Patient success stories from the MAX Series. Thanks to the MAX Series, when Chanel Artist, RN, Community Care Manager and Certified Case Manager at Health Quest, tells the story it is far from a chart recitation. “Elderly female with a complex medical history” becomes “our case conference really worked and the team understood how to help.”

Health Quest started the Community Care Manager (CCM) program in 2015 with two case managers funded through Vassar Brothers Medical Center (VBMC). The goal was to minimize avoidable admissions. “We were having a hard time identifying patients that needed the help — frequent readmissions. We were working with some but not enough to make an impact,” said Artist. “The MAX Series helped us restructure how we identify patients and their drivers of utilization.”

CCMs are a team of Registered Nurse Case Managers whose primary focus is to identify, assess, connect and reduce readmissions at VBMC. CCMs collaborated with the MAX Series program to restructure and enhance the identification of the hospital’s high-risk patients. Health Quest put together a core action team including community partners and skilled nursing facilities (SNFs) — keys to deferring many high-utilizer admissions. “In the past, we would refer a patient to resources from our individual assessments, but now, after team-based meetings with nursing homes, we are able to collaborate to accomplish a more comprehensive plan to reduce readmissions,” said Artist.

Another outcome of the MAX Series was the development of a data tool, called the Flash Report, which identifies high-utilizers and is generated daily. With this report, CCMs can assess the patient barriers and formulate interventions to decrease utilization. At the team-based meetings, patients are identified from the report and the team then collaborates with resources, such as nursing home leaders. Before MAX, the processes were not as efficient or consistent.

“The result is that the patient is better managed in the community,” said Manav Surti, MHVC Performance Management Specialist for the MAX Series. The CCMs work with patients who have heart failure, COPD, and multiple disease processes. For example, the CCMs provide scales to patients for weight management and to know when to call a clinician for diuretic management, an office or emergency room visit, if necessary. They also teach heart failure education — all to reduce readmissions. Transition of care calls are placed within 24-72 hours post-discharge to reduce the risks for readmissions. The paramedic program performs hospital follow-up visits in patients’ homes and collaborates with the CCMs for advocacy, education, and continuity of care.

“This team approach and the ability to follow up changed the way we deal with complex patients,” said Artist. The patient in Artist’s story had over five inpatient hospitalizations in the past year and her caregiver was unable to manage her needs without additional support. The caregiver became engaged during the discharge planning discussion, and a teach-back focused on education for her diagnoses. The patient was referred to homecare, long-term care services, and a community pharmacy that delivered pre-poured medication. After close monitoring from the CCM program, it became clear that the patient would be better-managed in a local skilled nursing facility. Since her last inpatient admission (more than three months ago) there have been no inpatient and/or emergency room visits.

“‘Elderly female with a complex medical history’ is just one of many examples of how our newly restructured team assisted a patient to a good outcome,” said Artist. “We consider that a real MAX success story.”