Transitioning patients from an acute-care setting to their homes or a post-acute care setting has become a priority for hospitals and accountable care organizations alike, as controlling the transition process can help lower unnecessary readmission rates — and therefore avoidable costs — drastically.
Like many other ACOs, Phoenix-based John C. Lincoln ACO, which has participated in the Medicare Shared Savings Program since July 2012, wanted to lower unnecessary readmissions for patients with chronic and severe illnesses. However, the 528-provider ACO had one other, somewhat unique concern — finding employment for military 
veterans.
"We were concerned about the dramatic number of combat medics and hospital corpsmen whose training would not allow them to have a medical job when they came back from military service," says Nathan Anspach, CEO of John C. Lincoln ACO. Medical training and experience gained in the military does not usually transfer to traditional medical licenses, leaving veterans unqualified for civilian healthcare jobs.
The combination of concerns resulted in a distinctive transition specialists program that utilizes veterans and lowers unnecessary readmissions for the ACO's roughly 10,000 Medicare beneficiaries. JCL hired military medics to serve as transition specialists starting in fall 2012. Veterans have a unique set of skills that encompass both medical training and the ability to handle the social needs of the patient, according to Mr. Anspach. For instance, they relate well to patients and are geared to recognize and solve problems creatively and quickly.
The transition specialists work with patients who are "frail and elderly," he says, a description that encompasses patients with chronic heart failure, acute myocardial infarction, pneumonia and COPD. The transition specialists meet with patients first in the hospital. They then either conduct home visits or follow up with patients via phone for 30 days post-discharge.
Best practices
The care transition program at John C. Lincoln ACO has improved the system's readmission rates drastically, dropping them to 6 percent, while the national average hovers around 20 percent. So why is the program so successful? Beyond employing combat medics as transition specialists, here are three more best practices for implementing a care transition program, gleaned from John C. Lincoln ACO's experiences.
Focus on more than clinical issues. While chronically ill patients certainly have a myriad of clinical problems that care transition specialists can address, most also face social barriers to getting healthy. "We studied a number of [chronically ill] patients to find out what needs they had, and we were surprised to learn that…they had a variety of social issues," Mr. Anspach says.
Therefore, care transition specialists need to address the social problems of their patients as well as boost their clinical care. For instance, when the ACO's transition specialists do a home visit, they conduct a falls assessment in the home. They also try to determine the patient's access to food and look into feeding programs if necessary. Focusing on these and other issues, like a patient's ability to read the label on their prescription bottle, minimizes social barriers to healthy living.
Incorporate specialists into the hospital. At John C. Lincoln, the transition specialists meet patients in the hospital prior to discharge, which has been a key part of the program, according to Mr. Anspach. By being present in the hospital, physicians and nurses can arrange for transition specialists to visit their patients without much wait. "We're fortunate here that [the specialists] have been accepted by the hospitalists and nursing staff," he adds.
Integrate specialists and seniors with the EMR. The third linchpin of the program is to have care transition specialists and their patients use the electronic medical record in a robust way. The specialists at John C. Lincoln have access to the EMR and can input information about their patients on their own, so primary care physicians and specialists involved in the patients' care are able to see how the patient is progressing at home.
Additionally, during home visits, the transition specialists assist patients in using the patient portal, JCLMyChart. "The transition specialists are really good for the seniors who have internet connection to set up JCLMyChart on their home computer," Mr. Anspach says. Once patients understand how to use JCLMyChart, they can schedule appointments and ask for prescription refills through the portal, among other features.
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