Strategies to Improve Care Transitions: Patient & Caregiver Engagement and Activation July 17, 2011 NATIONAL ASSOCIA

1. Strategies to Improve Care Transitions:Patient & Caregiver Engagement and ActivationJuly 17, 2011NATIONAL ASSOCIATION OF AREA AGENCIES ON AGING CONFERENCE

2. Scope of the Problem National Priority to Reduce Avoidable Re-Hospitalizations: • In 2009, inpatient hospital services accounted for the largest percentage of Medicare spending at 27% • In 2006, the top 5% Medicare fee-for-service (FFS) beneficiaries accounted for 39% of annual FFS spending • The costliest beneficiaries tend to have multiple chronic conditions, higher use of inpatient hospital services, have both Medicare and Medicaid, and in their last year of life • In 2006, the aged population account for the greatest percentage of Medicare beneficiaries and spending, 84% and 82.6% respectively • In 2006, 9.2% of Medicare beneficiaries reported relatively poor health and accounted for 19.0% of spending MEDPAC The Data Book: Healthcare spending and the Medicare program June 2010

3. The Driving Forces…. AARP Report: Chronic Care: A Call to Action for Health Reform (March 2009) According to the results of the patient survey: • Nearly one in four patients reported experiencing a medical error, and 61 percent of this subgroup said they had experienced a major problem as a result • About one in five reported that their health care providers did not communicate well with each other about the their individual condition or treatment, which some said compromised their health • Nearly one in seven said they didn't get a follow-up appointment after they were discharged or, if they did, it was more than four weeks later • Almost one in five said their transitional care was not well coordinated.

4. The Driving Forces…. American Geriatrics Society Health Care Systems Committee Position • Clinical professionals must prepare patients/caregivers to receive care in the next setting & actively involve them in decisions related to the formulation & execution of the transitional care plan • Bi-directional communication between clinical professionals is essential to ensuring high quality transitional care • The opportunity to collaborate with a coordinating health professional functioning across health care settings to reduce care fragmentation may enhance the care that these professionals deliver Source: J Am Geriatric Soc 51:556-557, 2003

5. Contributing Factors Patients are more chronically ill, more frail, and have more complex care needs • Multiple diagnoses • May see several physicians • Average 13-16 medications per day • May be cognitively impaired • May not have a Primary Care Physician • May lack a caregiver for safe transition to home • Access to and/or lack of community services

6. Other Contributing Factors • Not remembering / understanding physician instructions • Difficulty communicating with health professionals • Unrealistic expectations • Difficulty arranging for assistance • Finances/affordability • Not enough time for competing demands • Loss of mobility • Language barriers (Source: Beyond 50.09 Chronic Care: A Call to Action for Health Reform, AARP, March 2009)

7. Centers for Medicare & Medicaid Services Care Transitions Initiative August 2008-July 2011

8. New York Care Transitions Target Community • Five county region in Upper Capital Region of New York State with integrated referral patterns incorporating urban, suburban and rural communities within 84 zip codes • Warren, Washington, Saratoga, Rensselaer & Saratoga • Fifty providers • Hospitals (6), Home Health (6), Skilled Nursing Facilities (28), Hospice (5), Dialysis Centers (5), Multiple Physician Practices • Impacting 68,206 Medicare Fee for Service (FFS) beneficiaries

9. Dilemmas Focus is on discharge versus transition No ownership of transition Burden of coordination is placed on patient Caregiver may not be available / involved at discharge Absence of common medical record Absence of cross setting medication reconciliation Lack of advance directives & screening for palliative care No reassessment of patient and goals at each transition Communication gaps exist between disciplines and health care settings

10. Culture And Paradigm Shift Discharge Unload or fulfill an obligation Implies a “hand-off” to the next provider “Siloed care” Care Transition The movement of a patient between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness

11. Patient Engagement / Activation The person’s ability to manage their health and health care • Self efficacy in managing their behavior • Readiness to change - motivation • Knowledge, skill, beliefs, and behaviors • Linked to the person’s health outcomes

12. Patient Engagement / Activation Patients who were not interested or less involved in care tended to: (tended to report relatively “poor health”, when asked) • Have more problems with transitioning between care settings • Reported more problems with care • Less confident with there ability to manage their chronic condition • Worse health status and more chronic conditions • Required more assistance to arrange for care (Source: Beyond 50.09 Chronic Care: A Call to Action for Health Reform, AARP, March 2009)

13. Medicare Beneficiary Outreach

14. Aging Services in New York State • The Areas on Aging collaborate with NYS Office for Aging service provision • AAAs role is more related to senior advocacy • NYS Office for Aging coordinates aging services through local County Offices for Aging • NY CONNECTS (Single point of entry for all long term care services – not NYC) • Local long term care councils • Community supports navigator program

15. Key Practices Leading to Results • Collaborated with target community providers and stakeholders to identify sites where seniors gather for social and health activities • Senior Centers , Housing Units, Independent & Assisted Living Facilities, Churches, Libraries • Organized one hour beneficiary outreach sessions at each site • 20 educational sessions completed to date reaching over 315 Medicare beneficiaries in community • 3 community caregiver outreach exhibits with over 160 attendees • 2 senior health fairs with over 150 attendees • Developed large font, fifth grade level educational materials to share and reference during each session: • Hospital Discharge Planning “Golden Rules” • Medication Management “Golden Rules” • Personal Health Record • Caregiver Resource Handout • United Hospital Fund Next Step In Care Resources • Opened sessions by asking seniors to share their health care experiences and then used their stories in conjunction with the educational materials to discuss importance of self empowerment & self-management skills • Shared beneficiary feedback & perceptions with target community providers

18. Medicare Beneficiary Feedback Following IPRO Care Transitions Outreach Sessions After attending this session I now feel more prepared to…. Source: IPRO Medicare Beneficiary Outreach Program Evaluations

19. Medicare Beneficiary Feedback on IPRO Care Transitions Outreach Sessions • I am a retired public health nurse that practiced before the times of Medicare and Medicaid. I think the guidance you shared here with us today on how to navigate the health care system and take charge of managing our health information has been very helpful. It is not our way to ask questions of the people who provide us health care…we often feel we do not have the right and quite often when we do our questions and concerns go unanswered. Thank you for giving us permission to become empowered! • After participating in this session I am now aware of today’s health care environmental routines/personnel and the fact that I need to be more aware of the details of my health care. • The information shared will be very helpful to organize my health information. I feel more comfortable knowing it is okay to ask the health care team questions to enable me to become more involved in my care. • Before today I never thought about involving my Pharmacist to answer questions and concerns I have about my medications. Thank you for the suggestion! • I was so anxious in the hospital I did not even think about what I needed to plan for once I got home. This information and my experience over the past year will help me plan ahead next time. • The information you provided regarding the Hospitalist role was very helpful. I had never heard about that before and had no idea that my doctor I have gone to for the past 16 years may not even know I was in the hospital to be involved in my care

20. Internet Resources • Official US Government Medicare website: www.medicare.gov • IPRO Care Transitions: http://www.ipro.org/index/ct-care-transitions • Next Step in Care: www.nextstepincare.org(sponsored by the United Hospital Fund) • Ask Me 3 Campaign: http://www.npsf.org/askme3/ (sponsored by the national Patient Safety Foundation)

21. For more information Christine Stegel, RN, MS, CPHQ Senior Performance Improvement Specialist http:caretransitions.ipro.org CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY 11042-1002 REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY 12211-2370 www.ipro.org This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 9SOW-NY-THM7.2-11-21