TRANSITIONS: Improving Care for High-Risk Medicaid Beneficiaries in Tompkins County

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1 TRANSITIONS: Improving Care for High-Risk Medicaid Beneficiaries in Tompkins County Aging Concerns Unite Us Conference June 7, 2016 Lisa Holmes, Tompkins County Office for the Aging Sue Ellen Stuart, Visiting Nurse Services of Ithaca and Tompkins County 1

2 Why Care Transitions? 2

3 National Data on Hospital Readmissions New England Journal of Medicine (2009): Nationally, 1 in 5 Medicare beneficiaries are readmitted within 30 days following hospitalization Medicare cost of over $17 billion annually Heart failure, pneumonia, COPD were among most frequent medical diagnoses of patients readmitted Half of patients readmitted had no physician contact within 30 days post- discharge 3

4 National Data on Hospital Readmissions Medicaid patients have readmission rates as high or higher than Medicare patients 25% of Medicare patients with CHF returned to hospital in 30 days; 33% Medicaid patients. Medicaid readmission patterns: more behavioral health conditions, socio-economic factors affecting access, substance abuse. Agency for Healthcare Research and Quality 4

5 Tompkins County s Previous Care Transitions Experience CMS Community Based Care Transitions Program (CCTP) Goal: To reduce hospital readmissions among Medicare FFS beneficiaries by 20% Strategy: Collaboration of multiple community agencies facilitated and led by Tompkins County Office for the Aging: including VNS, Hospice, Cayuga Medical Center 5

6 CCTP Partners Tompkins County Office for the Aging: lead agency, coordination, reporting, billing Cayuga Medical Center community hospital Visiting Nurse Services coaching Hospicare coaching 6

7 Care Transitions Intervention Developed by Dr. Eric Coleman of the University of Colorado Designed to encourage older patients and their caregivers to assert a more active role during care transitions Low cost Low intensity Easily adaptable Short 30 days with 1 home visit and 3 phone calls 7

8 The Four Pillars of CTI 1. Medication self-management 2. Follow-up with PCP/Specialist 3. Knowledge of red flags or warning signs/symptoms and how to respond 4. Patient-centered medical record Transitions Coach is used to build skills, confidence and to provide tools to support self-management Model behavior for common problems Practice or role play for health care encounters Create an accurate medication list 8

9 Tompkins CCTP: Challenges and Lessons Learned Challenge: Low patient volume Smallest CCTP site in nation, small rural hospital Could only bill for Medicare FFS inservice patients (no Medicare Advantage or observation stays) Restrictive eligibility based on patient diagnosis: originally CHF, COPD, Pneumonia; later CMS granted permission to broaden criteria to include additional diagnoses, age, polypharmacy and social factors Lesson Learned: Cast a wide net Broaden targeting criteria to be all-inclusive 9

10 Tompkins CCTP: Challenges and Lessons Learned Challenge: Patient identification and referral Few referrals among hospital discharge planners Turnover among key hospital staff and leadership No direct access to charts/ medical records Communication of protected health information between partners a challenge Lesson Learned: Embed transitions staff in hospital system Staff credentialing at hospital (this took a champion ) Daily rounds Access to electronic medical records 10

11 Tompkins CCTP: Challenges and Lessons Learned Challenge: Too many cooks Two agencies involved in hospital case finding and inhome coaching Complex communication, information dropped Paid per coaching session: agencies losing money on staff time in rounds Lessons Learned: Streamline Right-size program to one agency 11

12 Tompkins CCTP: Challenges and Lessons Learned Challenge: Patient acceptance of intervention Patients declining intervention in hospital Patients accepting in hospital, declining when home Lesson Learned: Present program as standard part of discharge Schedule home visit while in hospital if possible Utilize same person to introduce program to patient to conduct home visit when possible 12

13 Tompkins CCTP Results Goal: reduce hospital readmissions of Medicare patients by 20% in 2 years Program served 85 patients total Though good results for individual patients, not enough volume to create impact CCTP contract period ended 5/31/14 13

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15 From CCTP to BIP BIP Innovations Fund: NYSDOH Target: Medicaid beneficiaries Goal: To increase access to community-based care options over institutional settings Tompkins submitted application: May, 2014 Notification of grant award: July, 2014 Start of service: Sept

16 Structure of BIP Transitions Program Tompkins County Office for the Aging: lead organization, coordination, reporting. Cayuga Medical Center community hospital Visiting Nurse Service coaching CAP CONNECT clinical integration organization, marketing, outreach, data analytics 16

17 Structure of BIP Transitions Program Studied hospital data on Medicaid readmission patterns In addition to chronic diseases, behavioral health issues, substance abuse, health literacy issues, barriers in accessing community supports Modified model to suit needs of Medicaid patients 17

18 Structure of BIP Transitions Program Modified Coleman approach: 1 or more home visits by an RN with physician s order Importance of medication reconciliation by RN Medicaid-reimbursable service: sustainable after grant period ends Available to ALL Medicaid patients who could benefit Including behavioral health patients Including patients discharged home from 2 large skilled nursing facilities Referrals accepted from community physicians 18

19 Goals of BIP Transitions Program 1) Raise awareness of Transitions Program among clinical partners/referral sources Outreach through CAP Connect 2) Foster case finding and patient introduction to Transitions Program Active involvement at daily rounds by VNS 19

20 Goals of BIP Transitions Program 3) Improve health outcomes and reduce avoidable 30 and 90 day ED visits and inpatient admissions Serve Medicaid beneficiaries with 1+ home visits by Transitions nurse, using modified Coleman approach 4) Ensure program stability beyond grant period Establish referral patterns to ensure program is regularly utilized beyond grant period 20

21 BIP Transitions Program Marketing 21

22 BIP Transitions Program Marketing 22

23 BIP Transitions Program Marketing 23

24 Patient Testimonials Vaness Joanne Andrew Martha 24

25 BIP Transitions Program Implementation 25

26 BIP Transitions Program Results ED Utilization: Number of ED Visits Per Enrollee Through December Days Prior 30 Days Prior 30 Days Post 90 Days Post

27 BIP Transitions Program Results Inpatient Utilization: Number of Inpatient Stays Per Enrollee Through December 90 Days Prior 30 Days Prior 30 Days Post 90 Days Post

28 BIP Transitions Program Results Estimated program savings through December 31st, 2015 ED visits per patient 90 days prior to enrollment = 2.31 ED visits per patient 90 days post enrollment = 1.28 Estimated ED visits prevented = 1.03 visits Number of patients enrolled = 137 Average charges for a Medicaid ED visit* = $ Estimated program savings related to preventable ED visits = $49, *This number based on the average charges for a Medicaid ED visit based on the 2013 Medicaid fee schedule 28

29 BIP Transitions Program Results Estimated program savings through December 31st, 2015 Inpatient admissions per patient 90 days prior to enrollment = 1.24 Inpatient admissions per patient 90 days post enrollment = 0.45 Estimated Inpatient admissions prevented per patient = 0.79 Number of patients enrolled = 137 Average charges for a Medicaid inpatient visit* = $3, Estimated program savings related to preventable inpatient admissions = $324, *This number based on the average charges for a Medicaid inpatient visit based on the 2013 Medicaid fee schedule 29

30 BIP Transitions Program Results Estimated total cost savings from September 2014 through December 31st, 2015: $374,

31 The Future of the Transitions Program Program infrastructure and procedures remain in place Transitions will be the model used for DSRIP Care Transitions project in Tompkins County Program details shared with Care Compass Network for consideration throughout DSRIP PPS. 31

32 VNS Role 1. Pt. Identification & Hospital Visit 2. Home Visits 3. Follow up Phone Calls 4. Referrals to other agencies 5. Integrating techniques to enhance results such as motivational interviewing 32

33 Identification of Medicaid Recipients Access & Review Hospital Census each morning Identify all newly admitted Medicaid patients Review identified patients at hospital rounds and discuss with discharge planning team to identify patients appropriate for the program. 33

34 Approach Medicaid Patient in the hospital about the program It has been determined through the Coleman project that the program is more successful if the same person making the home visits also approaches the patient in the hospital. This begins to develop trust in the relationship and more success in ensuring the home visit. There is usually a 50% acceptance rate. 34

35 Transitions Nurse called discharged patient and set up visit within 3 days of discharge This has been a challenge for the program! Medicaid recipients tend to be more mobile and not as likely to answer their phones or to be reached (or found) after discharge. Early in the program, Transitions RN would visit even if not reached on the phone first usually without success and this practice was stopped. Saw on average, 39% of patients that accepted the program in the hospital. 35

36 Home Visit Based on Four Pillars of CTI 1. Medication self-management 2. Follow-up with PCP/Specialist 3. Knowledge of red flags or warning signs/symptoms and how to respond 4. Patient-centered medical record 36

37 MEDICATION RECONCILIATION The key for our project was medication reconciliation by an RN which differed from the Coleman Model which did not require an RN for the coach. 37

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43 used. It is the responsibility of the nurse to Call the physician to reconcile any discrepancies 43

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49 Medication Tools for the Patient 49

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51 Steps to assure MD appointment Ascertain whether patient has a follow-up appointment with MD Confirm appropriate MD responsible managing patients Work with patient to schedule the appointment Discuss barriers to appointment including transportation and scheduling with family member, caregiver or friend Confirm/assist with transportation arrangements Provide appointment reminders and work with patient to put appointment information in a convenient place Confirm patient s use of personal health record Use coaching to encourage patient/caregiver to understand importance of scheduling the appointment Confirm that patient understands to take medication list 51

52 Physician Visit 52

53 Knowledge of red flags or warning signs/symptoms and how to respond Red Flags worksheets are disease specific Many free resources to find Red Flags including : 53

54 Red Flags-COPD 54

55 Red Flags Heart Disease 55

56 Red Flags- High Blood Pressure 56

57 Personal Health Record Booklet given to Patient to take to MD visits. Coach Provides Assistant to complete 57

58 Personal Health Record 58

59 Personal Health Record 59

60 Personal Health Record 60

61 Personal Health Record 61

62 Personal Health Record 62

63 Patient Activation 63

64 Follow Up Phone Calls 64

65 Important Components incorporated into the Program Teach Back Motivational Interviewing Health Literacy 65

66 Teach Back 66

67 Motivational Interviewing Designed to enhance client motivation to change Especially effective for patients that are stuck not making recommended health related behavior changes MI is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence MI helps activate the patient s own motivations to change 6 Source: Rollnick, Miller, and ButlerInterview: Motivational ing in Healthcare

68 Motivational Interviewing Collaboration through COACHING: An approach of partnering with patients to enhance self-management strategies for the purpose of preventing exacerbations of chronic illness and supporting lifestyle change (Huffman, 2007, p. 271). 68

69 Motivational Interviewing 69

70 Motivational Interviewing 70

71 Motivational Interviewing 71

72 Health Literacy 72

73 Health Literacy 73

74 Health Literacy 74

75 Resources List of websites to access resources :

76 Questions? 76