Laura Davie Co-Director Center on Aging and Community Living Amy Newbury

1. Laura Davie Co-Director Center on Aging and Community Living Amy Newbury Care Transitions Pilot Site Director (Formally) Aging and Disability Resource Center NASUAD Home & Community Based Services Conference Community-Hospital Partnership to Facilitate Improvements in Care Transitions Tuesday, September 10, 2013

2. Community-Hospital Partnership to Facilitate Improvements in Care Transitions Session Goals • Understanding of the enhanced BOOST model • Strategies for community and hospital partnerships • Sharing pilot outcomes/lessons learned Community-Hospital Partnership to Facilitate Improvements in Care Transitions

3. NH ServiceLink Aging and Disability Resource Centers Berlin Littleton Tamworth Lebanon Laconia Claremont Rochester Concord Portsmouth Manchester Keene Salem Nashua 1-866-634-9412 www.servicelink.org • Belknap County • Laconia • Carroll County • Tamworth • Coos County • Berlin • Grafton County • Lebanon • Littleton • Hillsborough County • Manchester • Nashua • Merrimack County • Concord • Monadnock Region • Keene • Rockingham County • Portsmouth • Salem • Strafford County • Rochester • Sullivan County • Claremont Community-Hospital Partnership to Facilitate Improvements in Care Transitions

4. SLRC Functions 1) Access to comprehensive information and awareness about services for individuals with public or private payment mechanisms (Information and Awareness function) 2) A single point of entry into public programs, including Medicaid funded in-home care and nursing home care (Streamlined Access function) 3) Screening for and assessment of Medicaid eligibility (Streamlined Access function); 4) Options Counseling (Options Counseling function) 5) Long-term care counseling (Information and Awareness function) 6) Tools for short term case-tracking (Quality Assurance and Evaluation function) 7) Counseling, respite care counseling, and other supports for family caregivers (Information and Awareness function) 8) Statewide coordination and counseling to Medicare beneficiaries under the State Health Insurance Assistance Program (SHIP) (Streamlined Access function). 9) Serve as Local Contact Agencies (MDS 3.0 Section Q) 10) Community Based Veterans Directed Programs (pilot) Community-Hospital Partnership to Facilitate Improvements in Care Transitions

5. NH ADRC Care Transitions Pilot Roles and Responsibilities Bureau of Elderly and Adult Service at NH DHHS (BEAS): • Administrator SLRC Network • Pilot oversight & directed policy and data collection Center on Aging and Community Living at UNH: • Agent of the State for the ACL grant • Sub-contracted with SLRC sites • Technical assistance and evaluation ServiceLink Resource Center Network: • Contracted agencies with BEAS to perform activities in alignment fully functioning ADRC model • Implemented care transitions pilot (three communities) Hospitals: • Partnered with local ADRCs for implementation and program design Community-Hospital Partnership to Facilitate Improvements in Care Transitions

6. NH ADRC Person-Centered Care Transitions Pilot Three local NH Aging and Disability Resource Center (ADRC) sites piloted care transitions models (2010-2013) • Care Transitions Intervention (CTI) and Better Outcomes for Older Adults through Safe Transitions (BOOST) • On-site staff • All payer sources • CTI- Increase linkages with NH’s ADRC services (care-giver support, information and referral specialist, long term care counselor, and Medicaid specialist) • BOOST- provide on-site long term care counselor Community-Hospital Partnership to Facilitate Improvements in Care Transitions

7. Community Profile

8. BOOST Model Vision • Reduce 30 day readmission rates • Improve patient satisfaction scores • Improve flow of information between hospital and outpatient physicians and providers • Identify high-risk patients and target specific interventions to mitigate their risk • Improve patient and family preparation for discharge www.hospitalmedicine.org/BOOST/ Community-Hospital Partnership to Facilitate Improvements in Care Transitions

9. Developing the Enhanced BOOST Model • Divine intervention • Building upon existing partnership with hospital and community (Business Agreement) • Working with Society of Hospital Medicine& Piedmont Hospital • Established Care Transitions Advisory Group • Leadership Team Meetings • Developed referral process (flow chart) Community-Hospital Partnership to Facilitate Improvements in Care Transitions

11. Developing the Enhanced BOOST Model • Divine intervention • Building upon existing partnership with hospital and community (Business Agreement) • Working with Society of Hospital Medicine& Piedmont Hospital • Established Care Transitions Advisory Group • Leadership Team Meetings • Developed referral process (flow chart) Community-Hospital Partnership to Facilitate Improvements in Care Transitions

12. New Hampshire ServiceLink Aging and Disability Resource Center, January 2013

13. Care Transitions Specialist Role • Linkages with Community LTSS • Options Counseling (not just about Medicaid) • Person Centered Approach • BOOST rounds • Additional Follow Up across Enhanced BOOST model • Liaison across care environments • No time restriction Community-Hospital Partnership to Facilitate Improvements in Care Transitions

14. Evaluation(March 2012-September 2013) Community-Hospital Partnership to Facilitate Improvements in Care Transitions

15. Evaluation(March 2012-September 2013) Community-Hospital Partnership to Facilitate Improvements in Care Transitions

16. Outcomes Person-Centered Hospital care transitions pilot (2010-2013) • Outcome 1: Reduce hospital readmission rates for target population. • Outcome 2: 80% of participants report feeling prepared for discharge. • Outcome 3: 50% of medical and social providers report good communication of medical and social services. • Outcome 4: The referral process to link patients to community resources is improved. • Outcome 5: 80% of participants report confidence in their ability to navigate the medical and social systems. Community-Hospital Partnership to Facilitate Improvements in Care Transitions

17. Outcome 1: Reduce hospital readmission rates for target population

18. Outcome 2: 80% of participants report feeling prepared for discharge

19. Outcome 3: 50% of medical and social providers report good communication of medical and social services

20. Outcome 4: The referral process to link patients to community resources is improved

21. Outcome 5: 80% of participants report confidence in their ability to navigate the medical and social systems.

22. Our Takeaway’s to build on • The ADRC model (social/community based) is a critical partner within the medical system to improve the quality of acute transitions for individuals. • Growing hospital awareness and investment in partnering with ADRC’s (social/community based systems). • Explore and refine data collection practices. Community-Hospital Partnership to Facilitate Improvements in Care Transitions