As CV service lines are expected to handle patient loads of increased size and complexity, there is no room for duplicative work or turf wars between providers. A top-of-license care model can be an easy-to-implement tactic to recover volumes, cut costs, and maintain high quality of care.
At Bon Secours Community Hospital, the CV care management team is working to provide higher quality care and avoid costly readmissions by delineating between care team roles and assigning providers to patients based on risk. The hospital's risk-based top-of-license care model:
- Risk-stratifies heart failure (HF) patients via an algorithm integrated into the EHR;
- Pairs patients to an intervention based on their risk level; and
- Assigns care team member(s) to the patient based on risk stratification.
Though the screening tool assesses risks related to HF, all patients' data are input to ensure no patients are overlooked. The tool mostly asks "yes or no" questions such as:
- "Has the patient had previous admission?"
- "Has the patient had more than two previous admissions?"
- "Does the patient have kidney complications?"
Based on the results, patients are placed in one of ten nodes of "risk." Low-risk patients require the least support, while high-risk patients receive a more comprehensive services led by a trained care manager. The patient risk system clearly defines care team roles to avoid redundancy and increase efficiency.
Bon Secours' risk levels and associated interventions
This risk-based top-of-license strategy has:
- Enabled patients to see providers most appropriate to their needs;
- Empowered staff to tailor interventions specific to the patient's likelihood of readmission; and
- Reduced readmission without additional staff hires.
Bon Secours' risk-based top-of-license care model productively uses each care team member's time and skill set. Of 400 patients in the pilot program, only 1.5% were readmitted and 100% of these patients were correctly identified as "high-risk." Bon Secours has developed an effective top-of-license care team to meet changing patient and market dynamics.
Embracing a risk-based top-of-license care strategy is an opportunity to promote efficiency and improve quality of care in the Covid-19 era and beyond.