Transitional Care Success Factors

In the more than eight years since the inception of Summit Health’s transitional care management program, several “tricks of the trade” have become apparent. These include:

Win them over. Any improvement project requires commitment from the organization—both philosophical and financial—to believe in the program and be willing to invest in a care team that supports the primary care providers. This should be an interdisciplinary team of pharmacists, social workers and care managers.

Invest in infrastructure. When it first started, the Summit Health care coordination program was staffed with three nurse care managers. As Summit Health’s number of risk-based contracts increased, there came a need to add staffing to better understand where the risk is and provide support to patients as they transition from one part of their care journey to the next. Today, Summit Health has a team of more than 30 nurses and social workers in a centralized care coordination department to manage reactive and proactive care coordination. This team is also supported by medical assistants and nonclinical patient care navigators.

It is also important to invest in a strong data analytics platform to provide comprehensive clinical and claims data on patient panels for physicians. 

Form effective partnerships with payers. This is referred to as the “we do-you do” approach. Understanding what “we” as the provider should contribute and what the health plan (you) should contribute has been a work in progress. Some value-based requirements that support TCM are hardwired into payer contracts such as the cadence of case review meetings and the types of data that will be exchanged.

Beyond these contractual elements, it also is critical to ensure tight relationships among key players. For example, Summit Health’s chief population officer and CMO and the medical directors of the health plan work closely together, as do the directors of quality and directors of care coordination for each side. The idea is to make sure there is structure and that each side has clarity about their roles. Key steps are outlined for each side, which also hold each other accountable. Regular meetings provide a venue for exchanging patient information that doesn’t appear in the data exchanges. This close collaboration optimizes the strengths of each side—avoiding any duplication of efforts that decrease efficiency.

Use incentives. Gaining physician buy-in first and foremost takes showing physicians the potential for improved care outcomes. Orienting physicians to the TCM program begins exactly then—on their first day of onboarding. Removing any pain points from the clinical process is also critical for there to be a win-win for providers and patients.

It also is necessary to acknowledge the role financial incentives play in changing behavior. Summit Health instituted the Universal Provider Incentive Program for physicians. For every specialty, 20% of the physician’s compensation is based on valued-based outcomes—quality measures, patient experience, appropriate use of resources, enhanced patient access and optimal clinical documentation. For PCPs, the measure is risk-adjusted admits per 1,000 for their patient panel, which includes primary admissions and secondary readmissions.

Use pharmacists. Medication errors are one of the leading causes of readmissions. To address this challenge, patients who are on multiple medications are automatically referred to Summit Health’s clinical pharmacist team, which conducts a medication reconciliation and discusses with the patient’s prescribing physician ways to simplify the medication list.

Ashish Parikh, MD, is chief quality officer (aparikh@summithealth.com) and Jamie Reedy, MD, is chief of populaton health (jreedy@summithealth.com) for Summit Health, New Jersey.