Ohio s Statewide Initiative to Reduce Avoidable Hospitalizations Among NF Residents Mary Applegate, M.D. Mina Chang, Ph.D. Ohio Department of Job and Family Services-Office of Ohio Health Plans (Ohio Medicaid) David Sand, M.D., M.B.A., F.A.C.S. Permedion Linda Noelker, Ph.D. Farida Kassim Ejaz, Ph.d., L.I.S.W. Benjamin Rose Institute on Aging Lorin Ranbom Barry Jamieson Ohio Colleges of Medicine Government Resource Center 1
OPPORTUNITY Studies have estimated that 30% to 67% of hospitalizations among nursing facility residents could be prevented with welltargeted interventions 2
PRIMARY OBJECTIVES: Reduce the frequency of avoidable hospital admissions and readmissions; Improve resident health outcomes; Improve the process of transitioning between inpatient hospitals & nursing facilities; Reduce overall health care spending without restricting access to care or choice of providers. 3
MANDATORY INTERVENTIONS Hire staff who maintain a physical presence on site at NFs & partner with NF staff to implement preventive services (cannot bill separately) Work in cooperation with existing providers; Facilitate residents transitions to & from inpatient hospitals and nursing facilities; Provide support for improved communication and coordination among existing providers; and Coordinate and improve management and monitoring of prescription drugs, including psychotropic drugs. 4
MANDATORY INTERVENTIONS Strong evidence base. Strong potential for replication & sustainability Supplement (rather than replace) existing care provided by nursing facility staff. Coordinate closely with State Medicaid and State survey & certification agencies and State public health and health reform efforts. Allow for participation by NF residents without need for residents to change providers or enroll in a health plan. 5
MAY INCLUDE: Education efforts with families/caregivers; Support for residents and nursing facility staff to facilitate a successful discharge to the community as appropriate; HIT tools to support sharing of care summaries, medications across transitions Enhanced behavioral health assessments, treatment, and management. 6
POPULATION TARGET Primary target population is fee-forservice, long-stay Medicare-Medicaid enrollees in nursing facilities. Applicants must describe how they will target their proposed intervention to long-stay beneficiaries. Targeting all long-stay Medicare- Medicaid enrollees residing in the facility preferred (over a subset) 7
EXCLUDES NFs in ICDS Regions ICDS (Integrated Care Delivery System) is a Proposal to CMS by Ohio Medicaid. Creates a coordinated delivery system for Medicare-Medicaid (Dual) eligible, including nursing home patients. Competitively selected managed care plans managing a comprehensive benefit package. ICDS regions include most urban areas (see map). 8
9
Organizational partners Benjamin Rose Institute the grant writer and applicant providing project management and administration. Permedion subcontractor implementing quality improvement science. Government Resource Center subcontractor assisting in data analysis, evaluation, and communication. Ohio Health Plans - Sponsor providing leadership and direction. 10
Ohio s NF Avoidable Hospitalization Data % of Preventable Admissions by Clinical Category Angina without Procedure 2% Uncontrolled Diabetes 0% Asthma in Younger Diabetes Short-term Complications 2% Adults 2% Lower-Extremity Amputations 1% Perforated Appendix 0% Diabetes Long-term Complication s 5% % of Preventable Admits in Non-ICDS Counties Medicaid & Dual Eligible 2006-2009 Urinary Tract Infection 21% COPD or Asthma in Older Adults 16% Hypertension 1% Bacterial Pneumonia 32% Heart Failure 16% Dehydration 2% 11
Ohio s NF Avoidable Hospitalizations Data Percent of Admissions that are Preventable Non ICDS Counties (AHRQ Prevention Quality Indictors) WILLIAMS WYANDOT BROWN PAULDING CARROLL FAYETTE AUGLAIZE MORGAN HOCKING HENRY LOGAN SANDUSKY MIAMI LICKING SCIOTO FAIRFIELD DARKE PREBLE PERRY ASHTABULA ERIE MORROW TUSCARAWAS CHAMPAIGN CRAWFORD HOLMES KNOX SENECA MUSKINGUM ATHENS WASHINGTON VINTON JEFFERSON PUTNAM JACKSON MARION LAWRENCE HANCOCK VAN WERT DEFIANCE GUERNSEY SHELBY ALLEN MONROE COSHOCTON HURON ASHLAND HARRISON ROSS RICHLAND NOBLE BELMONT GALLIA HARDIN MEIGS PIKE HIGHLAND MERCER ADAMS Ohio Medicaid & Dual Eligible SFY 2006-2009 0.% 10.% 20.% 30.% 40.% 50.% 12
Ohio s NF Avoidable Hospitalizations Data Percent of Admissions that are Preventable Non ICDS Counties (AHRQ Prevention Quality Indictors) Lake Ashtabula 14.08% Ohio Medicaid & Dual Eligible SFY 2006-2009 Williams 0.00% Mercer 30.00% Darke 13.46% Preble 13.53% Butler Hamilton Defiance 19.01% Paulding 5.56% Van Wert Shelby 19.48% Miami 12.50% Montgomery Fulton Auglaize 10.53% Warren Clermont Henry 10.96% Putnam 17.19% 18.95% Crawford Wyandot Allen 14.61% 3.23% 19.60% Clark Greene Logan 11.86% Clinton Hardin 26.02% Champaign 14.38% Brown 4.76% Wood Hancock 18.80% Highland 28.25% Lucas Union Madison Fayette 9.54% Adams 42.79% Marion 18.35% Ottawa Sandusky 12.50% Seneca 15.45% Delaware Franklin Pickaway Ross 22.65% Pike 28.08% Scioto 13.20% Morrow 14.10% Erie 14.09% Huron 20.41% Richland 22.77% Fairfield 13.44% Knox 15.03% Licking 13.05% Hocking 10.94% Jackson 18.26% Vinton 17.07% Perry 13.92% Gallia 25.91% Lorain Ashland 21.01% Medina Wayne Holmes 14.72% Coshocton 20.30% Muskingum 15.98% Athens 16.18% Meigs 28.02% Cuyahoga Morgan 10.81% Summit Stark Tuscarawas 14.11% Guernsey 19.08% Noble 24.00% Washington 16.20% Geauga Portage Carroll 8.59% Harrison 21.32% Belmont 24.94% Monroe 20.27% Trumbull Mahoning Columbiana Jefferson 17.11% Lawrence 18.47% 13
Ohio s NF Avoidable Readmissions* Data Percent of Admissions that had a Preventable Readmission Non ICDS Counties (3M HIS Potentially Preventable Readmissions) Total (ALL) COSHOCTON PUTNAM MIAMI WILLIAMS CHAMPAIGN SHELBY MERCER DARKE NOBLE LOGAN ASHLAND HARDIN AUGLAIZE PREBLE HARRISON VINTON BELMONT PAULDING BROWN ADAMS MARION MORROW HANCOCK HIGHLAND HENRY FAIRFIELD HURON ASHTABULA WYANDOT MORGAN WASHINGTON HOCKING LICKING ERIE KNOX DEFIANCE HOLMES ROSS MEIGS VAN WERT JACKSON PIKE RICHLAND JEFFERSON FAYETTE SENECA CRAWFORD SCIOTO TUSCARAWAS ALLEN GALLIA GUERNSEY CARROLL SANDUSKY MUSKINGUM ATHENS MONROE LAWRENCE PERRY Ohio Medicaid & Dual Eligible SFY 2006-2009 0.% 10.% 20.% *Readmissions within 30 days of discharge from hospital. 14
Ohio s NF Avoidable Readmissions Data Percent of Admissions that had a Preventable Readmission* Non ICDS Counties (3M HIS Potentially Preventable Readmissions) Lake Ashtabula 7.47% Ohio Medicaid & Dual Eligible SFY 2006-2009 Williams 2.86% Mercer 4.35% Darke 4.94% Preble 6% Butler Hamilton Defiance 8.43% Paulding 6.25% Van Wert Miami 2.6% Montgomery Fulton Auglaize 5.8% Shelby 3.57% Warren Clermont Henry 7.27% Putnam 2% 9.23% Crawford Wyandot Allen 11.29% 7.5% 11.61% Clark Greene Logan 5.41% Clinton Hardin 5.75% Champaign 2.97% Brown 6.67% Wood Hancock 7.23% Highland 7.26% Lucas Union Madison Fayette 10.8% Adams 6.75% Marion 6.8% Ottawa Sandusky 14.21% Seneca 11.11% Delaware Franklin Pickaway Ross 8.76% Pike 10.14% Scioto 11.33% Morrow 6.9% Erie 8.18% Huron 7.35% Richland 10.47% Fairfield 7.27% Knox 8.42% Licking 8.12% Hocking 8.11% Jackson 9.38% Vinton 6.06% Perry 18.18% Gallia 13.14% Lorain Ashland 5.71% Medina Wayne Holmes 8.7% Coshocton 0.96% Muskingum 15.69% Athens 15.79% Meigs 8.76% Cuyahoga Morgan 8% Summit Stark Tuscarawas 11.52% Guernsey 13.41% Noble 5.26% Washington 8.08% Geauga Portage Carroll 13.41% Harrison 6% Belmont 6.18% Monroe 17.65% Trumbull Mahoning Columbiana Jefferson 10.59% Lawrence 17.86% *Readmissions within 30 days of discharge from hospital. 15
NFs that Meet the CMMI Criteria Not in ICDS Geographic Area 100 beds or more No outstanding Violations 100 NFs meet these Criteria Other Considerations: NFs with a high concentration of Medicare and Medicaid enrollees Other NFs may be included as long as the average resident census among all facilities is at least 100. See attached spreadsheet (NFs with 100 beds or more in Non ICDS Counties). 16
Ohio s NF Avoidable Hospitalization Initiative: NFs that meet the CMMI Criteria for Participation 17
Characteristics of Interventions to Reduce Avoidable Hospitalizations Among Long-stay Nursing Facility Residents 18 www.benrose.org 18
How Prevalent Are Avoidable Hospitalizations? CMS-funded study in Georgia reviewed 200 hospitalizations from 20 NHs 68% were definitely/probably avoidable 32% were definitely/probably not avoidable 19 www.benrose.org 19
What Are Evidence-based Programs (EBPs)? Rigorously tested using randomized, controlled trials in initial studies Demonstrated positive outcomes in terms of improving the quality of care and quality of life of the target population Subsequently replicated successfully with other populations across the nation, and sometimes internationally Demonstrated similar positive outcomes in replication sites Clearly developed manuals, educational programs and protocols on how the intervention should be implemented to maintain fidelity to its original design 20 www.benrose.org 20
Examples of EBPs Used to Reduce Hospitalizations Featured in CMS Webinars on this Initiative Interact II: Developed by Joseph Ouslander, MD, and colleagues Evercare: Evaluated by Robert Kane, MD, and colleagues Goal of such interventions is to improve primary care of nursing home residents who experience changes in their health and well-being 22 www.benrose.org 21
EBP Strategies to Safely Reduce Hospital Transfers Prevent conditions from becoming severe by intervening early and assessing and monitoring changes in resident condition Manage some conditions in the nursing home when possible and safe Use advance care planning and palliative care for some residents instead of hospitalization Improve communication and coordination between nursing homes and hospitals Use continuous quality improvement strategies In some instances, help with more rapid transfer of residents who need hospital care www.benrose.org 22
Essential Elements of EBPs Used In Nursing Homes to Reduce Hospitalizations Provide training to nursing home staff to enhance their current model of care Recruit a facility-based champion Provide support to nursing home staff on an on-going basis Ensure that care is patient-centered and individualized Involve family members in identifying changes in resident health conditions Respect resident and family choice regarding hospitalization Respect resident and family choice to decline participation in the EBP 23 www.benrose.org 23
Role of Nurse Practitioner (Advanced Practice Nurse) Work on-site with primary care physicians and existing nursing home staff Monitor resident care to identify red flags or symptoms associated with certain health conditions (e.g., x% of weight gain in residents suffering from heart failure; high fever in residents suffering from pneumonia, UTIs; resident not being his/her usual self ; etc.) Train other nursing staff and nurse aides to identify and report risk factors before they become severe or lead to hospitalization Implement care pathways so nursing home staff know what to do when 24 www.benrose.org 24
Ohio s NF Avoidable Hospitalizations Initiative- PRELIMINARY Development Plan Ohio Medicaid and CMMI NF Initiative Committee will strategize, disseminate key information, identify and connect with care alliances or entities in geographic regions that have capacity or interests. Ohio Medicaid/GRC will assist to align strong care partners and to develop a robust statewide model for the grant. BRI and Permedion will participate in grant writing and development of this Ohio application Care alliance among Cleveland Clinics, UHHS, Metro, and Kaiser formed a strong capacity in the North East Region Ohio will propose an evidence-based care innovation model to improve and integrate patient-centered care for the NF residents with high rates of avoidable hospitalization stemming from multiple system failures. The model needs to accommodate regional variations that may be needed for operations Using Medicaid LTC Minimum Data Set and other CMS recommended data sets, Ohio will identify Medicaid and Medicare certified NFs with high costs, fee-for-service, and long-stay duals; engage innovative providers; and then form regional care alliance to participate in this initiative. Ohio will utilize rapid cycle quality improvement approach to implement these care innovations and spread successful strategies and lessons learned 25
Ohio s NF Avoidable Hospitalizations Initiative-Development Plan (ctd.) Date Actions Responsible Party 4/24 Gauge a single statewide proposal interest Medicaid, NF Initiative Committee 4/26 Draft statewide proposal development work plan and application framework 4/30 or Submit LOI to further collaborate single statewide by 5/7 proposal 4/30-5/1 Develop detailed Work Plan, develop State Application Framework (e.g., criteria in designs and anticipated outcomes), identify data analysis and data measures for Ohio proposal Date TBD Review data, finalize framework, disseminate final (by 5/4) framework and communication to interested parties Date TBD Designate Lead Agency (by 5/4) 5/7-5/8 Request for Information Meetings (via Webinars, teleconference) (Time TBD) 5/14 Submit key program input by Regional Care Innovators/alliances with NFs participation confirmed 5/14 6/1 Converge model variations, develop strategies, form Regional Care Alliance, write proposal Medicaid & GRC Permedion and Benjamin Rose Medicaid & GRC Medicaid, GRC, NF Initiative Committee Medicaid, GRC/Lead Agency, NF Initiative Committee Medicaid, GRC/Lead Agency, NF Initiative Committee, Interested care innovators Interested parties Medicaid, GRC/Lead Agency, NF Initiative Committee 6/4-6/6 Review State Proposal Medicaid, GRC/Lead Agency, NF Initiative Committee, Regional Care Alliances 6/6-6/8 Revise Proposal Medicaid, GRC/Lead Agency, NF Initiative Committee, Regional Care Alliances 6/9 Final Authorization Medicaid, Lead Agency, Regional Care Alliances 6/9-6/14 Submit Ohio Application to CMMI Lead Agency 26
Requirements of nursing facilities to be included in the application: Complete Survey. Submit Letter of Intent. 27
Forum for potential regional partners and nursing facilities 28
Open Forum 29
Ohio s NF Avoidable Hospitalizations Initiative-Next Steps 30