Upstate Care Transitions Coalition: Improving Transitions of Care

1. Upstate Care Transitions Coalition(UCTC)

2. Objectives • Describe an overview of Upstate Care Transitions Coalition Program • Explain the current state of Upstate Care Transitions Coalition • Define next steps for Upstate Care Transitions Coalition

3. Overview of Upstate Care Transition Coalition • History of CCTP • How our journey began – coalition partners • RCA • UCTC Population, Goals and Plans • Role of the UCTC Coach/Alignment with CTI • Application Process and Approval • Program “go live”

4. Community-Based Care Transitions Program (CCTP) The CCTP is a five-year program created by the Affordable Care Act. Participants sign two-year program agreements with CMS, with the option to renew each year for the remainder of the program, based on their success. As of the date of this announcement, CMS continues to accept applications and approve participants on a rolling basis as long as funds remain available. Taken from CMS announcement on January 15, 2013

5. CCTP The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Affordable Care Act, tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The goals of the CCTP are to improve transitions of beneficiaries from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high risk beneficiaries, and to document measurable savings to the Medicare program. Taken from Innovation Center website http://innovation.cms.gov/initiatives/CCTP/index.html

6. Upstate Care Transitions Coalition (UCTC) • Four Participating Hospitals in three counties (Spartanburg, Union and Cherokee) • Mary Black Memorial Hospital • Spartanburg Regional Healthcare System • Upstate Carolina Medical Center (Gaffney Medical Center) • Wallace Thomson Hospital

7. UCTC Community Partners • Appalachian Council of Governments • Catawba Council of Governments • Regional HealthPlus • Interim Home Health • Gentiva Home Health • Spartanburg Regional Home Health • White Oak Manor Spartanburg • Magnolia Manor Inman • Camp Care • Rosecrest • Oakmont of Union • Ellen Sagar Nursing Home

8. Our Beginning • Carolinas Center for Medical Excellence (CCME) provided data revealing 80% of the readmitted patients were shared among the four partner hospitals. • So the journey began…

9. Root Cause Analysis(RCA) Carolinas Center for Medical Excellence- Quality Improvement Organization • Reviewed charts of readmissions for Medicare Beneficiaries with the following diagnoses: • Heart Failure (HF) • Acute Myocardial Infarction (AMI) • Pneumonia (PNE) • Chronic Obstructive Pulmonary Disease (COPD)

10. Root Cause Analysis(RCA) • Review began in hospitals with a tracer to the post acute venues (HH & SNF) • Used standardized review tool • Focus groups with physicians • Patient interviews 10

11. RCA Findings • Lack of patient chronic disease self-management skills • The majority of patients are discharged home with self-care • Both objective and subjective data indicate patients would benefit from an initiative to engage, educate and support them to become competent and confident in self-care • Inadequate communication between providers and settings • Both objective and subjective data support the need for processes to support and enhance communication between providers

12. RCA Findings • Process failures • Both objective and subjective data support the need for standardized processes internally and externally to improve care transitions • Education deficiency • Objective and subjective data support the need for education for providers, patients/families, and the community • Socioeconomic factors • Subjective data support the need for “safety nets” for low-income patients to obtain medications, be transported to follow-up medical appointments, assist with meal planning and delivery, and meet basic life needs 12

13. Population Defined • National Statistics and RCA at the four participating facilities identified four principal diagnoses for Medicare FFS and dual-eligible beneficiaries including: - HF - AMI - PNE - COPD • All three counties (Spartanburg, Union & Cherokee) in the program include small, rural and medically underserved areas.

14. Four Goals Drive the Process • Community-based Care Transitions Program Goals: • Goal 1 – Reduce Unnecessary Readmissions • Goal 2 – Improve Quality of Care • Goal 3 – Improve Transition from Hospital to Home • Goal 4 – Document Measurable Savings 14

15. Identify Eligible Candidates • Hospital case managers in all four hospitals identify eligible candidates • Use of Eligibility Screening Tool upon initial case management assessment

16. Eligibility Requirements • Candidates for the program will have a primary diagnosis of: • AMI • HF • PNE • COPD • Candidates will have a financial class of Medicare FFS or dual-eligible • Candidates are inpatient and discharged to home with or without home health services or to a skilled nursing facility for short term care

17. Eligibility Requirements • Use the Boost Risk Assessment Tool to identify eligible candidates • Problem medications • Psychological • Polypharmacy • Poor health literacy • Patient support issues • Prior hospitalizations in the last 60 days

18. Eligibility Exclusions • Hospice or Palliative care patients • Patients with secondary diagnosis of psychotic disorders • Advanced dementia (unless they have an engaged caregiver) • Patients with Medicare Advantage Plans

19. UCTC Program • UCTCTransitions Coach works directly with case managers at the four hospitals to identify eligible candidates • UCTC Transitions Coach meets patient in hospital prior to discharge • The Program consists of a hospital visit, home visit and three follow-up phone calls over a 30 day period by the UCTC Transitions Coach 19

20. UCTC Program • If patient is discharged with home health services or to SNF for short-term rehabilitation, UCTC Transitions Coach communicates with both patient and home health or skilled nursing facility partner to ensure patient’s needs are being met • UCTC program begins upon discharge from home health services or skilled nursing facility with a home visit • UCTC Transitions Coach serves as transition “navigator” and advocate/liaison for patient to ensure communication among team of healthcare providers 20

21. UCTC Transitions Coach’s Role • Help patient navigate lifestyle changes given by PCP • Reinforce teaching given to the patient at discharge and if/when they are in contact with a home health nurse or other ancillary provider • Assist patient with medication reconciliation process and have patient work through lifestyle goals • Coaches are not clinical and visits are not clinical in nature 21

22. Care Transitions Intervention (CTI) • UCTC Care Transitions Coaching model aligns with Care Transitions Intervention (CTI) • Developed by Eric A. Coleman, MD • Four week program • Patients with complex care needs • Patient and family caregivers receive specific tools • Work with UCTC Transitions Coach to learn self-management skills that will ensure their needs are met during the transition from hospital to home 22

23. Care Transitions Intervention (CTI) • Four Pillars: • Medication self-management • Use of a dynamic patient-centered record, the Personal Health Record (PHR) • Timely primary care/specialty care follow-up • Knowledge of red flags that indicate a worsening in their condition and how to respond 23

24. UCTC Transitions Coach Processes Related to Goals • Facilitate follow-up appointment with PCP within stated time period (i.e. 7 – 10 days) • Ensure that patient has a medical home • Arrange transportation as needed to assure patient gets to follow-up appointment • Confirm receipt of discharge summary by PCP prior to appointment 24

25. UCTC Transitions Coach Processes Related to Goals • Work with patient on medication management • Assist with formulating questions for follow-up appointment with PCP • Work with patient on chronic disease management and identifying red flags to contact PCP • Utilize Case Management at Area Agency on Aging for patients in need of additional follow-up past the 30 days provided through the program 25

26. UCTC Transitions Coach Processes Related to Goals • Use of short-term supplemental support package for low income patients and those lacking caregiver assistance • Cafeteria-type package • Nutrition (meals for 7 – 14 days) • Transportation to PCP or medical appointment (1-2) • Limited non-medical home care (i.e. 2 hours several times per week) • Phone cards with limited minutes for follow-up phone calls and community case management/service coordination 26

27. UCTC Application Process • Committee Work • Steering Committee • Budget Committee • Previous Experience Committee • RCA Committee • Intervention Committee • Implementation Committee • Submission of UCTC application – August 2012 • Final application approval – January 2013

28. Preparing for “Go Live” • CM Staff Education • All four Directors of Case Management traveled to all four hospitals • Demonstrate community/unified effort to Case Management Teams in all four hospitals • Obtain coach access to hospitals • Official “go live” – April 22, 2013 • Initial go live with SRMC and Mary Black • Wallace Thompson and Gaffney Medical Center go live - August 2013

29. UCTC Current State • Overview of UCTC Current State • Perfecting the Program – Process Improvements • Enrollment • Coach Workflow • Home Health/UCTC Workflow

30. Overview of UCTC Current State • All four hospitals now referring to UCTC • Coach Manager has hired three coaches and recruiting for additional coach - workflows in place • UCTC referrals have been expanded to include eligible patients being discharged home with home health services • Ongoing biweekly teleconferences with Appalachian COG, Coach Manager and Directors of Case Management • Quarterly face-to-face meetings with Appalachian ACOG, Coach Manager and Directors of Case Management

31. Perfecting the Program • Ongoing process improvements as we plan, do, study, act (PDSA) • Process Improvements to impact enrollment • Inclusion criteria now includes primarily diagnosis OR past medical history of COPD, Heart Failure, Pneumonia or AMI • Inclusion criteria now requires one risk factor (initially required two) • Coaches now have access to Medicare census to facilitate screening of potential candidates (collaborative team approach between hospital case managers and coaches) • Coaches now have access to Medicare census and patient information via secure e-mail and remote access (provides for more timely screening and review of patient information)

32. Perfecting the ProgramImprovements in Target Enrollment

33. Perfecting the Program • Process improvements related to workflow of coaches • Placement of a coach screener who does all hospital visits for the larger hospitals • Field coaches complete home visits by territory (helps split up the large area served) • Coaches paid per case once initial home visit completed with opportunity for bonus $$ for completed cases with no 30 day readmission

34. Perfecting the Program • UCTC expansion to patients discharged with HHS • Initial roll out of workflow plan to Interim, SRMC and Gentiva Home Health Services – completed August 2013 • Initial plan – hospital visit by UCTC coach with coach/HHS champion communication until patient discharged from HHS – UCTC coach home visit following discharge from HHS • Based on feedback from patients/families, UCTC coach now sees HHS patients within first week of discharge (patient/family education regarding the difference between UCTC coach and HHS roles)

35. Perfecting the Program • Initially billing to CMS manually • Process now in place to allow for automated billing

36. Next Steps • Expansion of UCTC to eligible beneficiaries discharging to short-term SNFs participating in coalition • Initial pilot with White Oak Manor Spartanburg • Appalachian Council of Government RN to assist with screening for potential UCTC candidates • Hiring of additional coaches as enrollment numbers increase (anticipate a total of seven coaches at full enrollment) • Roll out patient surveys

37. Next Steps • Ongoing communication between Appalachian Council of Government, Coach Manager, and Directors of Case Management through biweekly conference calls and quarterly face-to-face meetings with additional process improvement as needed • Readmission data analysis – aggregate data for all four hospitals – goal = 20% reduction in readmissions • Quarterly CCTP meetings with focus on identifying best practices from CCTPs across the nation

38. Key Take Aways for Nurse Leaders • Acknowledge the power of community collaboration • Understand the value in RCA to drive action • Rely on evidence based practice and tools • Embrace process improvement (perfecting processes) through PDSA – be willing to change • Remember the ultimate focus – the patient • (Patient Stories)

39. It’s a Journey • So the journey continues… • This is a work in process and we will continue to perfect our processes to ensure quality and safety for our patients as they transition from hospital to next level of care 39

40. Question?