CMEC programs and services has been designed to address the current concerns of Acute Care hospital systems including: rehospitalization rates 30-days post-discharge from the Acute Care, rehospitalization rates 30-days post-discharge from the skilled nursing facility, reducing Emergency Department (ED) visits, and decreasing avoidable days in the Acute setting. CMEC programs and services focus on quality, decreased rehospitalization rates, decreased discharge times, and improved discharge processes.
Primary Goal: Quality Care, Reduce ED Visits, Length of Stay and Rehospitalization
Secondary Goal: Management of chronic diseases to meet CMS guidelines
Tertiary Goal: Support Acute Care Hospital Acquired Conditions (HAC) prevention models
- Patient seen on time < 72 hours (SNF) / 48 hours (sub-acute)
- Seen by MD & Physician Extender within 72 hours
- Medication Reconciliation
- Facility Meeting Participation – IDT, Care Planning, Discharge Planning, Post Discharge Follow-up (HCC/BPCI Program)
- Tracking high-risk diagnosis – CHF/Pneumonia/Post MI
- Discharge Summary to PCP and/or Home Health
- RCA (Root Cause Analysis) on Re-Hospitalized patients
- Post-SNF care management (BPCI and E-Visits)
The HCC program is a transitional care program that fills the void from the Post-Acute Care to the Primary Care Provider. CMEC manages patients identified as high-risk patients for 30-days post SNF discharge. CMEC coordinates care with community level providers and the SNF to eliminate the need for re-hospitalization.
CMEC will assist those enrolled in the CMS BPCI and other bundled payment programs in managing their patients. This includes serving as a resource for patients; patients enrolled in the program are able to call CMEC nurse practitioners 24 hours/day, 7 days/week for advice and to answer any questions they may have. CMEC nurse practitioners also act as a liaison where needed, including calling the patients home health company or specialty care providers to ensure proper communication and more timely appointments when possible.
The CPP improves communication and care coordination with SNFist and the community Primary Care Physician (PCP) by sending comprehensive discharge summaries that describe the patients SNF stay, including a reconciliation of medications. The coordination of patient care ensures a proper hand-off to the PCP (high-utilizers of ED).
CMEC uses a provider led Quality Assurance program approved by AMDA for post-acute facilities. Outcomes and action plans are collaboratively addressed and monitored for progress. CMEC then surveys facility outcomes and internal outcomes to improve organizational quality. The internal Quality Assurance program reviews all CMEC individual programs and service lines to enhance quality and achieve better patient outcomes.
After hours Physician Extenders and on-call providers ensure consistency of care via telephone management. The program creates consistency in management of acute changes in the patients. Call logs are monitored every weekday morning for issues sent to the facility administrators, Director of Nurses, Nurse Practitioners and Medical Doctors. The program reduces evening and weekend re-hospitalization by caring for the patient within the SNF environment when possible, rather than sending the patient to the Acute Care ED.