Sourcing Local: Adopting Confluence Health's Transitional Care Model across the region

NCACH’s Transitional Care and Diversion Interventions (TCDI) Workgroup focuses on emergency care. Specifically, how to divert someone away from the Emergency Department (ED) if they are not experiencing an emergency, and how to successfully transition someone from a hospital setting so that they are not readmitted for the original complaint. The TCDI Workgroup has been working to develop a series of strategies for ED providers to best support their Medicaid clients and provider staff since November 2017. Part of the Healthier Washington’s Medicaid Transformation Projects, Transitional Care and Diversion Intervention tactics are a critical part of whole person care.Deputy Director, and lead staff support for the TCDI Workgroup, John Schapman, says “Transitional Care provides that bridge between when a patient is discharged from the hospital for an acute condition to when they are followed up by their primary care provider. This bridge ensures patients understand the instructions they received in from hospital staff and confirms that those patients are connected with the appropriate providers to follow their care post discharge.”The TCDI Workgroup’s main approaches are:• Diverting people away from the Emergency Department to more appropriate services if they are not experiencing an acute condition or emergency.• Hospital partners in Chelan, Douglas, Grant, and Okanogan Counties to adopt a regional transitional care model (using Confluence Health’s Transitional Care Model)• Adopting a community paramedicine model, which creates a partnership and funding model to allow Emergency Services (EMS) providers to transport people in crisis who need to be taken to services other than the emergency department (e.g. homeless shelters, urgent care clinics)Recently, staff and members of NCACH’s Transitional Care and Diversion Interventions Workgroup had the chance to tour Confluence Health’s Call Center to learn more about Confluence Health’s Transitional Care Model.Adapted by Confluence Health, the transitional care management model is staffed by a nurse who makes a 24-48 hour post discharge phone call that confirms that the patient has a follow-up appointment with their Primary Care Provider, conducts a review of medications, and checks if they have all of their post-hospital services arranged, and/or caregiver help. Any problems are evaluated and directed to the appropriate resource (e.g. primary care provider, home health or hospice care, or a community-based service provider.) Patients are instructed to call their provider as needed for certain symptoms or seek immediate medical attention based on the severity of symptoms. A prompt follow-up visit with the patient’s primary care provider ensures that they receive follow-up care, ongoing symptom and medication management, and continuous access following discharge. By implementing a transitional care model, we can ensure that our providers are able to offer whole person care.At a board retreat on July 27, NCACH’s Governing Board voted to approve the application and process to fund and implement the transitional care process.Beginning August 2018, hospital partners across NCACH region will have the opportunity to join a peer collaborative to support the regional implementation of a transitional care model to support Medicaid clients being discharged the hospital. Ten partnering hospitals, as well as regional trainers, will be awarded a portion of NCACH’s Medicaid Transformation Project funding to implement the regional model. Confluence Health will serve as regional trainers providing technical assistance to the collaborative. It was a great opportunity to see how the model works, and how to best implement this model across the region. NCACH wants to give a shout out to our partners Confluence Health, especially to staff members: Corrine Lloyd, Joel Myrene, Kay Larson, and Christine Barber.To learn more about Confluence’s Transitional Care model, please visit: https://www.confluencehealth.org/specialties/hospital-services/ To learn more about NCACH’s TCDI Workgroup, please visit: https://ncach.org/transitional-care-diversion-interventions/