6/11/2013. Disclosures. 10 th SOW Contract Purpose. QIO s Work in Multiple Settings. The Carolinas Center for Medical Excellence (CCME) Overview

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1 Disclosures South Carolina Primary Health Care Association 2013 Annual Clinical Network Retreat: Care Transitions and Patient-Centered Care No relevant disclosures to report Mark Massing, MD PhD MPH Director of Research Tanishah Nellom, MSPH Care Improvement Specialist- Care Transitions June 9, Overview 1. About CCME: Your QIO in North and South Carolina 2. Overview of QIO Care Transitions activities in SC Communities 3. Care Transitions Overlap with Patient- Centered Care 4. Community Coalition Best Practices QIO s Work in Multiple Settings Healthcare Providers Inpatient (Hospital) Outpatient (Physicians, Practices) Skilled Nursing Facilities Pharmacy Beneficiaries Patients Families Communities Other Stakeholders Payers Academic Centers Public Health Local, state, federal governments 10 th SOW Contract Purpose QIO s support and partner with CMS to improve health and health care for all Medicare beneficiaries utilizing three broad aims as the foundation of the SOW: 1. Better care. 2. Better health for people and communities. 3. Affordable care through lowering costs by improvement. The Carolinas Center for Medical Excellence (CCME) Organizational mission to improve health care The Federally designated Quality Improvement Organization (QIO) SC & NC 3 year contract period with the Centers for Medicare & Medicaid Services (CMS) 10 th Scope of Work (SOW) - contract began on, August 1,

2 10 th Statement of Work: 4 Tasks 1. Beneficiary & Family Centered Care 2. Improving Individual Patient Care 3. Integrating Care for Population and Communities 4. Improving Care for Population and Communities Overview of QIO Care Transitions Activities in SC Communities 7 Scope of Problem- Financial Costs Approximately 20 percent of Medicare beneficiaries discharged from hospitals were readmitted within 30 days. Approximately 75 percent of those readmissions could have been prevented. We spend $12 billion annually on those avoidable readmissions. Scope of Problem- Human Costs Approximately 25 percent of discharged patients need outpatient workup, but more than 1/3 are not done. 2 in 3 Medicare FFS medical discharges are readmitted or dead within a year. 1 in 2 Medicare FFS surgical discharges are readmitted or dead within a year. Source: Medicare Payment Advisory Commission Source: Medicare Payment Advisory Commission The Definition Refers to the patients moving between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness (Care Transitions Program, University of Colorado). Definition of (Avoidable) Readmission An avoidable or preventable readmission is considered to be a readmission clinically related to the prior admission, if there was a reasonable expectation that it could have been prevented: Provision of quality of care in initial hospitalization Adequate discharge planning Adequate post-discharge follow-up Coordination between inpatient and outpatient health care teams 2

3 Common Reasons Patients are Readmitted Poor communication between sending and receiving providers Poor or lack of patient/caregiver education and instructions Lack of access to follow-up care appointments with primary care providers or no primary care provider available Lack of community support systems for patients and caregivers (e.g., nutrition home delivery, medical transportation) Socioeconomic factors (patients who cannot afford medications, specialty physician co-pays, nutritional food) Goals of Care Transitions Program Improve transitions of beneficiaries from inpatient setting to other care settings Improve the quality of care Reduce readmissions for high risk beneficiaries Document measurable savings to the Medicare program Scope of Readmissions Problem Impact on Hospitals Beginning with FY 2013 (October 1, 2012), CMS began imposing penalties for high readmission rates Initially Heart Failure (HF), Acute Myocardial Infarction (AMI) or Heart Attack, Pneumonia (PN) By 2014, list expands to 7 conditions Penalty exposure increases from 1 percent to 3 percent Medicare FFS over 3 years Care Transition Target Diagnoses In SC, our greatest readmission rates come from patients with: Congested Heart Failure (CHF) Heart Attack (AMI) Pneumonia (PNEU) Chronic Obstructive Pulmonary Disease (COPD) Diabetes and Complications (DM) End Stage Renal Disease (ESRD) CCME s Role Provide technical assistance to communities who are interested in improving care transitions. Educate Communities and Stakeholders on National Care Transition Initiatives. Assistance with Coalition Formation. Technical assistance with Community Root Cause Analysis (RCA). Components of the Root Cause Analysis Patient Interviews Inpatient on readmission Post-discharge Focus Groups Physician, Nurse, PA, Pharmacist, Allied Health Hospital, Outpatient, Skilled Nursing Facility (SNF), Home Health (HH) In person interviews Meetings Community Support Services, Community Meetings Chart Reviews *Results of the RCA are presented during Community Coalition Meetings to aid in intervention selection. 3

4 Top 10 Challenges Identified Across All RCA - What Have We Learned so Far? #10: Socioeconomic/Socio-environmental #9: Physician Lack of Confidence in Care Provided in Non-Acute Care Settings #8: ESRD Patients on Dialysis #7: Access to Care, esp. Mental Health #6: End of Life Education and Referral Top 10 Challenges Identified Across All #5: Patient/Caregiver Engagement #4: Patient Education Process #3: Physician Follow-up #2: Medication Reconciliation #1: Communication Top 10 Challenges By Community Community A B C D E F G H I J Socioeconomic Issues x x x x x x x x x x Physician Confidence in Care Provided in Non- Acute-Care Settings x x x x x x x x x x ESRD Patients on Dialysis Access to Care, Mental Health Services End of Life Education and Referral x Patient and Caregiver Engagement x x x x x x x x x x Patient Education x x x x x x x x x x Physician Follow-Up Medication Reconciliation Communication x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x Patient Centered Care Care Transitions Overlap with Patient-Centered Care "Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. - IOM Health care system is designed and delivered to address the health care needs and preferences of patients so that health care is appropriate and cost-effective Health care must be based on the following Five Principles: 1. Respect for patient and caregivers unique needs, preferences and values, as well as their autonomy and independence. 2. Choice and Empowerment - Patients have a right and responsibility to participate as a partner in making health care decisions. 3. Patient Involvement in Health Policy - Share the responsibility of health care policy-making through meaningful and supported engagement in all levels. 4. Access and Support - Patients must have access to the health care services. 5. Information - Accurate, relevant and comprehensive information. - Declaration on Patient-Centered Healthcare, International Alliance of Patients' Organizations, 4

5 Patient Centered Care Coordination Hospital Hospital Community Coalition Best Practices Outpatient practice Patient Pharmacy Outpatient Practice Patient Pharmacy Home and Community Services Home and Community Services Patient Centered Care Patient Centered Coordinated Care Our Goal Move from silos of fragmented, uncoordinated health care delivery. Top 10 Successes Identified Across All #10: Awareness of Problem #9: Culture Change #8: Data Monitoring and Management #7: Process and Policy Changes #6: Resource Sharing Top 10 Successes Identified Across All #5: Physician Engagement #4: Patient/Caregiver Engagement #3: Improved Communication #2: Forming Care Transitions Communities #1: Reduced Readmissions 5

6 Evidence-Based Care Transitions The Transitional Care Model (TCM) Re-engineered Discharge (RED) Care Transitions Intervention (CTI)* Project BOOST * INTERACT II * South Carolina Improvement Based on data comparisons between October 1, March 31, 2011 and October 1, March 31, 2012 SC hospital admissions of Medicare beneficiaries improved by 5.11percent SC hospital readmissions of Medicare beneficiaries improved by 4.36 percent * to be implemented (in part or fully) as a component of PART (Preventing Avoidable Readmissions Together) South Carolina Care Transitions Best Practices Community A Organizations Engaged: Two hospitals, >20 home health agencies and skilled nursing facilities, infusion services, wound center, dialysis centers, volunteer organizations RCA Overview: Poor communication between providers, lot of services available at the community level but not utilized, lack of standard transfer processes, wealthy population with younger (65-74) beneficiaries Interventions: Hired a care transitions navigator, provide transportation and lay health coaches, expanded disease management education Key Best Practices: RCA as a continuous process, meeting regularly as a community, inviting the care transitions community to grow, willing to work actively to make changes South Carolina Care Transitions Best Practices Community B Organizations Engaged: Two rural hospitals, two nursing facilities, 4 home health agencies RCA Overview: poor communication between providers; revolving readmissions from SNF; very poor, chronically ill population Interventions: Hiring an APN to follow discharges to home, HHA, or SNF for expanded disease management; SNF using communications tools designed by frontline staff and on the job (OTJ) training with nurses to prevent readmissions Key Best Practices: improved communications between hospital emergency department and SNFs, hospital working to meet needs of downstream providers so they can offer better care South Carolina Care Transitions Best Practices Community C Organizations Engaged: Three hospitals, Critical Access hospital, Federally Qualified Health Center RCA Overview: Disease burden in the population is critically high, need for coordinated aftercare, need for primary care Interventions: provide appointments with primary care physician prior to discharge, provide medications and DME to qualified patients, assist with transportation Key Best Practices: improving communication between providers as well as within hospital, inviting SNF and HHA as part of the community, welcoming suggestions for improvement and investing in changes. Link to Patient Centered Care Care Transitions Coalition Project Examples Hospital and FQHC are looking to connect care transitions with PCMH efforts. Home Health Work Group developed statewide education on when it is appropriate to refer to home health/hospice. Education was provided to physician practices, hospitals, and other facilities. Café to Home Program provided food for 3-5 days for limited number of patients upon discharge. Expanding disease management education upon discharge. 6

7 Link to Patient Centered Care Impact on Patient Centered Medical Home PCMH Element Must Pass Measure Examples of A Practice s PCMH Process Enhance Access/Continuity 20 Points Identify/Manage Patient Populations 16 Points Plan/Manage Care 17 Points Provide Self-Care Support/Community Resources 9 Points Track/Coordinate Care 18 Points Access During Office Hours Use Data for Population Management Care Management Support Self-Care Process Track Referrals and Follow- Up The practice provides electronic access. The practice identifies patients for proactive and point-of-care reminders. The practice addresses patient barriers to treatment goals. The practice works to include community resources. Identify patients with ER or hospital visits. Examples of Care Transitions Community Coalition Interventions Designated hospital staff scheduling follow-up visits with PCP. Practice prioritize scheduling acute care appointments as a part of open access protocols. Practice established hospital followup appointment slots Open Access. Community Coalition added transportation assistance for patients to get to PCP appt. Hospital hired care transitions coach for post-discharge follow up with PCP and specialists. Contact Information Mark Massing, MD, Ph.D., MPH Director of Research mmassing@thecarolinascenter.org Tanishah Nellom, MSPH Care Improvement Specialist tnellom@scqio.sdps.org Measure/Improve Performance 20 Points Implement Continuous Improvement Involves patients/families in quality improvement. Expanded disease management education. Source: CCME s Patient Centered Medical Home Chart- 10SOW-SC-C Questions? (NC) (SC) This material was prepared by The Carolinas Center for Medical Excellence (CCME), the Medicare Quality Improvement Organization for North and South Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-SC-C

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