National Coalition on Care Coordination (N3C) Care Coordination and the Role of the Aging Network. Monday, September 12, 2011

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1 National Coalition on Care Coordination (N3C) Care Coordination and the Role of the Aging Network Monday, September 12, 2011 Washington, DC Hyatt Regency on Capitol Hill Yellowstone/Everglades 4:00 PM 5:15 PM

2 Growth in Population of Older Americans & Increase in Chronic Disease The population of older adults is rapidly increasing: By 2030, the number of Americans over 65 is expected to reach 72 million, double the 65+ population of 2003 Older adults are at high risk for chronic conditions including cardiovascular disease, diabetes, and cancer, that require ongoing medical management Chronic conditions result in high health care costs and reduced quality of life

3 Psychosocial Issues also Common A significant subset of older adults also face substantial psychosocial issues, including: Depression, limited mobility, and diminishing finances and/or cognitive skills These issues add to service needs, plus Complicate access to and effective utilization of health and medical services

4 Delivery System Problems Health care systems (public and private) need improvement, especially chronic care delivery Barriers to improvements in care for people with chronic conditions include: Fragmented care delivery, Poor transitions across settings, and Poorly aligned payment incentives that fail to recognize the value of better integration of services S Reinhard, PPI, AARP

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6 Delivery System Problems Medicare is not perfect and needs improvement Care is not well coordinated, particularly for those with chronic conditions Fee-For-Service payments encourage over utilization of services S Reinhard, PPI, AARP

7 The Genesis of the National Coalition on Care Coordination (N3C) The American Society on Aging (ASA), and the New York Academy of Medicine (NYAM), Social Work Leadership Institute (SWLI) convened a distinguished group of thirty experts from health, human services and long-term care prior to the 2008 ASA Annual Conference on Aging to address key issues in care coordination. The meeting resulted in the formal establishment of the National Coalition on Care Coordination (N3C). Today consists of 40 members

8 2011 N3C Membership Steering Committee: American Geriatrics Society National Council on Aging (NCOA) American Society on Aging National PACE Association Consumer Coalition for Quality Health Care New York Academy of Medicine Matz, Blancato & Associates Partners in Care Foundation Medicare Chronic Care Practice Research Network (MCCPRN) Members: American Association of Retired People Long Term Care Educational Foundation, Area Agency on Aging (Mid-Columbia) George Mason University American College of Physicians National Academy of Certified Care Managers American Medical Association National Alliance for Caregiving Benjamin Rose Institute National Association of Professional Geriatric Care Managers Case Management Society of America National Association of Area Agencies on Aging (n4a) Center for Health Care Strategies National Association of States United for Aging Center for Medicare Advocacy, Inc. and Disabilities (NASUAD) Connecticut Community Care, Inc. National Transitions of Care Coalition COPE Health Care Strategies Paraprofessional Healthcare Institute (PHI) Family Caregiver Alliance Rush University Medical Center Gerontological Society of America SCAN Health Plan Hudson Health Plan SeniorBridge Health and Medicine Policy Research Group Society of Hospital Medicine Illinois Coalition on Aging University of Illinois College of Nursing LeadingAge (formerly American Association of University of Pennsylvania School of Nursing Homes and Services for the Aging) Urban Institute

9 N3C Accomplishments Over its history has convened major sessions at the 2009, 2010 and 2011 American Society on Aging conferences Convened additional meetings with stakeholders in Washington D.C. Commissioned papers discussing current models of care coordination Maintained a visible presence working with relevant individuals in Congress and the Administration in the following areas:

10 N3C Accomplishments cont d During development of language in the Affordable Care Act Implementation of the ACA including filing comments on proposed rules including and meetings with offices such as CMMI Meeting with Administration officials and appropriate Congressional staff on the upcoming reauthorization of the OAA

11 N3C Mission and Goals Improve the quality of life for vulnerable older adults by promoting care coordination as an essential part of health care reform. Convene experts from health, long term care, aging and public policy to develop consensus on effective models of care coordination and build evidence for the effectiveness of care coordination. Understand how expertise of coalition members can be most effectively utilized. Identify opportunities to work with coalition members as allies, thought partners, and policy advocates.

12 N3C Mission and Goals, cont d Develop evidence based specifics about Care Coordination, its benefits, and personnel qualifications. Educate federal and state policy makers on care coordination. Provide interested parties with specifics about the role and benefits of care coordination as part of health care reform.

13 N3C Definition of Care Coordination Care coordination is a person and family-centered, assessment-based, interdisciplinary approach to integrating health care and social support services in a cost-effective manner in which an individual s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an evidence-based process which typically involves a designated lead care coordinator.

14 N3C research/ SWLI review of current programs The majority of programs described in the literature originate in the health care system: Created and implemented either by an insurer or a health provider system Programs implemented by community based organizations appear to be under-represented in the literature We know there are a lot of them; they are not being evaluated and reported on as frequently as medicalbased programs

15 Population Served Programs included serve a diverse population of older adults with respect to: Physical health Mental health and cognitive function Available social support Location (e.g. rural/urban)

16 Setting for Service Delivery Includes:* Clinics Home Adult Day Centers Senior Centers VA Medical Centers Phone * SWLI review focused on community and home-based programs. Hospital-based and residential care programs were excluded by search criteria

17 Program Staffing Commonly nurse lead, with an interdisciplinary team that may include MDs, pharmacist, OT/PT, dietician, social worker community liaison, psychiatrist, psychologist Care manager often works in conjunction with or maintains communication with primary care provider

18 Program Services Baseline and ongoing assessment* Development of individualized care plan* Care management* Communication with PCP* Referrals to medical and supportive services* Medication management Health education Mental health services Communication/advocacy with health care provider Discharge planning Caregiver support * Most commonly included in reviewed programs

19 Care Coordination Program Objectives Improved service utilization Increased use of social and community supportive services and outpatient services Less ER use Fewer and shorter hospital and nursing home stays Improved (or sustained) health, functioning, mental health, and quality of life for care recipients Reduced caregiver burden Improved knowledge and behaviors, including chronic disease self management Reduced health care costs Satisfaction with services

20 Program Outcomes Outcomes measured vary widely between articles Most common positive outcomes include improved service utilization, functioning, mental health, quality of life, satisfaction with services, and reduced caregiver burden Among articles reporting cost outcomes, program costs may be offset by reductions in the cost of institutional services

21 Effective Practices Analysis is ongoing and difficult due to variability in program structure, services, and outcomes measured Preliminary findings regarding effective practices include Program targeting to identify the population who can most benefit from a given intervention Baseline and ongoing assessment of health and social needs Interdisciplinary approach to allow providers to address a spectrum of health and social service needs Enhanced communication among providers, frequently including the primary care physician Flexible provision of services and service intensity Connection to existing community health and supportive services

22 Effective Practices (continued) Although less frequently reported on, literature also highlights the importance of: Shared electronic health record Evidence-based protocols to assess health and social condition and develop care plan Technology-assisted, in-home monitoring (by telephone or remote health monitoring systems) to enhance communication between community-dwelling older adults and providers, especially in rural areas

23 Promising models include: Geriatric Resources for Assessment and Care of Elders (GRACE) After Discharge Care Management of Low Income Frail Elderly (AD-LIFE) Both models improve the quality of care for low income seniors by the longitudinal integration of geriatric and primary care services across the continuity of care Integration with affiliated pharmacy, mental health, hospital, home health, and community-based services

24 Where N3C Advocacy for Care Coordination and Support for New and Existing Models of Care Has Succeeded Advocated Care Coordination as central focus of provisions in PPACA targeting older adults o Center for Medicare Innovation o Support for new and existing models of care coordination (PCMH, Independence at Home and others) Focused on evidence in support of care coordination o Center for Medicare and Medicaid Innovation focus on best practices and evidence-based measures Focused attention on the challenges for the reimbursement mechanisms that support care coordination o Bundled payments and value based purchasing (Medicare Accountable Care Organizations and shared savings)

25 Where N3C Succeeded, Cont d Focused on vulnerable populations and integration of health and long term care o Care coordination models for dual eligibles focus on integration of health and long term care Long-term care measures o Class Independence Benefit Plan o Continued support for Aging and Disability Resource Centers Support for home and community based services o Community based health teams in Patient Centered Medical Homes (PCMH), Community-Based Care Transitions Program, ADRC Support

26 Federal Initiatives to Support State/Community-Based Approaches to Coordinated Care

27 The Aging Network _Structure_Program.pdf

28 Wagner s Chronic Illness Model Change that Works Self- Management Support Health System Organization of Health Care Decision Delivery Support System Design Clinical Information Systems Informed, Activated Patient Productive Interaction s Prepared, Proactive Practice Team Improved Functional and Clinical Outcomes

29 Overview Alignment through implementation of the Affordable Care Act Strategic Framework on Multiple Chronic Conditions National Quality Strategy Federal HIT Strategic Plan Partnership for Patients Themes recurring across multiple initiatives: Importance of care coordination Focus on care transitions Role of community-based services Focus on the patient and family caregivers Triple Aim: Better care, better health, lower cost J Howell, ONC

30 National Quality Strategy Aims Better Care: Improve quality, by making health care more patient-centered, reliable, accessible, and safe Healthy People and Communities: Improve health of population Affordable Care: Reduce cost of quality health care Six Priorities and Goals to help focus public and private efforts: Safer Care: eliminate preventable health care-acquired conditions Effective Care Coordination Person- and Family-Centered Care Prevention and Treatment of Leading Causes of Mortality: prevent and reduce harm caused by cardiovascular disease Support Better Health in Communities Make Care More Affordable National Quality Strategy

31 Partnership for Patients Public-Private Partnership to make care safer, potentially save up to $50 billion Two Goals of the Partnership: Keep hospital patients from getting injured or sicker: decrease preventable hospital-acquired conditions 40% by 2013 cf Up to $500M from CMS Innovation Center Help patients heal without complication: decrease preventable complications during transition from one care setting to another so that hospital readmissions will be reduced 20% by 2013 cf Up to $500M available through Community-Based Care Transitions Program authorized by Section 3026 of ACA J Howell, ONC

32 Partnership for Patients: Community- Based Care Transitions Program 5 years beginning April 12, 2011; rolling application process Program Goals: Improve the quality of care transitions Reduce readmissions for high-risk Medicare beneficiaries Document measureable savings to the Medicare program by reducing unnecessary readmissions Creates source of funding for effectively managing transitions from acute to community-based settings Eligible entities paid on per-discharge basis for Medicare benes at high risk of readmission, including those with multiple chronic conditions, depression, or cognitive impairment. J Howell, ONC

33 Community-Based Care Transitions Program: Selection Criteria Preference given to Administration on Aging grantees that Provide care transition interventions in conjunction with multiple hospitals and practitioners Provide services to medically-underserved populations, small communities, and rural areas Applicants must Identify root causes of readmissions and define target population and strategies for identifying high-risk patients Specify transition interventions, including improving provider communications and patient activation Indicate how community and social supports and resources will be incorporated to enhance beneficiary post-hospitalization management outcomes J Howell, ONC

34 State Demonstrations to Integrate Care for Dual Eligible Individuals Partnership between Federal Office of Integrated Care and the Innovation Center Testing delivery system and payment reform that improves the quality, coordination, and cost-effectiveness of care for dual eligible individuals. On April 14, 2011, 15 states awarded contracts for up to $1million to design new models for serving dual eligibles: West: California, Colorado, Oregon, Washington Midwest: Oklahoma, Michigan, Minnesota, Wisconsin South: North Carolina, South Carolina, Tennessee East : Connecticut, New York, Massachusetts, Vermont Models will be person-centered and fully coordinate primary, acute, behavioral and long-term supports and services. J Howell, ONC

35 CLASS ACT CLASS ACT and care coordination: Based on the model in the Federal Long Term Care Insurance, N3C will work to have care coordination as a benefit in the LTSS package.

36 Bundled Payment Described as the health care reimbursement middle ground between fee-for-service and a capitated payment system. CMS introduced the Bundled Payment for Care Improvement initiative and is seeking applications for different models of bundled care Participants in models would set a target for reimbursement, test new models of care, receive payment for services under the traditional fee-forservice system, and at the conclusion of an episode share in the savings compared to the target price. Letters of intent due Sept. 22

37 CARE COORDINATION AND THE OLDER AMERICANS ACT N3C has recognized the reauthorization of the Older Americans Act is an ideal opportunity to strengthen links between health and long term care and the medical and social models of care. The OAA, through the Aging Network, is a pioneer in development of coordinated services for older adults. Through State Units on Aging, Area Agencies on Aging, service providers, and Aging and Disability Resource Centers

38 Care Coordination and the OAA Reauthorization In anticipation of reauthorization, N3C submitted a paper to Administration on Aging proposing changes to OAA to strengthen care coordination: N3C s recommendations are based on the principle that care coordination must: be assessment driven, include a comprehensive care plan, require ongoing evaluation, and utilize a qualified care coordinator

39 Care Coordination and the OAA Definition: The OAA should include care coordination within its definitions of its programs and services. In particular ADRC s. Integration: The OAA should encourage SUA s and AAA s to integrate care coordination into their plans. The care coordinator should be widely accessible The care plan should be client centered

40 Care Coordination and the OAA Administration: The Assistant Secretary should work with the Administrator of CMS to coordinate efforts and develop ways to ensure that older adults with multiple chronic illnesses receive coordinated care. This can include sharing best practices and disseminating information to the network and health care providers. AOA should ensure a standardized process that the aging network uses to build and Improve linkage between social and medical/health services.

41 Care Coordination and the OAA Title III: Support improved outreach by area agencies with health and medical care entities around care coordination Title IV: N3C supports testing of care coordination models under Title IV subject to funding as well as develop appropriate training curriculums.

42 OAA Reauthorization U.S. Senate Subcommittee on Primary Health and Aging in the Health, Education, Labor and Pensions committee held listening sessions on the Older Americans Act Brian Lindberg presented N3C s care coordination recommendations on August 23 Status of OAA reauthorization remains unclear.

43 Further Information Websites: General Innovation Center SWLI/N3C For Questions:

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