THE BRIDGE MODEL. Walter Rosenberg, MSW, LCSW Manager of Transitional Care Rush University Medical Center Health and Aging

Transcription

1 THE BRIDGE MODEL Walter Rosenberg, MSW, LCSW Manager of Transitional Care Rush University Medical Center Health and Aging

2 "If patient engagement were a drug, it would be the blockbuster drug of the century, and malpractice not to use it." - Leonard Kish

3

4 POST-ACA

5

6 Triple Aim of Health Reform: Focus on Value

7 Volume vs. Value Traditional Fee-for-Service Payment System Direct Contracts with Employers Option on the Health Exchange Medicare Advantage Plan Population Health Per Capita Payment System Readmission Rate Penalties Bundled Payment Pilots Accountable Care Organizations Adapted from Ian Morrison

8 Forces at Play Consumerism CVS Walmart Immediate care Population health Accountable Care Organizations Managed Care The ACA and the newly insured Value-based Purchasing

9 Fundamental Change These efforts require interprofessional teams Physicians are critical - but others needed too Nurse practitioners Physician s assistants PT, OT Social workers Nutritionists Pharmacists Direct care workers Many more Also requires community support systems, innovative care models

10 BRIDGE HISTORY AND DESCRIPTION

11 In The Beginning Rush University s Enhanced Discharge Planning Program (EDPP) 2005 Pilot started with discharge planner concerns Approx. 2,500 patients served 2009 Randomized Controlled Trial (n=720) Aging Care Connections' Aging Resource Center A response to concerned field case managers meeting with clients in need post-discharge Successfully integrated the community INTO the hospital to capitalize on the servable moment and maintain a patientcentered care transition

12 Bridge Replication Sites North Dakota Aging Services Division Illinois Hospital Assoc. partnership across State 26 Sites Chicago & Suburbs, IL 6 Aging Network (CBOs), 2 hospitals Lansing, MI 2 Sites; Aging Network (AAA) Detroit, MI 1 Site; Housing Ottawa, Canada 1 Site; Hospital Washington 4 Sites: Aging Network (AAAs), hospital system Brooklyn, NY 1 Site; CBO Carbondale and Herrin, IL 3 sites; Aging Network (CBO) Philadelphia, PA 2 Sites; Aging Network (AAA) San Fernando, CA 3 sites; CBO (CCTP) Texas 2 Sites: Aging Network (AAAs) Danville, IL 2 Sites; Aging Network (CBO) (CCTP) Georgia 6 Sites; Aging Network (AAA)

13 Bridge Model National Office (BMNO) Bridge Model Collaborative National advisory board Experts from a broad spectrum of backgrounds Physicians, Pharmacists, Foundations, Government, Research Program management team Maintain model fidelity Update training materials Conduct trainings

14 Building Blocks of Bridge

15 The Typical Transition Hospital Community Physicians Discharge Planner Home Health Providers PCP Specialists Nursing Staff Other Services Community Based Services Other Outpatient Care Hospital and Community providers are fragmented across disciplines and settings

16 The Quarterback Hospital Community Physicians Nursing Staff Discharge Planner Other Services BCC, Patient, Caregiver Home Health Provider Community Services PCP Specialists Other Outpatient Care Hospital and Community providers communicate across disciplines and settings under the facilitation of a care coordinator

17 Bridge Model Phases Model Findings (n ~3,000) Readmission decrease 20+% Mortality decrease 13+% Physician follow-up 75%

18 Community-specific focus BCCs must be experts in the community Aging network Community organizations Faith-based and volunteer groups Non-traditional resources Cultural humility Impact on treatment plan Home remedies Decision-makers

19 Social Work Clinical Skills Bridge relies on expertise of master s-prepared social workers Person-in-Environment perspective Client-centered interviewing Motivational interviewing, Acceptance and Commitment Therapy, Cognitive Behavior Therapy Stages of change Cultural humility

20 QUALITY IMPROVEMENT AND OUTCOMES

21 Lean transitional care

22 Continuous Quality Improvement Process data Identified needs and Interventions utilized Number per case Top three (or four, or five ) Relationship status (Excel) Most frequently utilized providers Five best and worst Cases per month Length per case Outcome data Readmissions Physician follow-up ER utilization Mortality

23 Bridge Impact

24 Community-based Care Transitions Program ( ) Impact of Bridge on readmissions at six sites in Chicago area (n=5,753) 30-day: 30.7% fewer (vs. baseline) 60-day: 9.4% fewer (vs. weighted hospital average) 90-day: 13.9% fewer (vs. weighted hospital average) 30.0% 25.0% 20.0% 15.0% 10.0% 30-day Readmission Rates Bridge recipient 30-day readmission rate Baseline 30-day readmission rate for target population: 25.4% 5.0% 0.0% 2012 Q Q Q Q Q Q Q Q1 Mean Bridge recipient readmission rate: 17.6% *CMS disclaimer: The readmission data presented here are calculated using raw, unadjusted Medicare claims for the specified periods of time. They do not indicate impact or take trends or other initiatives into consideration. These metrics are provided by CMS for performance monitoring purposes only and while they inform evaluative results, they do not constitute the entirety of the program evaluation.

25 Readmission Reduction Number of Patients High Utilizer Pilot 30-day Readmission Reduction 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 % Reduction 11.6% 0.6% 29.6% 12.3% 42.3% 18.5% 21.0% 40.0% Average 22.0% 22.0% 22.0% 22.0% 22.0% 22.0% 22.0% 22.0% Number of Medicare High-utilizers at Rush Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 High-utilizers High-utilizer 5 or more admissions within a calendar year Less than 3% of the patient population, but responsible for nearly 50% of the readmissions Additional protocols added to Bridge Care Coordination Calls Longer-term support

26 THANK YOU Walter Rosenberg, MSW, LCSW