Health Care Reform, Chronic Care Management, Care Transitions and the Future of Nursing

1. Health Care Reform, Chronic Care Management, Care Transitions and the Future of Nursing Duke Carolina Visiting Professorship in Geriatric Nursing Duke University School of Nursing May 5, 2010 William A. Dombi National Association for Home Care & Hospice wad@nahc.org

2. Health Care Reform: What Happened • Health Insurance Reform • Expanded Coverage of the Uninsured • Medicare Spending Reductions • Health Care Cost Containment??? • Health Care Delivery Reform???

3. Health Care Reform • There is much more of health care cost and care delivery reforms than mass media has focused on • Great attention paid to: • The “public option” • “death panels” • States rights

4. Health Care Reform • Without public fanfare, the HCR legislation will revolutionize significant parts of health care delivery • Preventive care coverage expansion • Primary care supports • Accountable Care Organizations • Transitions in Care plans • Acute and post-acute care payment bundling • Long term care and chronic care management • Workforce supports • All these reforms involve nurses as central players

5. Health Care Reform • Long Term Care and Chronic Care Management • CLASS Act • Medicaid Home and Community Based Care Expansions • Federal Coordinated Care Office • Special Needs Plans • Medical (Health) Homes • Independence at Home pilot • HHA-based chronic care management demonstration

6. CLASS Act: Long Term Care Returns to the Agenda • Community Living Assistance Services and Support • Payments made to cover individuals with ADL needs in home or nursing facility • Federal LTC insurance program • Premium withholding in wages • Opt-out of program authority • Participation begins 2010 • Eligibility based on ADL needs • Benefit payments begin in 2016 • Preset daily payment to insured • Boon to Private Pay home care starting in 2016

7. Medicaid Provisions: HCBS Expansion • Major home care expansion/rebalancing through federal money (FMAP) • Community Free Choice Option • Removal of barriers to HCBS services • Money Follows the Person Demo extension • Spousal impoverishment protection

8. Chronic Care Management • Federal Coordinated Care Office • CMS based • Coordinate Medicare ad Medicaid dual eligible patients • Develop coordination tools • Special Needs Plans • Reauthorized through 2013 • Refocus on enrollee characteristics

9. Chronic Care Management • Medical (Health) Homes • Grant programs and Medicaid supports • Interdisciplinary team approach • Required hospital referrals on Medicaid patients • Retains Medicare demo and includes authority for CMS Innovation Center creation of more models

10. Independence at Home • Pilot Program • Physician-centered interdisciplinary team • Focus on patients with: • 2 or more chronic illnesses • Recent hospital, SNF or HHA admission • Shared savings based payment • Coordinates care across all settings • Specialized physician qualifications

11. HHA-based Chonic Care Management • CMS Innovation Center based demonstration • Nurse/care coach centered • Interdisciplinary team • Direct patient contact • Use of remote monitoring technologies • Shared savings reimbursement

12. Medicare/Medicaid Payment Bundling • Flexible authority for CMS • Many approaches to bndling available • Likely will include hospital, physician, and post-acute care • A community care-based bundling model possible

13. Community-Based Care Transitions Program • Medicare demonstration program • Competitively selected • Targets high readmission rates • Supports beyond routine discharge planning • Expansions possible by HHS authority

14. Workforce Supports • Primary Care physicians, NPs, Pas • Nurses • Direct care workers • Home care aides

15. Workforce Supports • Nurses • Student loan program • Loan repayment supports • Public health recruitment and retention programs • Nurse-managed health clinics • Advanced nursing education grants • Nurse education, practice, and retention grants • Geriatric education and training career awards

16. Direct Care Workers • Personal Care Workforce Advisory Panel (CLASS Act) • Demo grants to establish competency standards • Training and career ladder opportunities

17. REVOLUTION UNDERWAY • Broad recognition that chronic illness is a major factor in health care cost • Understanding that community-based care is an effective way to address needs of chronic care patients • Goals shifted to prevention and management, away from crisis intervention • Identification that workforce supports needed to staff the new care delivery models, with different skills

18. Who Will Be Crucial To Success • Nurses, nurses, nurses…… • Home care aides/personal care attendants • Primary care physicians • Committed/engaged patients and family members

19. What Will Be Crucial To Success • New skills • Coaches • Educators • Coordinators • communicators • Technological supports • Remote monitoring • Interoperable EHR • Financial supports/incentives • Medicare and Medicaid may need to lead

20. CONCLUSION • EXCITING TIMES! • Opportunities, but no guarantees • Taking the initiative essential • Teamwork prevails over silos • Dreams coming true