Transitions of Care A Medicare Advantage QualityBLUE Pay for Performance Model

1. Transitions of CareA Medicare Advantage QualityBLUE Pay for Performance Model Geriatric Practice Change Agent Meeting Judith S. Black MD, MHA Medical Director, Highmark Senior Products September 27, 2007

2. Agenda • Rationale for the Program • Overview of the Program • Program Outcomes to Date • Lessons Learned

3. Transitions of Care - Definition and Rationale • Closely managing patient movement from one level of care to another accomplishes the following: • Reduces fragmentation • Improves patient satisfaction • Results in a reduction in readmissions • Ultimately impacts care costs • Information related to advance care planning more consistently communicated to receiving facility • Health plan moved from Per Diem to CaseRate in 2005. A set of actions designed to ensure the coordination of care as patients transfer between settings. Transitional care encompasses both the sending and the receiving aspects of the transfer and includes preparation of the patient and family, transfer of information, coordination among practitioners.

4. Variation in Care - Hospital Readmit Analysis The above 25 acute care facilities account for 85% of hospital admissions

5. Variation in Care - SNF Readmit Analysis SNF C ranked # 29 by percent of admissions

6. Highmark Initiative: QualityBLUE Transitions of Care Program • Focused Initiative: Three-year SecurityBlue Medicare Advantage (MA) Pilot Study • Quality Indicator: Transitions of Care • Involve hospitals in year one. Focus on developing “best practices” standard for coordination of discharge, i.e., levels of transitions. • In year two of the program select skilled nursing facilities will be asked to participate. Focus on care coordination between the SNF and the hospital or alternate sites.

7. Volume - top readmit rates Hospital/SNF relationships Geographic location Willingness to work with health plan. 3 to 5% of SNF payment 2.4% of hospital payment Amount payout equal projected cost savings. Facility Selection and Incentive

8. Payment Methodology Five Parameters Program Administration 5%Planning 35%Action 40%Measurement 10%Results 10%

9. Highmark MA P4P Timeline 1st Q 04 4thQ 03 2ndQ 04 3rdQ 04 1stQ 05 3rdQ 05 4thQ 05 1stQ 06 2ndQ 06 4thQ 06 4thQ 04 2ndQ 05 3rdQ 06 Develop Concept Business Requirements & Funding 6 Months Hospital Engagement 6-10 Months SNF Program Development 9 Months Engage 2nd Hospital Engage SNF’s SNF Profile 4 ½ Mths. Develop & Refine Data Elements (Pie Charts & Graphs) 2nd Expert Visit Dr. Eric Coleman Dr. Eric Coleman 1st Expert Visit

10. Initiative Goals: • To improve the quality of care for the geriatric patient • To develop appropriate reimbursement methodology to align reimbursement between health plans and institutions • To identify indicators and measurement techniques that focus on “transitions of care” issues for the hospitals in year one • To develop methods for ongoing monitoring of quality indicators.

11. Hospital/SNF Performance Strategies: • Reduce readmissions from skilled nursing facilities • Reduce admissions for patients transitioned home with diagnoses of heart failure, COPD, or pneumonia • Prevent or reduce medication errors • Facilitate effective communication sharing between facilities and enhance accountability of patient transfers • Improve patient satisfaction by ensuring their preferences be passed from one setting to the next • Ensure patient’s ability to manage their health care condition.

12. Hospital/SNF Performance Strategies: • The Care Transitions Measure Tool • To assess caregiver perception (satisfaction) of the transition process and to assess overall quality of care transitions. • The UCHSC Care Transition Measure • The hospital staff took my preferences into account in deciding what my health care needs would be after discharge • Before I left the hospital, the people that were going to help me when I got home clearly understood what my health care needs were • Before I left the hospital, I had a phone number I could call to get answers to my questions.

13. Hospitals Outcomes to Date • A work group was established to implement this quality initiative and; • Evaluated the current transfer/discharge process • Developed a written model for the Care Transitions Program • Standardized the transfer process to skilled nursing facilities • Developed essential data elements to be conveyed to the receiving practitioner • Enhanced discharge instructions for patients returning home including a system to establish follow up contact.

14. Hospitals Outcomes to Date • Developed a medication reconciliation tool • Developed an advance care planning process & implemented the POLST • Designed educational programs to inform staff members of treatment/procedural changes • Established electronic connectivity • Rapid Response Team for 600 bed SNF • Established Subcommittee with ED and SNF • Developed tools, audits, and surveys to determine the impact of the program.

15. SNF Outcomes to Date The Skilled Nursing Facilities developed a workgroup and accomplished the following: • Implemented a Performance Improvement Plan • Senior Leadership committed to continuity of project • Upon admission to the Skilled Nursing Facility, project the resident’s length of stay, establish needs and goals of the resident and regularly communicate the resident’s progress toward the goals with the family or responsible party • Developed plans and begun using CTM and transfer impact survey. • Established a performance improvement plan and timeline for incorporating the POLST.

16. 2007 Program Administration Program Manual & Ongoing Mtgs. Results Distributed Mid-Year Review Reimburse- Ment Determined Year-End Review Scoring

17. Program Year 2007-2008 • Hospitals will continue transition of care initiatives with goal to decrease readmissions • Continue to refine the SNF measures. Less emphasis on Planning & Action & greater focus on Measurement & Results • Heritage Valley Skilled Nursing Facilities to begin program (The Villa, Friendship Ridge, Beaver Elder Care).

18. SNF Outcomes to Date • Implemented a mutually agreed upon format for transfer information • Worked collaboratively with the hospital to utilize computer connectivity to enhance transfer communication. • Working in a Collaborative on Medication Reconciliation. • Participated in regular conference calls and meetings with hospital and health plan.

19. What Were the Challenges? • Selling the concept to Senior Management • Establishing an effective internal Highmark team with commitment to new program • Ongoing funding with a lag in financial data • Resources with the expansion of the Hospital QualityBLUE Program.

20. What Worked Well? • Engagement • Bringing in outside expert to help sell the program • Providing comparison data and tools • Sharing experiences • Implementation • Team experience with a commercial hospital QualityBLUE program • Detailed scoring grid • Team work with frequent contact. • Relationship building • Hospital/SNF working together.

21. Lessons Learned • Develop a detailed three year project timeline • Don’t underestimate the engagement time • Collect data in auditable format.

22. Key Success Factors • Facility Champion • Effective Team • Willingness to share tools • Leveraging off of other programs • Striving for a win/win program • Rewarding for process measures not just bottom line.

23. Sustaining the Program

24. Tools/References • www.caretransition.org • www.polst.org • “One Patient, Many Places: Managing Health Care Transitions,” a report from the HMO Workgroup on Care Management. • Coleman, Eric A. et. al. “The Care Transitions Intervention – Results of a Randomized Controlled Trial.” Arch Intern Med. 2006; 166: 1822-1828. • Davis, M. Neila, et al. “Improving Transition and Communication Between Acute Care and Long-Term Care: A System for Better Continuity of Care.” Annals of Long-Term Care. May 2005; Vol. 13 No. 5: 25-32. • Coleman, Eric A., et al. “Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention.” JAGS 52: 1817-1825, 2004. • Coleman, Eric A., Berenson, Robert A. “Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care.” Ann Intern Med. 2004; 140: 533-536.