A Bridge Back Home: Care Transition Coaching for the Post-Acute Heart Failure Patient. February 8, 2018

Transcription

1 A Bridge Back Home: Care Transition Coaching for the Post-Acute Heart Failure Patient February 8, 2018

2 3 Partners in Care (Partners) A Mission-Driven Organization Our Mission Partners shapes the evolving health system by developing and spreading high-value models of community-based care and self-management Our Partnership Partners collaborates with hospitals, physician groups, health plans, community-based organizations, and government agencies to deliver services that support adults with complex health and social services needs and their caregivers and families Evidence-based programs demonstrated to significantly reduce costly hospital readmissions, ED visits, and nursing home placements Our Focus on Innovation We shift the emphasis from illness care to preventive care, reducing costs and improving quality of life for those with chronic conditions NCQA accredited for Complex Care Management as defined by CMS.

3 4 CBOs Can Affect 60% of US Premature Deaths Shortfalls in Medical Care, 10% ^ Indicates a modifiable risk factor in the social services domain ^Social Circumstances, 15% Genetic Predisposition, 30% [CATEGORY NAME], [VALUE] Adapted from McGinnis JM, Williams-Russo P, Knichman JR. The case for more active policy attention to health promotion. Health Affairs (Millwood) 2002;21(2): ^Behavioral Patterns, 40%

4 5 Partners in Care Foundation Service Overview Long-Term Services & Supports (LTSS) Health Self- Management Short-Term In-Person Services LTSS MSSP: Services to keep people at home (nursing home diversion) Community Care Transitions: Returns people home from nursing home ( repatriation ) Health Self-Management Multi-session workshops such as Chronic Disease Self- Management (or pain or diabetes versions), Diabetes Prevention Program, Arthritis Walk with Ease, A Matter of Balance, Tai Chi Short-term (mostly) In-Home Services Care Transition Choices: Coaching or telephonic social work support (Bridge) after discharge from hospital HomeMedsPlus: Psychosocial, functional, cognitive & home safety assessment & service coordination TCM/CCM: Medicare fee-for-service physician billing codes for transitional care management & chronic care management.

5 6 Partners in Care/Providence Saint Joseph Care Transition Choices 3 Evidence-Based Interventions: Eric Coleman MD S Care Transitions Interventions Partners in Care s HomeMeds Rush Medical Center s Bridge Intervention For people outside service area or who refuse home visit Experienced, culturally/linguistically appropriate coach in each ministry Target population: Medicare patients identified as high risk of readmission Fragile health; care is complex and costly

6 7 Coleman Care Transitions Intervention (CTI) Develop patient/family skills for self-care and connecting with community resources to recuperate safely at home. Hospital visit to introduce program and gain consent Home visit by coach (social worker) within 72 hours of discharge Review red flags for disease exacerbation Plan what to do if signs/symptoms get worse Patient activation for self-care and self-management Instruct on use of Personal Health Record, including medication list Reminders and coaching to schedule follow-up medical appointments, with transportation if needed HomeMeds medication risk screening & pharmacist intervention can be added Ensure DME, prescriptions, diet-compliant meals, etc. available as ordered Refer to longer term self-management programs as appropriate Telephonic follow-up for 30 days

7 8 HomeMeds: Coach + Pharmacist = Improved medication safety Inventory all meds being taken: out of system meds, drugs from other countries, borrowed, and OTC Assess for potential adverse effects; e.g., BP, pulse, falls, dizziness, confusion Document adherence issues and understanding Algorithm identifies targeted potential medication-related problems (MRPs) Pharmacist reviews potential MRPs & makes recommendations for resolution, contacts provider and/or patient Telepharmacy available in home Adherence Inquiry: 1. Why do you take this (purpose)? 2. How much do you take at one time? 3. How often do you take it? 4. Does it seem to work for you? If NO, why? 5. Do you have any side effects? If YES, what are they? 6. How long have you been taking the medication (months or years)?

8 9 The Bridge Model Transitional support through intensive service coordination that starts in the hospital and continues after discharge to minimize the risk of complications. Hospital visit to introduce program and determine needs Telephonic service coordination by social worker Arrange for services and follow-up appointments as needed after discharge Also address caregiver issues Refer to longer term self-management programs as appropriate RCT outcomes: Participants were more likely to make and keep follow-up appointments, Lower mortality at 30 days, and 24.4% fewer readmissions at 60 days Less caregiver burden Faster access to community-based support services

9 10 Track Record in Care Transitions Coleman CTI for IEHP in % readmission rate for intervention group. 19.8%. readmission rate for referred, not served CMS-funded Community-based Care Transitions Program (CCTP) ,000 pt. at 11 hospitals; average reduction in readmission rate = 34% Internal UCLA study of CCTP: Readmission rate for intervention=10.6%; rate for referred but not served was 28% (same risk level) CMS lauded performance as top decile in country (140 CCTP sites) HomeMedsPlus (adds in-home psychosocial assessment & service coordination) for UCLA Medicare Advantage/ACO/Med Group 3% lower population-level readmission rate (net of low-risk decrease) 10.6% of intervention group readmitted vs. 26.9% of high-risk, not served

10 Readmit Rate 11 CMS Innovation Results 25.0% 20.0% 15.0% 10.0% 5.0% Results by CCTP Site 21.1% 28% 29% reduction % reduction % 15.2% 14.4% 41.5% reduction % Best in CA Source: HSAG, CA QIO, November % Westside (3 Hospitals) Glendale (3 Hospitals) Kern (5 Hospitals) Readmit Pre Readmit Post CCTP Collaborative Participants Served % Reduction in Readmissions Program to Date through October Baseline (Pre): All-Cause, All-Condition, Medicare FFS: Westside & Glendale = Jan Dec 2012; Kern = Apr 2012-Mar CCTP (Post): Medicare High-Risk FFS Population, Readmission Rate to Date (Westside= May 2013 Jul 2016; Glendale = May 2013-Mar 2016; Kern = Nov 2013 Jul 2016 # Readmits Averted Program to Date Westside 14,086 28% 831 Glendale 6,745 29% 391 Kern 10, % 904 Source: Final CMS Quarterly Monitoring Report, Released March 21, 2017

11 % Readmission rate HomeMedsPlus: Population-level readmission outcomes in Medical Group/Medicare Advantage [VALUE] 31.3 Pre-Post 3% Absolute Decrease among entire high-risk population; Net of background decrease Background 1.4% pre-post decrease among low-risk patients Intervention group 66% relative decr. Pre June May 2015 Post June Jan 2017 High-Risk (LACE 11) Others (LACE 10) Intervention

12 13 HomeMeds Summary/Results Nationally recognized; chosen for research quality: Aging & Disability Programs & Practices and AHRQ RCT Vanderbilt; consensus panel led by Mark Beers, MD Targeted problems chosen for availability of alternatives Typically 40-60% of those screened need changes to meds Implemented in 20 states for about 7,000 older adults each year HealthCare Partners post-acute results After pharmacist review 63% needed intervention 12.8% reduction in rate of ED visits within 30 days of d/c 22% reduction in rate of 30-day readmissions

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14 16 CM Work Flow 1. CM to review list of potential referrals and send daily to Partners via EPIC using Community Services 2. CM to notify Partners of anticipated DC date. Preferably within 2-3 days of discharge 3. CM goes with Partners Transition Coach to patient room and introduces Coach to patient CM Department to print a copy of the CM assignments daily for Transition Coach to pick up Patient Leave Behind to be printed by CM department and stored in the department for Transition coach

15 17 Coach Work Flow 4. Coach will: Explain the program Schedule Home Visit Schedule F/U MD visit 5. Transition Coach enters MD appt date/time and Date of Home Visit on the AVS, writes it on whiteboard in patient room and on back of Patient Leave Behind 6. Coach will then follow patient home (or to SNF then Home) and provide 30 day coaching program Care Transitions Intervention (CTI; in-home) Bridge Care Coordination (telephonic)

16 18 Patient Success Story 74 year old Caucasian female admitted to St. Joseph for shortness of breath Medical conditions include congestive heart failure, pulmonary hypertension, and pneumonia Home visit helped identify: patient needed a caregiver; access to low-cost prescriptions and low sodium meals; patient was at risk for isolation Outcome: Secured caregiver, who assisted with preparing low-sodium meals and housekeeping, plus other services as needed Applying for grant to assist with paying for medications Connected with local senior centers, community activities and volunteer opportunities Patient empowered to take charge of her own health

17 19 Chronic Disease Self-Management Program Healthier Living Six-week program 2.5 hours, one day per week Target Audience participants Individuals with different chronic conditions Workshop Format Lead by two trained leaders Group discussions Activities Short lectures Action Planning 2/27/2018

18 20 Learning Self-Management Skills Physical Activity Medications Decision Making Action Planning Breathing Techniques Understanding Emotions Reduce Fear of Falling Problem-Solving Using Your Mind Social Activity Strength, Mobility, and Balance Communication Healthy Eating Weight Management Working with Health Professionals

19 21 In-Person, On-line or Tool-Kit 2/27/2018

20 22 Chronic Disease Self-Management Program (CDSMP) Clinical Outcomes Population: 571 union members w/chronic conditions in MCO Intervention: CDSMP + monthly meetings + incentives (discounted medication copays) Outcomes: Compared to baseline, after 12 months Self-rated health good or excellent: 60% vs. 32% at baseline BMI 1 point A1C 1 point Systolic BP 11 points Depression score from 5.8 at baseline to 3.2 Pain from 3.2/10 to 2.0/10 Compared to baseline, after 12 months aerobic exercise from 51 to 75 minutes per week stretching/strength exercise from 21 to 35 minutes per week 2/27/2018

21 23 National Retrospective Study Health Outcomes CDC Meta-analysis of 20 studies: CDSMP contributes to improvements in Psychological & physical health status Self-efficacy, and Selected health behaviors 2013 National Study IMPROVEMENTS: Depression 21% Managing Sleep Problems 16% 13% Physical Activity 10% Fatigue Management 11% Pain Management 12% Medication Compliance 9% Communication with Physicians Reduction in ER and Hospital Stays, resulting in $714 of savings per person *Brady, Teresa J. Executive Summary of ASMP/CDSMP Meta-Analyses. CDC, May gov/arthritis/docs/asmp-executive-summary.pdf *Ory, Jiang, Lorig, Laurent, Whitelaw, and Smith, /27/2018