mallama CA, Rogers A, Teter C, Hurt C, Schaeffer C. Using hospital use trends to improve transitional care. Healthc (Amst). 2018 Dec; 6(4):259-264. doi: 10.1016/j.hjdsi.2017.08.001. Epub 2017 Aug 8. PubMed PMID: 28800938.