Better Medicine

Care Assure leverages HCA Healthcare’s scale, IT investments and commitment to patient care to improve patient outcomes

For Evelyn Brown, November 13, 2014 was one for the books. It began with her feeling a little off, progressed to an unexpected hospitalization and, soon after, she found a new friend.

“I was a few days away from having heart surgery, because I was dealing with atrial fibrillation and couldn’t take blood thinners,” Brown recalls. “I was due at the doctor’s office for advance blood work. By the time I got there I really felt bad, and it was just getting worse. They sent me straight to Orange Park [Medical Center], where it turned out that my potassium was so low that I could have died.”

Although in and out of consciousness for the next few days as her potassium levels improved and her heart procedures were performed, one person she remembers throughout is Deb DeGarmo.

“She was there the minute I was, and we talked about a few things while I was coming in and out,” Brown says. “And she’s been with me through rehab and everything else since. She’s a godsend.”

New role, new challenges

DeGarmo, a former hospital director of cardiac services, is now the Orange Park Medical Center nurse navigator for Care Assure, an innovative clinical navigation program developed by HCA Healthcare to ensure better communication, better care and better outcomes, by educating and helping navigate patients after hospitalization.

By acting as the bridge between patient, doctor and hospital, Care Assure’s nurse navigators are able to make sure that patients understand their often-complex care pathway, schedule and attend important follow-up appointments, get and take their medications appropriately and otherwise secure the vital services they need.

Patient feedback and experience with Care Assure, which launched at JFK Medical Center in Atlantis, Fla., in 2012, has been highly favorable and the program is now making its way across HCA Healthcare. It also gets high marks from physicians for helping them treat patients more efficiently, especially those who often need their care most, while providing better care coordination throughout the process.

“It’s an extension of their care,” DeGarmo says. “Many people are confused once they go home. They get a lot of paperwork and instructions as they are preparing to leave the hospital, and it’s an anxious time for them. What we’re doing with Care Assure is making certain that the transition of care goes much more smoothly, so they actually receive the care that is prescribed.

“While answering questions and concerns, I was able to ease Evelyn’s anxiety about her planned care. I also explained that as the Care Assure nurse navigator, I would be contacting her upon discharge to ensure follow-up. We connected numerous times both before and after surgery, including at rehab and several months later when she was back home, truly building a long-term relationship.”

Old idea, new concept

Post-discharge follow-up isn’t a new part of healthcare, but building an entire program to identify and then help specific groups of patients as they navigate the system is a more unique and robust approach, says Chuck Hall, president of HCA Healthcare’s National Group and one of Care Assure’s founders.

“This idea goes back many years,” Hall says. “Through a lot of conversations with experts in this space, we realized that the best way to continue care coordination for a particular population when they leave the hospital is to establish our own system and processes, and use certain clinical information that we have readily available through the electronic medical record and other information systems, to provide better care.”

Indeed, HCA Healthcare’s ability to leverage its data collection and analytics tools are a key to Care Assure’s success in the long term. “Given the often high-risk and time-sensitive nature of their conditions, coupled with complex case pathways, the program’s focus now is on cardiovascular patients. The impact of coordination is measured through clinical and operational metrics and necessary adjustments are made to further improve patient experience and outcomes,” says Dr. Steven Manoukian, vice president, cardiovascular service line, for HCA Healthcare’s Operations and Service Lines Group and another of the program’s leaders.

“Improving healthcare value is an important goal, which means improved clinical outcomes, potentially at lower healthcare cost, in part due to more efficient processes,” Dr. Manoukian says. “Care Assure focuses on improving clinical navigation, which can lead to better outcomes and reduction of waste. The program helps prevent patients from falling through the cracks in healthcare and instead facilitates navigation, even when patients have complicated clinical 
care plans.”

Identify, interact and facilitate

Care Assure uses a data approach to identify individuals who may need care coordination. The program also employs widely accepted evidence-based guidelines to develop individualized care plans in conjunction with the patient’s healthcare provider(s), which often includes important follow-up after discharge.

At present, Care Assure is primarily being used for cardiac patients, although other service lines may be added in the future.

“Care Assure is an excellent example of clinical innovation, in that we are always enhancing what it can do,” Dr. Manoukian says.

“By leveraging the latest clinical guidelines, we regularly revise the Care Assure program to include new disease processes, treatments and/or patient populations who might benefit. We are currently exploring additional cardiovascular conditions such as heart failure, due to the high risk of short- and long-term adverse outcomes and readmission.”

Care Assure also helps patients who may be at risk for cardiovascular disease later in life. “There are certain criteria that help identify these patients with risk factors for cardiac issues who would benefit from Care Assure,” DeGarmo says. “For instance, if they have cardiovascular risk factors and do not have a primary care physician, that’s a concern right there. Also if they are diabetic and more than 50 years old or a smoker, a Care Assure navigator will be notified. I see some of them before they are discharged, and others I get in touch with just after they’ve left the hospital. We talk about their diagnosis, clarify questions regarding medications, schedule all necessary follow-up appointments and anything they want to know more about, really.”

The next step, she continues, “is to help ensure they attend their appointments and if they don’t, I reach back out to determine what obstacles they encountered and provide necessary resources to help overcome them.

If they are supposed to have home healthcare and that hasn’t happened, I will call and see what’s going on. There are a lot of intersections where something can get turned the wrong way, so I work to correct that.”

Ensuring patient follow-up and care coordination

There are some basic numbers that help illustrate the need for Care Assure. Approximately 80 percent of patients do not understand their discharge instructions. Only 40 percent of patients follow up with their specialist or primary care physician, despite the majority being instructed to do so.

“There are a multitude of reasons why patients may leave the hospital, but don’t follow up and instead just disappear,” says Lindsay Stergar, HCA Healthcare’s operational leader of Care Assure and AVP of the cardiovascular service line. “Care Assure focuses on patients who have high-risk conditions, works with their providers to schedule the care they need and facilitates navigation through that process. In addition, the team educates patients and provides additional resources needed to help overcome challenges with the continuation of care. Lastly, as patients live longer, they are often less capable of understanding and complying with increasingly complex care pathways.”

“The Care Assure process increases the likelihood that a patient receives their physician-ordered care and is not lost to the healthcare system,” Stergar adds.

For example, a patient might be admitted to the hospital for shortness of breath due to lung disease. While there, he or she undergoes an echocardiogram, revealing a cardiac abnormality which requires follow-up. On discharge, since the patient feels fine, they may never make nor attend a follow-up appointment for the potential heart issue. That’s when Care Assure identifies the patient based on the abnormal echocardiogram and swings into action.

“When a Care Assure navigator identifies a patient at high risk for future complications based on their condition, and they reach out to the patient, they increase the likelihood that patients are navigated to the evidence-based care they need and that’s a huge win,” she says. “Care Assure does more than ensure follow-up, it is potentially saving lives.”

“It’s a great feeling to see so many lives being affected,” Hall adds. “We measure the number of years the quality of life will be improved and/or extended by the early identification and treatment of diseases, and when I see those quality-adjusted life year (QALY) numbers go up for a patient because of early intervention, it’s very satisfying. HCA Healthcare has the resources to take this very good idea that’s been developed and deploy it across the entire enterprise, so it will help hundreds of thousands of people. That’s hugely rewarding.”

“Care Assure is a way for HCA Healthcare to be truly proactive and get patients the care they need,” adds Bruce Moore, president of HCA Healthcare’s Operations and Service Lines Group. “We use data to reach patients who might need crucial care, but may be unsure how to obtain it or unable to navigate the healthcare pathway. Healthcare is complicated. Patients aren’t unwilling to seek care; they often just don’t know where to start. Care Assure gives them someone to talk to, and helps them move to the next stage of getting diagnosis and follow-up care. Since HCA Healthcare is in the business of helping people get better, Care Assure fits right in with our mission statement.”

Resuming a regular life

For Evelyn Brown, that also meant help with some issues around her rehab stay, continued input on medications and much more.

“When I had a problem, Debbie made a call and got it fixed,” she says. “I got home, rested up for about three months and went back to work. I teach an art class once a week. It’s a Japanese form of advanced embroidery with silk thread, called bunka shishu, and we compete internationally. I was told I’d eventually feel like a new human, and I do.”

The best part, she says, wasn’t just having someone help with medical issues, but just having someone show concern.

“Debbie is very diplomatic,” Brown says. “She would ask about pills and medicines, but never made me feel like a child. She made me feel like part of the team. She’s just so kind, and when you’re ill, kindness means everything.”