Improving Transitions in Care

1. Improving Transitions in Care From Hospitals to Community

2. Care Transitions Poorly executed care transitions lead to poor clinical outcomes, dissatisfaction among patients, and inappropriate use of hospital, emergency, and post acute services.

3. Care Transitions Nursing home Hospital Rehab Facility Home

4. Readmissions Reflect a breakdown in the process, a failure in our ability to effectively transition clients between care settings and providers.

5. The Problem • Hospital Readmissions are costly and can be avoided • 90% of patients nationally who were readmitted to the hospital have experienced a breakdown of post- discharge care • Costs to Medicare for hospital readmissions is estimated at $15 billion a year, $12 billion of which is for cases considered preventable

6. Root Causes? • Medication discrepancies • Lack of patient follow up with PCP • Poor communication and handoffs • Lack of ownership – personal responsibility over their own care • Variety of complex family, psychosocial problems • Lack of alignment with payment incentives and provider risk

7. Southwest Ohio Community Care Transitions Collaborative • Includes: • Council on Aging of Southwestern Ohio • Greater Cincinnati Health Council • Hospitals: • University Hospital • The Christ Hospital • Jewish Hospital • Mercy Fairfield • Clinton Memorial Hospital • Health Collaborative • Healthbridge • Health Care Access Now • Mental Health and Recovery Services Board

8. Affordable Care Act • Beginning in October 2012, Medicare can withhold a portion of payments to hospitals that have high readmission rates for patients with certain conditions such as heart failure and pneumonia • Section 3026 created a Community-based Care Transitions Program (CCTP)

9. CMS Community-based Care Transitions Program • The Community Based Care Transitions Program (CCTP) goals are: • to reduce hospital readmissions • test sustainable funding streams for care transition services • maintain or improve quality of care • document measureable savings to the Medicare program

10. Eligibility • 65+ • Medicare FFS • Admitted to one of five participating hospitals • CHF, AMI, Pneumonia, and/or multiple chronic conditions • Patient agreement and activation assessment

11. By the numbers… • We are one of the first seven funded • Will serve 5,400 patients each year • Scheduled to begin March 19th • Annual net savings to Medicare of $1 Million • Two year project with extension of another three • Not a grant … bundled payment

12. Council on Aging Care Transitions Program Background • Developed a Care Transitions Pilot: • December 2010 University Hospital • June 2011 The Christ Hospital • November 2011 Jewish Hospital

13. COA Care Transition Program Two Outcomes: #1 Reduce avoidable re-hospitalizations. #2 Reduce unnecessary long-term nursing facility placements.

14. Admitting Diagnoses for Participants(n=311) Admitting Diagnosis 23% of the total were admitted with a diagnosis considered to be high risk for readmission by CMS. Source: Council on Aging of Southwestern Ohio, 10/27/11 n= 170 Note: Respiratory includes shortness of breath, pulmonary edema, bronchitis and related issues. In addition to items considered to be ‘other’, other also includes AFIB (2%), CVA (1%), and HTN (2%).

15. Our Initial Results: 65% were discharged directly to a community setting Of those who were discharged to a short term nursing facility or in-patient rehab, 37 (41%) were discharged back to the community for a total of 239 (77%) of CTI participants successfully transitioning back to their homes and communities. Source: Council on Aging of Southwestern Ohio, 3/5/12: n=311 Note: N/A: includes individuals discharged from CTI and individuals who are still in the hospital. Not equal to 100% due to rounding.

16. Care Transitions Intervention Designed to encourage older patients and their caregivers to assert a more active role during care transitions. (c) Eric A. Coleman, MD, MPH

17. Transition Coach • Role is NOT to be a service broker, Assessor, or Care Manager • Client empowerment and skill transfer is key for continued success after the intervention

18. Transition Coach • Do not fix problems • Do not provide skilled services • Do model and facilitate new behaviors and communication skills for clients and caregivers

19. The Care Transition Intervention • Hospital/NF Visit • Home Visit • Follow up Phone Calls

20. The Four Pillars • Medication self-management • Use of a dynamic patient-centered record: The Personal Health Record • Timely primary care/specialty care follow up • Knowledge of red flags that indicate a worsening in their condition and how to respond.

21. Client personal goal • “What is one personal goal that is important for you to achieve in the next 30 days?”

22. #1: Medication Review • Client collects all medications (prescription and non-prescription) for review during the home visit. • Client describes medications they are taking and how • Compares what the client is actually taking with the pre and post-hospitalization lists and identifies discrepancies. • Shows client how to update the medication list in the Personal Health Record. • Discusses with client how he or she will follow up with practitioners and PCP

23. #2 Patient-centered record • Teach the client how to complete the Personal Health Record • Discuss the importance and how to update the PHR on a continual basis • Discuss the value of taking the PHR to all health care encounters and sharing its contents with health care professionals • The consumer/caregiver assumes ownership of the PHR to facilitate cross-site communication and ensures continuity of core information across different practitioners and settings.

24. #3 Timely primary care and specialty care follow up • Have client contact PCP. • Schedule appointment • Prepare questions • Identify barriers like transportation

25. #4 Knowledge of Red Flags • The client identifies signs and symptoms that his or her condition may be worsening • Determines how she/he would respond to those “red flags” • Use the PHR for the client to list red flags and plan of action. • Use educational materials about condition given at the hospital

26. COA’s Fifth Pillar • Community Resources such as… • Ongoing care coordination • Home delivered meals • Medical transportation • Home Care Assistance

27. Coming soon… • Improved targeting of care transition intervention • Integration with patient centered medical home • Assistance with finding physicians and access to behavioral health care • Shared medical information across care providers and settings

28. Care Transitions in Action “It’s been really wonderful to help me stay at home.” DONNA, CARE TRANSITIONS CLIENT WITH HER COACH, BETH