By Stan Smith, MBA, Senior Vice President – Sentinel Services, Prodigy Care Services
A critical set of healthcare events requiring the attention of workers’ compensation payers and post-acute care (PAC) providers occurs before injured workers ever arrive at the providers’ doorsteps. Broadly characterized as transitions of care or care transitions, these events are defined as “the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness”.1
Workers’ compensation payers have traditionally looked to PAC providers for quality treatment outcomes after the injured worker has been admitted to their treatment settings. These are provided across the PAC healthcare continuum from long-term acute care hospitals, rehab hospitals, residential brain and spinal cord injury centers, and skilled nursing facilities (SNFs) to home health care.
An injured worker’s overall plan of care can include multiple admission and discharge events. They may move from a multi-day acute care hospital stay into inpatient care in a rehab hospital or SNF. After returning home, the workers’ comp patient may continue to receive home-based PAC services such as durable medical equipment and home health services.
A lack of communication and collaboration among PAC providers during these pivotal care transition events can result in poor clinical outcomes for the injured worker and wasteful expenses for the claim.
Care transition risk issues include medication errors, duplicative diagnostic testing performed at multiple provider locations, errors introduced into the injured worker’s medical record during transfers, and miscommunication by treating providers across the care continuum during patient migration.
Another important risk is the negative psychosocial impact on the injured worker that can result from treatment fatigue and the depersonalizing effects of progressing through the various treatment systems. Finally, any of these risk factors can be exacerbated if the injured worker’s social determinants of health factors2 are also creating the potential for the patient to be less able to effectively engage with the healthcare delivery system they find themselves in.
Of these various risk issues, medication errors, particularly with treatment in PAC (post-acute care) treatment settings, can be critical to ensure positive outcomes. Our CEO and co-founder Del Doherty, Pharm.D., Ph.D., sees it every day: “The complex nature of ongoing care delivered in PAC settings typically also involves more extensive drug regimens,” he says. “By the time injured workers have begun their journey from acute to their first post-acute care destination, polypharmacy becomes a significant risk for the injured worker. It’s essential that drug regimen review occur at every stop (care transition) in the post-acute care continuum.” (A prescription regimen of five or more medications is typically considered polypharmacy.)
Fortunately, PAC providers have increasingly concentrated on improving patient outcomes during the critical period of transfer from one PAC setting to another. This intense PAC-industry-wide focus came about as requirements of the Affordable Care Act were implemented. Some were:
“In October 2012, the Centers for Medicare and Medicaid Services (CMS) instituted penalties for facilities with high readmission rates … CMS is also encouraging outpatient providers to focus on safe transitions through new reimbursement codes issued in 2013 … Improving care transitions for complex patients moving from hospitals to SNFs, to their own home, or to another setting can result in significant savings while improving patient safety.”3
Recognizing the need to achieve effective outcomes during care transitions hasn’t been limited to the PAC providers treating injured workers. The American Case Management Association (ACMA) has developed best practice standards due to the need for improved outcomes. Excerpts from its 2019 Transitions of Care Standards include: “It is critical that crucial information is collected and communicated effectively, ensuring that patients receive seamless, comprehensive care in every treatment setting. It is well understood that poorly managed transitions impact quality and costs … From a patient safety perspective, it is crucial for care management clinicians to have a clear understanding of their care delivery system as they navigate patients across a growing continuum of care.”5
Industry stakeholders focused on injured workers receiving the best quality post-acute care outcomes, be they insurers, case management solutions or PAC providers, can partner together using guideposts like ACMA’s benchmark standards, which include processes and measures directed in five key outcome areas:
- 1.0 Identify Patients at Risk for Poor Transitions,
- 2.0 Complete a Comprehensive Transition Assessment,
- 3.0 Perform and Communicate a Medication Reconciliation,
- 4.0 Establish a Dynamic Care Management Plan That Addresses All Settings Throughout the Continuum of Care,
- 5.0 Communicate Essential Care Transition Information to Key Stakeholders Across the Continuum of Care.
Other best practices for managing care transition include the Agency for HealthCare Research and Quality’s Transitions of Care best practice library.6
Workers’ compensation payers, case management companies and PAC providers can adopt these standards to effectively manage care transition risks. Communication and collaboration will produce higher health care outcomes for injured workers and more effective cost-containment for payers.
1Coleman EA. The Care Transitions Program. Aurora, CO: Division of Health Care Policy and Research, University of Colorado Denver; [February 8, 2013], www.caretransitions.org.
2Social Determinants of Health at CDC, The Centers for Disease Control and Prevention, https://www.cdc.gov/about/sdoh/index.html, 2023.
3R. Burton. Health Policy Brief: Improving Care Transitions. Health Affairs, (Issue Brief), September 13, 2012. www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=76.
4Care Transitions: Best Practices and Evidence-based Programs, Center for Healthcare Research & Transformation, www.chrt.org, January 2014.
5Transitions of Care Standards – A new way forward, American Case Management Association, www.acmaweb.org, 2019.
6Transitions of Care Toolkit, Agency for Healthcare Research (AHRQ), https://www.ahrq.gov/topics/transitions-care.html, 2023.
About Stan Smith
As Senior Vice President of Sentinel Services, Stan Smith develops and oversees Prodigy’s innovative and proprietary specialty services focused on post-acute care, acute and ambulatory care cost containment and supporting the growth of ProdigyRx, the company’s PBM.
Smith has over 30 years of executive leadership experience in healthcare administration with inpatient rehabilitation and long-term acute care hospitals, skilled nursing facilities, rehab centers specializing in traumatic brain and spinal cord injuries, and psychiatric and addiction centers. Additionally, he has developed acute and ambulatory care cost containment services and a specialty healthcare provider network for catastrophic workers’ compensation injuries.
Smith has presented at several national conferences and published articles in a variety of healthcare admin topics, including catastrophic care management, acute – post acute care discharge management, post-acute care traumatic/acquired brain injury treatment, and quality assurance.
He holds a Master of Business Administration / Healthcare Administration degree from the University of Dallas, is a licensed long term care administrator and can be reached at email@example.com.
About Prodigy Care Services
Based in Austin, Texas and founded in 2020, Prodigy Care Services is a healthcare services technology company dedicated to positively impacting the lives of workers’ compensation patients by delivering outcomes-driven care solutions and increasing payer efficiency across the continuum of care. It provides services nationally to insurers, third-party administrators, bill review and case management companies, and other workers’ comp payers. PACparency along with the ProdigyRx pharmacy benefit manager, proactive clinical controls, and a suite of evidence-based, patient-centric clinical programs and tools are among Prodigy’s offerings. For more information, please see www.prodigycareservices.com or call (713) 322-6667.