National Association of State Veterans Homes
Hospital Referrals via the Web
February 28, 2013
Agenda
 Discharge Today
 How hospitals refer and discharge patients
 Total Living Choices (TLC)
 Who we are
 What we do
 Why we have been successful
 TLC and the VA Hospitals
 The Future of Discharge
 Care Coordination
 Health Care Partnerships
 NASVH’s role
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Today’s Struggle
 Discharge, the process of getting a patient out of the hospital, is characterized by difficulty
 It is a highly manual process
 It involves multiple parties (patient/family, hospital, potential post-acute facilities, nurses, discharge
planners, social work, etc.)
 It is hard to place patients with complex clinical needs or poor financial status
 No clean technology solution exists
 Pay-to-play networks may create legal risk
 Following “in network” and “out of network” providers separately is double work
 The connection to clinical documentation is not straightforward
 Certain constituents are left out of the process (i.e., patient/family)
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TLC’s Story
Ted Tanase, Founder
History
 1999
 Total Living Choices founded by Ted Tanase
 2000
 Began connecting families to every post-acute care facility in the U.S.
 2006
 Began connecting hospitals to every post-acute care facility in the U.S.
 2012
 Continue to expand throughout the U.S. and grow program offerings
 TLC has helped thousands of families and their loved ones find the best living solution
 TLC reaches 20 states and 95 hospitals
 2013
 TLC delivers new technology to drive true care coordination
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Total Living Choices’ Solutions
Family
Portal
Provider
Network
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Care Finder-Pro
 Easy-to-use online care management program that connects the hospital, patients, families and
post-acute care providers
 Makes every licensed post-acute care provider in the nation instantly available 24/7 to hospital
discharge and case management staff
 Provides immediate, qualified referrals to post-acute care providers
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Family Portal
 Total Living Choices is the only transitional care company to offer these free resources for families
 Embedded in hospital’s website
 Accessible 24/7
 Matches an individual’s needs with the best living choices
 Educates patients and their loved ones on the complexities
of the long-term care industry
 Helps family members living in different locations connect and
communicate through one secure online resource
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Family
Portal
Family Portal
 Care Interpreter
 Generates free personal report containing the different care settings available based on needs and
wants such as price range, health status, insurance and personal requirements
 Facility Finder
 Provides information on facilities that match the individual’s needs and wants:
 Website information with 360° virtual tours
 Toll-free phone numbers
 Schedule visit/tour
 Home Care Finder
 Provides access to medical and non-medical home health services and products:
 Medical: Licensed home health, home care and hospice providers
 Non-medical: Housecleaning, meal preparation, companionship, shopping
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Provider Portal
 Allows any facility to receive referrals, view clinical
documents, and respond
 Available anywhere you can access the internet
 No cost for participation or portal use
 Complimentary training and support
Providence Everett has sent you a referral
for patient #16331956. Please log onto
the Provider Portal and respond by 4:35
PM today. Thank you.
The Discharge Process
1. Hospital Case Manager (CM) searches for and locates facilities online
2. CM uploads clinical documents needed by facilities
3. Facilities view documents online and decide if they can accept patient
4. Facilities respond yes or no or need to discuss with CM (in 30 minutes or less)
5. CM discusses facilities with patient/family; patient decides
6. Forms completed and submitted by CM for selected facility and other agencies
7. Reports completed for Hospital and Facility Management to measure and
improve performance
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Total Living Choices: Existing Success
 Engage and educate the patient and
their family
CareFinder Pro Value Statement
 TLC has built a strong acute and postacute care network of more than 70,000
providers
Before
TLC
 Coordinate the transition of care through
innovative technology
 90% provider engagement
After
TLC
 Median Response Time of 30 min.
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Benefits for Hospitals
Clinical performance impact:
 Accelerated post-acute placement
 Post-acute care coordination
 Reduced time to discharge
 Improved throughput
 Increased patient satisfaction
Financial performance impact:
 Reduced operating costs associated with avoidable days
 Decreased length of stay
 Minimized readmissions
 Revenue enhancement associated with increased or virtual capacity
 Ability to establish a Continuing Care Network (CCN) with post-acute care
providers
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Benefits for Post-Acute Providers
Better Care Transitions:
 Finds a better patient “fit” by matching facility profile with patient’s clinical needs and lifestyle
desires
 Facilitates information sharing and enables quick collaboration
No Cost Engagement:
 Every facility is (or can be) included in the provider network
 Access to the provider portal with training and support have no cost
Increased Referral Traffic:
 Facilities are automatically available for hospitals based on patient needs
 Referral traffic and volumes can be managed through unique analytics
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Some of Our Clients
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& Proprietary
National Reach
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Channel Partnership
 Total Living Choices introduced partnership with Cerner in 2011
 Cerner Corp. provides complete systems for hospitals and other medical organizations to manage and
integrate all electronic medical records (EMR), computerized physician order entry (CPOE) and financial
information.
 Cerner integrated and now sells Care Finder-Pro within Cerner’s Care Management solution
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Veterans Administration Pilot Program
 2011 – Information Technology
Discharge Solution (ITDS) Pilot
through VISN 1 & White River
Junction VAMC
 3 companies selected to
participate
 9 reviewers
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VA and Military Health Opportunities
RECOMMENDATION:
 “Total Living Choices should be offered the opportunity to further pursue discussions with VA to
potentially transition their (Care Finder-Pro®) Discharge Planning software from Class lll to Class I to
be incorporated with the VA Enterprise (CPRS-GUI/ViSTA).”
SUMMARIZATION:
 “The test period was effective in identifying a unanimous decision that the Total Living Choices
software program best fits the VA mission and philosophy and should be recommended for
implementation as the VA‘s lnformation Technology Discharge Solution.”
 The decision to support TLC was unanimous from all reviewers
 Currently there is language on Capitol Hill to implement a Military Health Service follow-on project
 The Coast Guard is also exploring a project to look at ITDS following the VA’s lead
 All contingent on individual VA/VISN decisions or national funding
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Making the Transition from Volume to Value
 TLCs’ track record of success in:
 Coordinating Care
 Building strong networks
 Engaging patients
 Finding the right community partners
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Care Coordination
 Care coordination has been a Top 10 (now Top 5)
priority for hospital leaders the last few years
 Stakeholders know transitions of care provide
opportunities for improvement
 Provider-risk or bundled payment financially links
different settings of care
 Hospitals are likely in one of the best positions from
which to manage a coordinated care enterprise
 In the real world, hospitals have started programs that:
 Assign case managers/care coordinators to a
significant percentage of all discharges
 Send hospital employees physically into other
providers
 Are time and resource intensive
Need for a Mentality Shift
“Practitioners need to shift their mind-set from the concept of a patient
discharge toward that of a patient transfer to continuous care management.”
Caretransitions.org
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How Do We Approach The Transition?
 Many health systems (and some of our clients) are faced with deploying a high cost, personnel-heavy
solution to tackle coordination and avoid readmissions penalties
 We believe there needs to be more than one solution based on risk stratification:
 High-Risk Patients: More frequent monitoring, greater access to personnel and resources
 Moderate-Risk: Remote Monitoring to focus limited resources and recognized complications early
 Low-Risk Population: Provide the patients with a set of resources to motivate and self-manage/report
 The best solution is a combination of:
Evidence-based medicine
-
Lean process
Your Risk: $18.7M to $30.7M
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-
Enabling technology
TLC’s Enabling Technology
Patient has no primary
care physician
Ongoing Care
Coordination
Family members lack
proper knowledge
Medication
confusion
Lack of proper home
health resources
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Avoidable Post-acute provider
Incapability
Readmissions
Lack of transportation for
physician follow-up
Patient
Engagement
Outcomes
Measurement
Poor communication between
hospital and post care
TLC’s Enabling Technology
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TLC’s Ensocare: Targeted Focus
 Engage and activate patients
 Connect patients to proper post-discharge providers
 Provide rapid communication among disparate providers and
hospital
 Focus limited hospital personnel on the right patients for follow-up
 Understand the “why” and the “how” of readmissions
 Measure outcomes for all patients
Why is TLC uniquely positioned to achieve these goals?
1) The process starts with discharge and provider engagement
2) TLC‘s no-cost network model encourages participation
3) TLC’s call center and service focus drives results
4) Innovative insight is provided through measurement,
reporting and analytics
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Use Case #1: Tracking Patient Flow Outside Your Hospital
A high-risk patient is discharged from hospital to a post-acute
facility outside of the hospital system:
 The post-acute facility has a free electronic system to
communicate any changes in the patient’s condition
 The post-acute facility can access and see instructions, care
plans, or other relevant information from hospital personnel
 Predictive analytics, built on network data, estimates
readmission risk
 Care plan steps can be monitored with a regular frequency,
automating the hospital’s watch on high-risk patients
 If the patient is discharged from the post-acute facility or
readmitted to another hospital, hospital is notified
 Audit trails and outcomes reporting allows hospital to
“manage their network” by tracking and monitoring the
quality of clinical partners
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Hospital A
3
Post-Acute Facility
1
Patient Home
2
Hospital B
Use Case #2: Engaging Patients When They Go Home
CHF patient is discharged home from a system facility:

All discharge instructions and the patient’s care plan are
available online for 4 weeks (set by care plan)

Patients can log in from home and answer conditionspecific questions to monitor their progress (i.e. Are your
rings or clothes fitting more tightly?)


Hospital

“Yes” answers alert a Care Coordinator who intervenes
and gets resources to the patient

“No” answers are tracked for use at the next care
opportunity
If questions are not answered within a period of time, a
Care Coordinator or the TLC call center reaches out to the
patient to ensure the data is collected
Hospital/system can set thresholds through the Care Plan
to alert all relevant ACO entities of patient risk
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Home
PCP
Family
Specialist
Payor
Pharmacy
Data Analytics to Drive Outcomes
 To properly manage coordination networks and readmissions patterns, data analytics will be key
 Focus on data mining, analysis, operationalizing the results
 Understanding the trends of “how” and “why” readmissions or care breakdowns occur
 Enable comparative effectiveness studies of coordination best practices
 Put relevant data at the point of care to drive proven results
 Enabling predictive analytics
 Risk profiling and stratification
 Anticipating clinical outcomes
 Predicting clinical “cliffs”
 University of Iowa’s Computational Epidemiology Group is great example
for collaboration crossing the School of Medicine with Computer Science
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Clinical Partnership – Adventist Health
 Highlighted by The Advisory Board,
Adventist Health Portland is one of
three “Phase 1” beta sites for TLC
 Part of the clinical focus Adventist
brings to the partnership is how they
implement risk stratification
 Adventist has primarily impacted
inpatient care plans – working with
TLC to drive post-acute planning
 Working with Adventist on system-wide
issues around implementation of
processes and building expertise into
the Ensocare system
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Your Role
 Most Important - Fill out online survey
www.TLChoices.com/hhsurvey
 Tell your medical community to use “electronic discharge” – including the VA/VISN
 Sign-up for TLC’s Provider Portal (Paperless Provider Feature)
 Respond to referral requests in 30 minutes or less
 Refuse to “Pay to Play”
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Key Outcomes
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