LONG TERM CARE CHAMPIONS

Transcription

1 LONG TERM CARE CHAMPIONS J E W I S H H E ALT H C AR E F O U N D AT I O N O C TO B E R,

2 LTC is more than a skilled nursing facility 2 AND SKILLED NURSING HAS CHANGED DRAMATICALLY A REALITY CHECK

3 The Patients 3 What We Think Of The Reality

4 The Care They Need 4 What We Think Of The Reality Long term custodial Growing trend towards post acute and chronic care management

5 The Staff 5 What We Think Of The Reality Highly skilled clinical team Mostly nurse aides and LPNs

6 Information and Data Systems 6 What We Think Of: The Reality Electronic health records Huge paper charts

7 The Payment 7 What We Think Of Fee for Service, like hospitals The Reality Per Diem, all in payments Growing percentage of post acute Medicare

8 Resident s Prognosis 8 What We Think Of The Reality Growing number of short-stay residents who return to the community Long, long term care or death

9 9 I rob banks because it s where the money is! Willie Sutton Question: Why is JHF focusing readmission prevention efforts at Skilled Nursing Facilities? Answers: It s where the patients are! It s where the staff are concentrated! It s where connections can be made! They might not get there alone.

10 30-Day Readmission Rates from Skilled Nursing Facilities Are Highest 10 Kind of Discharge To Home To Home Health Service in Anticipation of Covered Skilled Care # of Admits Share of Admits 30-Day Readmit Rate 466,226 57% 14% 141,309 17% 21% To Skilled Nursing Facility 112,799 14% 24% To Rehabilitation, Long-Term, or Critical care Facility 57,018 7% 21% Source: Pennsylvania Health Care Cost Containment Council, October 2007 September 2009 (24-month sample), an all-payer database. Data is for the 11-county region of southwestern Pennsylvania (813,896 discharges).

11 11 How Big Is the Problem of Readmissions from SNFs Accounts for more ED visits than any other residential settings About ½ of residents have at least one ED visit, and ½ of these have two or more per year More than 1/3 of residents are admitted to a hospital at least once a year, more than 40% have two or more admissions

12 Four Categories of Readmissions Planned 12 Unplanned Related Unrelated Chemotherapy, staged surgery Unrelated procedures CHF, stroke, pneumonia, medication errors, infections Trauma and harm from environment, e.g., falls, behavior health

13 Is This a New Problem? 13 NO, BUT IT S GROWING SLOWLY AT FIRST, BUT NOW MORE QUICKLY.

14 It s what keeps LTC Administrators Up At Night 14 Used To Be Regulation Documentation Surprise inspections Declining Payments Family Complaints Staff Turnover Reality All of the Same PLUS Changing Payment Mechanisms The Need for New Staffing Patterns Being Chosen as an ACO partner Transitioning to EMR Transparency Competitive Marketplace Avoiding Hospital Readmissions Avoiding Hospital Readmissions Avoiding Hospital Readmissions

15 Hypothesis: % OF HOSPITAL ADMISSIONS MIGHT BE AVOIDED WITH HIGH-QUALITY SNF CARE THAT RETURNS PATIENTS SAFELY TO THE COMMUNITY WHERE POSSIBLE

16 Long Term Care Champions 16 PLAN FOR AN ENHANCED CHAMPIONS MODEL

17 The Players 17 5 Pittsburgh area continua of LTC 4 faith based, one county system And their hospital and home and community based partners Community partners: Area Agency on Aging, Quality Improvement Organizations (QIO), Workforce Investment Board

18 What Our Skilled Nursing Partner Needs Leadership Tools and an understanding of Policy Enhanced skill level at SNF Countermeasures for earlier intervention (chronic disease assessment, resources coordination, infection reduction) Advanced Care Planning Tools Process improvement skills Data tracking skills and tools Communications Skills and tools across settings 18

19 Timeline Pre Engagement July-August 2012 LTC Champs Launch September 2012 Training tools to focus on Key Skills Gaps (data, clinical and communications) to be developed by December, 2012 Ongoing Coaching and Training Months 1-18 Engagement of Residents and Families Months

20 20 Outcomes: What We Will Measure Rate of change in readmissions rates and contributing factors: falls, infections, immunization rates, pressure sores, depression, decline in ADLs, medication management issues Appropriate use of Best Practice models including Interact, Palliative Care and Advanced Care Planning Resident, Family and Staff Engagement and Satisfaction

21 The Role we see for Grantmakers Capacity Building for providers Exposure to best practice models (Interact, POLST) Tools for Data collection, communications across sites Front line staff training Bridge Building across providers 21 Funders as community conveners Inclusion of LTC providers in policy and model building (ACOs, state plans)