AN OPPORTUNITY TO INTEGRATE NUTRITION SERVICES IN YOUR LOCAL HEALTHCARE SYSTEM
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1 AN OPPORTUNITY TO INTEGRATE NUTRITION SERVICES IN YOUR LOCAL HEALTHCARE SYSTEM KIMBERLY K. DELP, RN BSN January 26, 2017 AN OPPORTUNITY TO INTEGRATE NUTRITION SERVICES IN YOUR LOCAL HEALTHCARE SYSTEM 1
2 WELCOME Ask Questions Using the Box on the Control Panel OBJECTIVES Integrate your nutritional support program into a healthcare delivery model. Determine what data/outcomes will allow the effectiveness of your program s nutrition interventions to reduce the use of healthcare costs. Identify ways you can make it easier for healthcare entities to work with you. Learn how to successfully approach the evaluation of your nutrition intervention program. 2
3 OUR HEALTHCARE DELIVERY MODEL OUR PARTNERS Healthcare providers i.e. Hospitals, Social Workers, Case Management, Physicians, Home Health/Hospice Providers Insurers/Contracts Community Stakeholders Funders i.e. Foundations, Donors Patients & Caregivers COMPELLING RESEARCH WHY? NATIONAL DATA Long-term expenditures billion, 346 by % expenditures in Community Based Services 2/3 healthcare dollars spent on chronic illness >65 yrs. 68% deficient in 2 or more ADL s 35% will enter a SNF before they die >85 yrs. Is the fastest growing population 3
4 POST ACUTE NUTRITIONAL SUPPORT WHY? BACKGROUND Malnutrition is common upon admission and declines during hospitalization Poor nutrition increases the risk of re-hospitalization Common conditions for unplanned 30-day readmissions include: Myocardial Infarction, Congestive Heart Failure and Pneumonia (CMS AHRQ QualityNet) HEALTHCARE MODEL GOALS Reduce unplanned hospitalization Prevent Hospital, Skilled Nursing Facility (SNF) and/or Homecare Healthcare penalties Identify early interventions Educate payers that Community Based Services are cost effective Start services quickly 4
5 HEALTHCARE DELIVERY MODEL GOALS CONTRACTS WITH INSURERS Integrate nutritional support into Managed Long Term Services & Supports Prevent SNF admissions - long and short term Develop Value Add/Early interventions Reduce utilization of Hospital & Urgent Care Centralize ordering & contracting POSITIONING YOUR PROGRAM IN THE COMMUNITY Find funding to start/maintain early intervention Help support clinical integration into your program Secure donations and marketing support Engage in pilot & research projects Provide assistance with documenting results 5
6 POSITIONING YOUR PROGRAM IN THE COMMUNITY Perceptions & Expectations of clients and caregivers Relationships of delivery staff to recipient Value of frequent touches Cost effective OUR HEALTHCARE DELIVERY MODEL ACTION STEPS Define program as nutritional support, not as meal delivery Develop Standards of Care Activate a Change of Condition tool Document alerts, interventions & outcomes Compare and report results (hospitals, insurers etc.) Educate internal/external staff about reporting protocols 6
7 CHANGE OF CONDITION TOOL WHY? Standardize Alerts i.e. - Health Status - Falls - Loss of Caregiver - Appearance - Living Arrangement, - Poor Nutrition - Emergency Report and Record Alerts Assure prompt Follow Up OUR CHANGE OF CONDITION TOOL Find an intervention specialist (clinical & social) Define protocols for interventions Record interventions Calculate impact of interventions Report interventions in cost savings 7
8 CHANGE OF CONDITION TOOL IMPORTANT STEPS Develop staff education Secure buy-in Assure staff understands alerts and feedback on alert Make it a simple process OUR CHANGE OF CONDITION APP 8
9 POLLING QUESTION 1 Question: How does the delivery driver of your Meals on Wheels program report an observed change of condition in a client? Response: (multiple answers) Alerts a MOW staff member of their observation Notifies through an electronic or mobile alert system Utilizes a paper log to be entered in MOW database We do not have a formal process/protocol HEALTHCARE COST REDUCTION DATA COLLECTION Change of Condition alerts Interventions i.e. Referrals to primary care physicians (PCPs), home healthcare, home modifications, transportation, referrals to county programs, medication management. Develop a system to record and document Identify planned vs. unplanned hospitalizations 9
10 HEALTHCARE COST REDUCTION DATA COLLECTION Follow up on undelivered meals promptly Document interventions that decrease SNF/hospital admissions Document interventions that keep folks in their own homes HEALTHCARE COST REDUCTION CASE SCENARIO ALERT: Gerri is a 84 year old female living alone c/o foot pain and difficulty ambulating. Health status alert posted from delivery staff. INTERVENTION: Call from intervention specialist finds wound and fall risk. Discussion with PCP and orders obtained for home health RN, Physical Therapist and wound care all covered by medical insurance. RESULTS: Prevention of hospitalization due to early intervention. 10
11 POLLING QUESTION 2 Question: Do you evaluate the outcomes (impact) of your interventions? Response: Yes No COMPONENTS OF AN EVALUATION TOOL THREE QUESTIONS THAT NEED ANSWERING How the Change of Condition is implemented? How is the intervention perceived by the recipients? To what extent has the Change of Condition monitoring been successful in achieving goals of preventable hospital/snf admissions and getting timely attention to seniors health issues? 11
12 COMPONENTS OF AN EVALUATION KEY FACTORS Compare data for regular MOW clients to CoC pilot group Compare early interventions results Obtain input from program staff and recipients Compare admission rates for SNF/Assisted Living Facility (ALF)/Hospitals at 30, 60 & 90 days (avg. cost per event) Plan for scalability PILOT PROJECT POST ACUTE NUTRITIONAL SUPPORT PROGRAM 150 individuals discharged from 2 hospitals 30 days nutritional support & Change of Condition monitoring Diagnosis of Congestive Heart Failure, s/p Myocardial Infarction (MI) and Pneumonia Goal: Prevent re-hospitalization within 30 days 12
13 POST ACUTE NUTRITIONAL SUPPORT RESULTS 150 enrolled, 88 urban hospital, 62 suburban hospital Median age 74, 63% female, 71% not married 40% received additional services of home healthcare upon discharge. Most common insurance was Medicare or Medicare Advantage plan Meal started within 5 days, only 9% cancelled POST ACUTE NUTRITIONAL SUPPORT RESULTS Total sample, over 30 days following discharge 2.7% were treated in emergency departments; and % were readmitted to the hospital Readmission rate comparison - Congestive Heart Failure % (national rate 20.2%) - Myocardial Infarction 9.1% (national rate 17%) - Pneumonia 10.5% (national rate 17.4%) 13
14 POST ACUTE NUTRITIONAL SUPPORT SUCCESS Only 9% discontinued the program prior to 30 days Readmission rates for Medicare sentinel conditions were lower with patients receiving nutritional support and using CoC Education for healthcare providers achieved Continue to get inquiries from hospitals POST ACUTE NUTRITIONAL SUPPORT LESSONS LEARNED Not all patients were approached No access to claims to categorize/index hospitalizations Difficult to determine which element was responsible for reductions in readmissions (meals, CoC, RN calls) No comparison with discharges without MOW/CoC MOW does not have an EASY access referral system 14
15 POLLING QUESTION 3 Question: What changes will MOW programs have to make to effectively work with healthcare entities? Response: (multiple answers) Expand meal choice Track consumer hospitalizations Simplify service and reporting processes Design flexible delivery times/days QUESTIONS? 15
16 ENGAGE WITH THE LEADERSHIP ACADEMY ONLINE! Join our Linkedin Discussion! - Follow us on Twitter! Next Academy Webinar February 7, 2017 Topic: THE LEADERSHIP KALEIDOSCOPE ADAPTING TO A DIVERSE WORKFORCE 16
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