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Executive SummaryThe Mandate to Provide Seamless, Cross-Continuum CareAll too often, patients receive fragmented, episodic care—which leads to suboptimal clinical outcomes,avoidable health care utilization, and unnecessary spending.Fragmented care is costly to both the nation and individual health care providers. Researchers estimateinadequate care coordination leads the US to waste between 25 and 45 billion each year. And individualproviders are increasingly accountable for the total cost of care for their patients. Neither the country, norproviders, can afford to continue to deliver fragmented and episodic care.Building a Health System That “Never Discharges” the PatientTo break down silos and deliver continuous care, health care providers need to fundamentally rethink howpatients transition between settings. Currently, the central element of any transition is a patient being“discharged” from one setting and “admitted” to the next. But by definition, “discharging” a patient impliesclinicians are relieved of the burden of responsibility for a patient’s care.Health systems must broaden their aspiration to include building a health system that “never discharges” thepatient. The goal is for clinicians in any setting to feel responsible for a patient’s care across the full continuum.For example, nurses on an inpatient medical unit feel responsible for the care and outcomes of their patientsboth on the medical unit as well as all other care settings the patients go to across the continuum—includingprimary care clinics, ambulatory clinics, post-acute care facilities, and patients’ homes.Avoiding the Trap of Perfecting One Transition at a TimeWhen it comes to building a health system that “never discharges” the patient, the Nursing Executive Centerrecommends against a one-off approach in which leaders perfect one individual transition before moving to thenext. This effort can be compared to assembling a puzzle—and piecing together each care setting one by one.The challenge with this approach is perfecting each transition is time consuming and resource intensive. Thereare simply too many “puzzle pieces” for it to be feasible. In addition, this approach can lead to a piecemeal endresult, rather than a cohesive system that seamlessly supports patients as they move through the carecontinuum.To build a system that “never discharges” the patient, the Nursing Executive Center strongly recommendsleaders address underlying, systematic issues that affect all patient transitions. The goal is to implementstrategies that improve transitions across multiple care settings at once—rather than working setting by setting.Read the Study in Full to Learn MoreAchieving Care Continuity equips nurse leaders with four imperatives to build a system that “never discharges”the patient. The four imperatives to achieve care continuity are:1. Equip clinicians to provide continuous care.2. Promote clinician ownership for cross-continuum care.3. Promote patient and family ownership for self-care.4. Scale up support for vulnerable patients.Read the complete study for detailed guidance and best practices to act on each imperative. 2015 The Advisory Board Company 303586advisory.com

Nursing Executive Center EssayWhy We Need to Stop ThinkingAbout “Care Transitions” 2015 The Advisory Board Company 303587advisory.com

Despite health care leaders’best efforts to improve carecoordination, patients continueto receive fragmented, episodiccare. This manifests as caredelivered in one-off visits in highacuity settings, or as avoidableutilization. According to recentstudies, more than 70% of EDvisits are avoidable, 4.4 millionhospital trips are preventable,and 18% of hospitalized patientsare readmitted within 30 days.Huge Opportunity for ImprovementPercentage of ED Visits ThatAre Avoidable in the US171%4.4MEstimated number ofpreventable trips to UShospitals each year18%30-day all-causereadmission rate2Source: Truven Health Analytics, “Avoidable Emergency Department Usage Analysis,” /EMP 12260 0113 AvoidableERAdmissionsRB WEB 2868.pdf;Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, “Nationwide Frequency andCosts of Potentially Preventable Hospitalizations, 2006,” 2.jsp;CMS's 2012 Inpatient Standard Analytical File (SAF); Nursing Executive Center interviews and analysis.1) Based on Truven Health Analytics analysis of 6,135,002 ED visits in 2010; “Avoidable” includesall ED visits except those for which medical care was required within 12 hours in the ED setting.2) CMS, 2012. 2015 The Advisory Board Company 303588advisory.com

Not only does siloed caredelivery lead to sub-optimaloutcomes, it is also costly.Researchers estimate the USwastes between 25 and 45billion annually from inadequatecare coordination.The benchmarks shown hereprovide a closer look at the costof poorly coordinated care. Theyshow the difference in permember per-month costs forpatients whose care is “looselymanaged” versus “wellmanaged.” According to thisdata, patients with looselymanaged care cost at least 100per month more than those withwell-managed care.Poor Coordination Costing Billions NationallyDifference Between “Loosely Managed”and “Well-Managed” PMPM1 Spending2MedicaidCommercial 100.48LooselyManaged 131.84LooselyManagedWellManagedHealth care providers are keenlyaware of the high cost and suboptimal outcomes that resultfrom siloed care delivery.Accordingly, there is strong workalready underway to improvecare transitions.WellManaged 449.79LooselyManagedWellManaged 25B- 45BEstimated annual amount of wastefulspending resulting from inadequatecoordination31) Per member per month.2) 2011 data from Milliman.3) 2011. 2015 The Advisory Board Company 30358MedicareSource: Milliman; Health Affairs, “Health Policy Brief: Improving Care Transitions,” 2012, ?brief id 76; Nursing Executive Center interviews and analysis.9advisory.com

A common starting point forimproving care transitions ispreventing readmissions. Andnew policies—includingMedicare’s HospitalReadmissions ReductionProgram—have createdfinancial incentives that makereadmissions a logical place forhealth care leaders to start.For organizations tacklingreadmissions, the NursingExecutive Center recommendsreviewing our publication NurseLed Strategies for PreventingAvoidable Readmissions. Asshown here, it offers a strategicframework and best practicesfor improving two specifictransitions in care: the transitionfrom acute care to post-acutecare, and from acute care tohome.A Common Starting Point for Improving TransitionsNurse-Led Strategies for Preventing Avoidable ReadmissionsLeveraging the Inpatient Stay to Equip Patients for Long-Term Self-Management123Scale Interventionsto Level of RiskIdentify and ActivateKey LearnersEquip Patients with Accurateand Easily ActionablePost-Discharge InstructionsFacilitating Seamless Transfer to the Post-Acute Care Setting456Ensure Patients AreDischarged to theAppropriate Care SettingElevate PAC Qualityto Ensure Safe Carefor Complex PatientsEnable a Safe Transition Homewith Immediate Follow-Up Carefor Most Vulnerable PatientsAccess Nurse-LedStrategies for PreventingAvoidable Readmissions onadvisory.com/nec.Source: Nursing Executive Center, Nurse-Led Strategies for Preventing AvoidableReadmissions, 2011; Nursing Executive Center interviews and analysis. 2015 The Advisory Board Company 3035810advisory.com

While preventing readmissionsis a strong starting point forimproving care transitions,providers need to expand theirefforts. This is becauseproviders are increasinglyaccountable for the total cost ofcare for patients.As illustrated here, providersalready assume full risk foruninsured patients, MedicaidManaged Care patients, andhealth system employees. Overtime, many health careproviders will assume full risk foradditional patient populations,such as patients within anAccountable Care Organization(ACO) and commerciallyinsured patients.Being accountable for total costof care means organizationsmust focus on all caretransitions—not just the twotransitions that are part of typicalreadmission efforts—becauseunnecessary health carespending occurs at many pointsalong the care continuum. Whilepreventable readmissions costsMedicare about 12 billionannually, this is only a portion ofthe estimated 25 to 45 billionannual cost of inadequate carecoordination in the US.Providers Increasingly Accountable for Total Cost of CarePopulations for Which Health Care Providers Assume Full RiskCommerciallyInsured PatientsPopulationsat RiskACOPatientsUninsured, MedicaidManaged Care, HealthSystem Employees2015Time 12B 25B- 45BEstimated annual cost ofpreventable 30-day hospitalreadmissions1Estimated annual amount of wastefulspending resulting from inadequatecoordination21) Medicare.2) 2011. 2015 The Advisory Board Company 30358Source: Health Affairs, “Health Policy Brief: Improving Care Transitions,” 2012, ?brief id 76; Nursing Executive Center interviews and analysis.11advisory.com

There is an additional benefit tobetter coordinating care andimproving transitions betweenall settings: it keeps patientswithin your network.This benefits all health careproviders regardless of theirpayment environment. Forproviders in a fee-for-serviceenvironment, higher patientvolumes drive revenue. Forproviders in capitated contracts,keeping patients in networkmeans they can controlspending by providing care inthe lowest-cost, clinicallyappropriate setting within thenetwork.Keeping Patients in Network Through Care CoordinationCoordination Benefits All Organizations, Regardless ofPayment EnvironmentBenefits of Keeping Patients in Network by Reimbursement StructureReimbursementStructureBenefit ofKeepingPatients inNetworkFee forServiceFully CapitatedPaymentsDrive revenuethrough increasedpatient volumesControl spendingthrough high-quality,in-network careSource: Nursing Executive Center interviews and analysis. 2015 The Advisory Board Company 3035812advisory.com

In sum, health care providers’future success will hinge onimproving transitions betweenall care settings. But beforetaking action, it is important toclarify what it means to “improvetransitions.”Currently, the central element ofany transition is a patient being“discharged” from one settingand “admitted” to the next. Butthis concept of “discharging” apatient contributes to siloed caredelivery. By definition,“discharging” a patient impliesclinicians are no longerresponsible for the patient’scare.Clarifying Our AspirationBuilding a System That “Never Discharges” the PatientDefinition of “Discharge” “To relieve of a charge, load, or burden” “To release from an obligation”Merriam-Webster DictionaryIn order to improve caretransitions between all settingsand deliver seamless careacross the continuum, healthsystems must broaden theiraspiration beyond “discharging”patients from one setting to thenext. Instead, health systemleaders must build a healthsystem that “never discharges”the patient. The goal is forclinicians in any setting to feelresponsible for a patient’s careacross the full continuum. Forexample, nurses on an inpatientmedical unit feel responsible forthe care and outcomes of theirpatients both on the medical unitas well as all other care settingsthe patients go to across thecontinuum—including primarycare clinics, ambulatory clinics,post-acute care facilities, andpatients’ homes.Source: Merriam-Webster, e; Nursing Executive Center interviews and analysis. 2015 The Advisory Board Company 3035813advisory.com

When it comes to building ahealth system that “neverdischarges” the patient, theNursing Executive Centerrecommends against a one-offapproach in which leadersperfect one individual transitionbefore moving to the next. Thiseffort can be compared toassembling a puzzle—andpiecing together each caresetting one by one.The challenge with thisapproach is that perfecting eachtransition is time consuming andresource intensive. There aresimply too many “puzzle pieces”for it to be feasible. In addition,this approach can lead to apiecemeal end result, ratherthan a cohesive system thatseamlessly supports patients asthey move through the carecontinuum.To build a system that “neverdischarges” the patient, theNursing Executive Centerstrongly recommends thesecond approach shown on thispage, in which leaders addressunderlying, systematic issuesthat affect all patient transitions.The goal is to implementstrategies that improvetransitions across multiple caresettings at once—rather thanworking setting by setting.Building a System That “Never Discharges” the PatientEvolution of Patient Care PerspectivePerfecting Individual omeHealthAchieving Care ContinuityThe following pages describehow this systems approach hasbeen applied to a select patientpopulation.Source: Nursing Executive Center interviews and analysis. 2015 The Advisory Board Company 3035814advisory.com

Some progressive organizationshave already begunimplementing a systemsapproach to improving carecontinuity for select patients. Anexample comes from PremierHealth in Dayton, Ohio.Care Navigator Role Gaining MomentumPremier has designed aprogram to improve crosscontinuum care for their 1%most costly patients, regardlessof condition. A key component ofthe program is a navigator1 whoserves as patients’ primary entrypoint to the health system andcollaborates with interprofessional team members toensure all of their patients’health and social needs are met.An excerpt of Premier’s “Top 1%Navigator” job description isshown here.The following pages describekey elements of Premier’s Top1% Navigator Program.A complete version ofPremier’s Top 1%Navigator job descriptioncan be accessed throughan online version of thispublication onadvisory.com/nec.Excerpt of Top 1% Navigator Job Description at Premier HealthPremier HealthJob Description: Advanced Illness Management Navigator, RN or MSWPosition Summary: The Navigator will be an integral member of the Advanced Illnessmultidisciplinary team. Together with nurses, social workers and community healthcoaches, the Navigator will oversee the enrollment of new patients into the project; assesshealth care needs and oversee care plan implementation; help develop care managementstrategies; and work with team members to provide linkages for the various health andsocial needs of patients with cost effective solutions.Nature and Scope: Must have available phone to communicate and transportation, withappropriate licensure and insurance, to visit homes and other sites. Interacts withphysicians, nurses, social workers and other disciplines, administrative personnel, andcommunity resources.Qualifications: Ability to effectively provide clinical care to socially and medicallycomplex patients in a variety of nontraditional settings; ability to work collaboratively ina team and manage multiple priorities, utilize effective time management skills, andexercise sound administrative and clinical judgment; demonstrated ability to work wellwith people of various ages, backgrounds, ethnicities, and life experiences.One navigatoron call to beavailable topatient 24/7by phoneCase in Brief: Premier Health Five-hospital health system headquartered in Dayton, Ohio; includes over100 sites of service In March 2014, piloted community-based navigator program for 25 patientsgenerating greatest number of readmissions and ED visits at one Premierhospital; staffed by one RN and one MSW Navigators serve as single point of contact for all patient medical andcommunity resource needs; coordinate with patient’s primary careclinician, home health Navigators are available to patient 24/7 by phone; conduct communitybased patient visits, call patient on regular basis (frequency based onpatient needs); timeframe of care is 10 months By January 2015, expanded program to include 175 patients acrossmultiple Premier hospitals; new model includes two RNs, two MSWs, oneLPN, one health coach Expanded program serves patients with the greatest number ofadmissions, and patients 64 and older with a large number of admissionsby CMS hospital penalty diagnosis CHF, COPD, and select high-risk patients are monitored by the RNnavigator via remote telemonitoring; monitoring units include ancillary toolsfor weight, pulse oximetry, blood pressure; parameter triggers directly alertnavigator of any abnormality, navigator then contacts patient 180 days post-implementation of Top 1% Navigator pilot, reducedreadmission rate of patient group by 52%, reduced monthly costs forpatient group by 50%1) A navigator team of an RN and an MSW share a panel of 50 patients. 2015 The Advisory Board Company 30358Collaborateswith RN orMSW to servemedicaland nonmedical needsSource: Premier Health, Dayton, OH; Nursing Executive Center interviews and analysis.15advisory.com

First, Premier selects patientsfor the program by analyzing EDencounters and admissions.Second, a navigator team of anRN and an MSW share a panelof 50 patients. Third, one of thetwo navigators is on call 24hours per day, seven days perweek. This enables the team tocollectively serve as the singlepoint of contact for the patient.Fourth, navigators coordinatewith a multidisciplinary careteam to meet patients’ medicaland psychosocial needs. Fifth,navigators use remotetelemonitoring for select1patients. Sixth, navigators adjustthe intensity of their support toeach patient’s risk level.Additional details on how this isdone are on the following page.Establishing a First Line of Defense for the Top 1%Key Elements of Premier’s Top 1% Navigator ProgramPatients selected forprogram based onnumber of EDencounters andadmissionsRN and MSWnavigator teamshares panel of50 patientsNavigators available24/7; serve as primarypoint of contactfor patientNavigators coordinatemultidisciplinary careteam to meet medicaland psychosocial needsNavigators trackpatient health viaremote telemonitoring1(including patients withCHF and COPD)Navigators interactwith patient minimumof twice per month;can be as often as 21times per month1) Remote telemonitoring used primarily for CHF, COPD, and other selected high-risk (high-touch) group patients as deemed appropriate. 2015 The Advisory Board Company 3035816Source: Premier Health, Dayton, OH; Nursing Executive Center interviews and analysis.advisory.com

Even within the top 1% of mostcostly patients, leaders shouldfurther stratify patients within thenavigator program to provideadequate support to those whoneed it most.As shown here, Premierstratifies patients in their Top1% Navigator Program intothree different groups, based onhow much support they need.Low-touch patients meetmonthly with the RN navigator.To make sure they stay ontrack, an LPN or health coachcalls them every other week tocheck in.Medium-touch patients meetweekly with the RN navigator,twice per month with the MSWnavigator, and three times permonth with an LPN. An LPN orhealth coach also calls mediumtouch patients every other week.High-touch patients receive themost hands-on support. Inaddition to multiple visits withthe two navigators each month,they have several in-person andtelephone check-ins with othermembers of the care team.Finally, the RN navigatorobserves select3 high-touchpatients through remotetelemonitoring.Scaling Support to Level of Patient RiskElements of Naviga

Mayo Clinic Rochester, MN Lisa Carter Debra Cox Pam Johnson Victor Montori Methodist Le Bonheur Healthcare Memphis, TN Sally Aldrich Kimberly Lamar Nikki Polis mHealth Solutions Larkspur, CA Andrew Dick Premier Health Dayton, OH Barbara Johnson Sylvain Trepanier Scripps Health San Diego, CA Athena Philis-Tsimikas The Center for Health Care Services