Meal and Rest Period Issues. Changing Policies and the Transformation of Care. Jennie Chin Hansen RN, MSN, FAAN President, AARP. Current Health System

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1 Meal and Rest Period Issues 1 Changing Policies and the Transformation of Care Jennie Chin Hansen RN, MSN, FAAN President, AARP California Hospital Association San Diego, CA October 29, 2009 Current Health System 1

2 Hard to Navigate Even for Pros Health Reform Principles Access to affordable health care coverage, including Rx drugs without burdening future generations Choice in providers, to maintain independence at home or in community Quality improvement through comparative effectiveness research; greater use of HIT; reduction of preventable errors Chronic Conditions on Rise 60% 50% Medicare Beneficiaries % 30% 20% 10% 0% High Blood Pressure High Cholesterol Diabetes Cancer Mental Illness Back Problems Source: AARP. Beyond 50.09: Chronic Care: A Call to Action for Health Reform. Washington, DC

3 Spending per Chronic Condition Average Annual Spending for Adults 50+ $16,000 $14,000 $12,000 $10,000 $8,000 $6,000 $4,000 $1,425 $2,000 $0 $3,994 $5,411 $7,382 $10,293 $15, Number of Chronic Conditions Source: AARP. Beyond 50.09: Chronic Care: A Call to Action for Health Reform. Washington, DC publication forthcoming. 75% Spent on 5 Conditions Diabetes Congestive heart failure Coronary artery disease Asthma Depression Source: Health Care Reform Now!: A Prescription for Change, George Halvorson, CEO, Kaiser Foundation Health Plan, 2007 IOM Recommendations 2008 Interdisciplinary team care Chronic disease self-management Preventive home visits Proactive rehabilitation 3

4 Chronic Care Model-Wagner Self-management support Community resources Organization of health care Interdisciplinary teams Decision support Clinical information systems Source: AARP. Beyond 50.09: Chronic Care: A Call to Action for Health Reform. Washington, DC publication Consumer-Professional Communication Professionals educate consumers to: Manage medications Manage chronic condition(s) Stanford Chronic Self Care Model 13 state pilot Adopt healthy behaviors Coordinated Care Helps avoid unnecessary/costly treatments Provides more timely intervention Helps delay/prevent institutional care Helps support family caregiver 4

5 Program of All Inclusive Care for the Elderly (PACE) 1997 Originated at On Lok in San Francisco 1979 Community-based Comprehensive Capitated Coordinated PACE Philosophy: Honor Frail Elder Preferences Stay in familiar surroundings Maintain autonomy Maintain maximum level of physical, social, cognitive function Integrated Service Delivery & Team Managed Care Interdisciplinary Teams Social Services Pharmacy Home Care Activities Nutrition Primary Care Personal Care OT/PT Transportation 5

6 Capitated,, Pooled Financing Medicare capitation rate adjusted for frailty of PACE enrollees Integration of Medicare, Medicaid & private pay payments Location of PACE Programs PACE Lessons Learned Alignment: Goals Clear expectations by participant & family Agreed-upon plans, clinical, quality of life Goals & outcomes drive operating team structure Effective team communication Electronic Medical Records (On Lok since 1993) Role flexibility 6

7 Alignment: Incentives Staff Access to professional/paraprofessional services Ability to provide preventive & extended services that may not be reimbursable (therapy sessions, recreation) 24/7 care coordination & management to enable medical & social home Defined transition handoffs (5 pm Friday discharge can be handled routinely) Ability to use judgment/accountability without hoops PACE Lessons Learned: Current Policy Relevance Medical Home Care Coordination Transitional Care Accountable Care Organization(s) Issues of Scale & Cross Program (Medicare/Medicaid) Savings Medical Homes Patient centered One primary provider/practice Coordinated Convenient Timely Accessible Health IT 7

8 Medical Homes Round-the-clock access Periodic assessment Education/training for patients/caregivers Patient-Centered Medical Home American College of Physicians supports including nurse practitioner-led practices in Medical Home demonstrations/pilots National Committee for Quality Assurance (NCQA) developed criteria to qualify practices as Medical Homes Potential Savings 4 million hospitalizations, billions of dollars annually by improving quality of primary care & getting more Americans to adopt health behaviors. Agency for Healthcare Research & Quality (AHRQ) Medicare: $194 billion over 10 years if all fee-forservice patients enrolled in Medical Homes The Commonwealth Fund 8

9 Pilot Programs CMS implementing Medicare Medical Home demonstration project for 2009 in 8 states Private insurers: January, Horizon Blue Cross Blue Shield of New Jersey announced pilot with NJ Academy of Family Physicians American Academy of Family Physicians introduce national demonstration project TransforMED, 2009 Challenges Cost Provider payment Sweeping change Message Legislative Prospects 2007 Medical Homes Act American Recovery & Reinvestment Act 9

10 Necessary Investment Comparative effectiveness Health IT Accountability Pay-for-Performance Opportunity Waste in U.S. healthcare today equals 30% of total costs Geographic variations demonstrate no correlation between costs and quality Top Ten Savings Targets 1. Poor quality 2. Overuse 3. Lack of chronic care management 4. Overpayments 5. Duplication 6. Consumer behaviors 7. Failure to use lower-cost alternatives 8. Fraud & abuse 9. Administrative excesses 10. Public health challenges 10

11 Slowing Growth in Healthcare Spending Quality Initiate cost-containment measures to effectively constrain growth in price, volume, intensity of health care services No compromise to quality, inappropriate denial to access No incentives if shift costs to patients/other payers Payment Reform Incentives for good outcomes Robust risk adjustment Provider accountability Slowing Growth of Healthcare Spending: Readmissions 20% Medicare hospital patients readmitted within 30 days of discharge One third re-hospitalized within 90 days Medicare spends $17 billion on re-hospitalizations Slowing Growth of Healthcare Spending: Reduce Medications Mismanagement Cause 25% of nursing home admissions Medication Errors: NO progress in 10 years (HHS AHRQ) 11

12 Slowing Growth of Healthcare Spending: Falls $20 billion/year in direct medical costs Cost per fall = nearly $20,000 (includes hospitalization, nursing home, emergency room, home healthcare services when indicated) Slowing Growth of Healthcare Spending: Transitional Benefit Reduce hospitalizations/readmissions Better follow-up care Better caregiver support Help people self-manage treatment Provide comprehensive care plan Health Care Reform: Likely Legislation Connector National Health Exchange National standards for: Guaranteed issue/renewal No medical history underwriting or pre-existing condition exclusions Premiums vary only within clear & reasonable limits by: family composition, age, & geography More insurance $ to med services, not admin 12

13 Benefits of Reform: Delivery Medical Homes expanded significantly Incentives for MDs/hospitals coordinate care Value-based purchasing Health promotion incentives Quality reporting/rewards Chronic care reform Benefits of Reform: Innovation Flexibility granted for HHS Secretary to establish demonstration projects, move quickly to widespread implementation CLASS Act Community Living Assistance Services and Supports Act begins to lay groundwork for long-term care protection Benefits of Reform: Medicare Solvency Aims to bend cost curve downward 1½% per year Independent Medicare Commission (not Congress) given authority to adjust provider reimbursement Doughnut hole substantially filled New inspection and monitoring capacity to reduce fraud & abuse 13

14 Benefits of Reform: Improved Care More geriatric specialists More incentives More pay/benefits More mentoring, input, respect More informal caregiver training Opportunities for Post-Acute Providers Show value of current competency to impact quality & cost to Medical Homes, Episodes of Care, Accountable Care Organizations Show how your competencies allow you to do good & patients to do well 14