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Session Code: C28 This project was funded in part by the West Health Institute Trading Spaces: Remodeling Acute Care for Seniors Brought to you by team members from the Unplanned Acute Events Learning and Action Network (UAELAN) December 11, 2018 1:30-2:45 pm

What we hope you take away from this session P4 Value-based care and payment models are here to stay A new vision for acute unplanned events Providing acute care services at home and in skilled nursing facilities ED-based screening and new disposition options Identifying key lessons learned and challenges faced Ensuring resources are available to support work to redesign care for older adults with high-needs/high-costs Accelerating change with aligned incentives and shared learning

Who We Are P5 Jon Zifferblatt, MD, MBA, MPH Chris Crowley, PhD Mary Pisciotta, MPH Cory Sevin, RN, MSN Ana Tuya Fulton, MD, AGSF, FACP Amy Stuck, PhD, RN Liane Wardlow, MsEd, PhD Joan Grebe, MA, OT, AICF Ruth E. Scott, RN, MHA

Applied medical research Policy research and advocacy Outcomes-based philanthropy

West Health s Acute Care Vision: In Place, Proactive & Opportunistic P7

Institute for Healthcare Improvement (IHI) 8 Mission Improve health and health care worldwide Vision Everyone has the best care and health possible Strategic Approach IHI applies practical improvement science and methods to improve and sustain performance in health and health systems across the world. We generate optimism, spark and harvest fresh ideas, and strengthen local capabilities. # Health Equity How We Work Convene Innovate Partner for Results What We Do Value Safe & High Quality Care Health of Populations Improvement Science Joy in Work

Poll Everywhere Instructions Bring out your laptop or cell phone When poll is active, respond at PollEv.com/maryp127 OR text MARYP127 to 22333 Index Cards-write down your questions This Photo by Unknown Author is licensed under CC BY-SA

Q: Why focus on acute care? P13 A: Chance to avoid highest cost driver admissions - intercept at the ED (the last exit ) if possible... 70% of senior admissions originate in the ED 3.7X more likely for Medicare beneficiaries to be admitted from ED vs. non-medicare beneficiaries and mobilize sooner than the ED if you can!

Innovations are needed across the continuum to disrupt the typical ED-to-inpatient trajectory P14

We gathered experts and Next Generation ACOs P15 Faculty Learning & Action Network Al Siu, MD, MSPH: Mt. Sinai April Kane, MSW: UPMC Mike Malone, MD: Aurora Health Regina Berman, RN, MA: Strategic Advantage Participants Atrius Bellin Integra Park Nicollet UnityPoint University of North Carolina

P16 Testing new models for acute unplanned care Acute Care at Home Rapid deployment of resources Low rates of clinical complications Improved experience Lower costs ED-Based Interventions Developed highly coordinated care and care plans Reduced barriers to care Direct scheduling, transportation solutions, connections with community agencies

Our measurement strategy included outcome, process and balance measures P17 Description Type 1 % unplanned ED visits Outcome 2 % unplanned admissions Outcome 3 Est. episodic cost savings Outcome 4 % intervention response initiated Process 5 % intervention executed to protocol Process 6 % intervention with a quality issue Balance 7 Experience: Likely to recommend Balance

Park Nicollet implemented a process to address COPD exacerbations P18

UNC implemented an ED screening and referral intervention P19 7-Day Unplanned Admission 7-Day ED Revisit Rate Patients discharged from UNCMC ED with CM assessment %UNCMC assessed with 7-day unplanned admission Patients discharged from UNCMC ED with CM assessment %UNCMC assessed with 7-day ED Revisit

Atrius focused on pre-enrollment for their Medically Home program P20 After pre-enrollment, 18 of 20 or 90% of members called the practice when they need acute care. Percentage of Medically Home admissions via membership program 19.5% admissions via membership program

Financial models needed to balance implementation costs with potential cost savings P21 Cost to Implement Staff Training Equipment Supplies Cost Savings Avoided ED visits Avoided ED revisits Avoided admissions Avoided readmissions (penalties) Positive ROI Neutral ROI Negative ROI Potential savings (using hypothetical scenario/data) DRG avoided Cost of care provided Net Episode 1 $10,900 $4,500 $6,400 Episode 2 $14,000 $9,000 $5,000

To ensure sustainability, we helped teams build P22 financial models Program Costs: Staffing Training Equipment, supplies Benefits: Reduce ED & hospital utilization Reduce ED bounce backs and hospital readmissions Reduce readmission penalties Increase satisfaction scores Increase CMI Patients and Caregivers: Provide a trusted & reliable connection to communitybased resources Improve patient outcomes Reduce iatrogenic complications

Early lessons learned can help others who are contemplating similar models P23 Make a business case within your own system as you get started and update assumptions as you learn Balance up-front investment and sustainability costs with reductions in utilization (hospitalization, ED visits) Information system and EHR needs can take much longer than first anticipated identify these early Look for local partnership opportunities (ambulance companies, home infusion, etc.) Be realistic about timeline to get up and running

Integra s Journey: Remodeling Acute Care For Seniors Ana Tuya Fulton, MD, AGSF, FACP; Medical Director Ruth E. Scott, RN, MHA; Director of Care Management Integra Community Care Network, LLC

Outline for Integra Who we are What are we aiming to accomplish? Why? What is the value proposition to the ACO? How we worked to develop our model Team make-up Choosing the population of patients Simulations-how many before seeing 1 st pt? Go Live - Patient #1: lessons learned Looking ahead future growth and plans

Who are we at Care New England & Integra? Three hospitals Certified home health & hospice agency The Providence Center - ambulatory behavioral health provider Affiliated with RI Physician Corporation Primary Care Integra Community Care Network Integra is responsible for ~ 130,000 covered lives MA, NGACO, AE, Commercial, Medicaid

Rhode Island and our patients Smallest state (48 miles N S; 17 miles E W) Population - 1,059,639 (7.1.17) Race/Ethnicity: White (81.4%); Black (5.7%); Asian (2.9%); Other race (6.0%); Two or more races (3.3%); Hispanic/Latino (12.4%) Gender: Male (48.3%); Female (51.7%) Age: Under 18 (19.6%); 18-64 (63.6%); 65 and over (16.8%). Median Age: 39.4

Integra Community Care Network Est. May 2014 Care New England Health System Rhode Island Primary Care Physician Corp. South County Hospital Project Team Members:

Why is this work important? Needs assessment results Hospitals can = unnecessary or harmful interventions High costs at end of life both: immediate (3-4 months) and remotely (last 2 years of life) High costs often equate to incongruous care with Goals: patient wishes and are causing suffering Trigger goals of care conversations Anticipating emergencies, expected complications

Complex Care Management Team Mobile Integrated Health PCP & Team Resource Specialist Enrollment factors: Cost analysis Claims, utilization Geriatrician Case Conference Patient and Family Nurse Care Manager PCP referral Hospitalization outreach Risk assessment - payers Behavioral Health Home Team Social Work Medical Assistant Many are frail & older with multi-morbidity

Why I@H? (Integra@Home) Opportunity to participate in the IHI/West Health learning and action network to design better models of care for unplanned acute events in older adults Needs assessment Our patients needed higher level of care at home, and often expressed a desire to stay out of the hospital Our staff were hungry for better options!

Our Model: Built off/out of our Complex Care Management program Patient selection Nurse Case Management referral Goals of Care Conversations / *MOLST Caregiver support Criteria for enrollment - both inclusion and exclusion *Medical Orders for Life Sustaining Treatment

33 Total Population NextGen ACO members MA Members # of members Population of Focus for LAN (e.g. seniors in top 10% of costs; seniors using X ED; seniors with CHF and COPD) 15,000 Adults over age 80 Higher Risk Population Multiple medical illness Frailty Underlying dementia Kent ED Users Target Diagnoses Cellulitis Pneumonia CHF exacerbation COPD exacerbation UTI Exclusion Criteria Needing more 4L nasal cannula O2 Evidence of early sepsis Lack of caregiver Monitoring requirements hard to meet # of members in this segment 750-1000 (increased to 10 miles) 1009 Total patients 1759-2009 (Updated 8.7.18)

Team Aims Team Aim 1: 80% of patients who receive care from the Integra at Home program will avoid a hospital admission during this care episode and for 7 days after the conclusion of the Integra at Home care episode. Team Aim 2: 65% of patients who receive care from the Integra at Home program will avoid an unplanned ED visit during this care episode and for 7 days after the conclusion of the Integra at Home episode. Team Aim 3: Integra at home will target a 25% reduction in costs compared to BAU costs through care at home using our intervention.

Value proposition ROI/value for ACO Aligned incentives Integra wants to avoid ED visits & hospitalizations, and care for patients at home who would do better there/prefer there. Challenges payment models, limited number of visits for home care, response times (4 hours for RN visit, meds, IV placement)

LAN 1 st month Utilized our complex care team with NP support to treat more at home and augment PCP We implemented a call first campaign and we are using this engagement with patients and families to jump start our Integra at Home efforts Patients were engaged in needs assessment and they are excited about the idea of the option for more care at home

Timeline Progress summary L

June-key learnings and decisions Most successful team for our go-live involved: physician, physician assistant/np clinician team nurse care manager as the communication lead/hub of care community paramedicine as core partner and team member Recruiting for clinicians

Timeline Progress summary

Pre-enrollment Complex care management team patients, from Next Gen and Medicare Advantage in the population of focus area Choosing those to pre-enroll based on diagnoses 38 Potential Candidates Identified for Integra @ Home

Team building Weekly huddles Integra @ Home team and community paramedics Team met to create checklists with process for Integra @ Home episodes with exclusions and communication plans Working on layers of coverage to have backup available tough when only 2 team members in place for clinicians

Early lessons learned: Finding the right partners is important Response time is key Test, test and test some more! Adequate coverage and collaboration is crucial Home care, infusion company, lab service, mobile XR, physician/pa, NP, community paramedicine all explored and included in simulations

Model at Go Live! Patient identified and pre-enrolled Pre-enrollment visits by I@H clinician (PA or MD), MSW and community paramedicine team Safety assessment, medication reconciliation, goals of care discussion, plan of care, caregiver stressors VNA, Pharmacy, IV infusion, lab services lined up Activation call to Integra on call triggers I@H episode Followed x 30 days after discharge from acute episode of care

Tools Folder in the home Checklists Educational Materials

Family and caregiver education When, Why and How to call us Disease specific information Integra @Home folder Neon yellow folder, brochures, consent, lab orders, contact info, patient education materials, MOLSTs, checklists.

Updates since Go-Live on 9/28/18 4 patients enrolled in active episodes of I@H Successful response times, partner activation, communication 10 pre-enrolled Both patients followed for 30 days after acute episode

Team exercise: Identifying top safety risks Response to change in condition can we be timely enough? Adverse events medications, disease escalation? Injury due to physical hazards in the home? Non-arrival of equipment O2 for example Adverse effects on family caregivers - How can we watch for that?

Costs and Burdens to Patients Consider this as you implement Cost sharing medications, paramedicine, transportation How can you keep ROI but also protect patients from increased costs? Waivers?

Patient satisfaction survey

Our Lessons Learned: Hospitalization = control over diet, activity, bad habits! Integra @ Home work needs to consider those factors Caregiver and patient education is crucial Each site will have to test and retest to find the best team and partners

Questions? Reflections? P53 This Photo by Unknown Author is licensed under CC BY-NC-ND

Resources and Keeping in Touch P54 Handouts uploaded to Forum site: Payment Pathway Patient Burdens and Costs in Alternative Models UAELAN Driver Diagram UAELAN Measurement Strategy IHI Blog post: Trading Spaces: Remodeling Acute Care for Seniors

Keeping in Touch IHI Joan Grebe: jgrebe@astound.net Mary Pisciotta: mpisciotta@ihi.org Cory Sevin: csevin@ihi.org Integra Ana Tuya Fulton AFulton@CareNE.org Ruth Scott RScott@CareNE.org P55 WHI Amy Stuck: arstuck@westhealth.org Chris Crowley: ccrowley@westhealth.org Jon Zifferblatt: jzifferblatt@westhealth.org Liane Wardlow: lwardlow@westhealth.org