March 17 th, 2016
Introduction Roll Call RHP 8 Learning Collaborative Questions and Answers Meredith Oney Heather Beal Cheri A. Lattimer, RN, BSN Executive Director, NTOCC All
A National Transitions of Care Perspective March 17 th 2016 Presented By: Cheri A. Lattimer, RN, BSN Executive Director, NTOCC NTOCC is a 501(c)(4) nonprofit coalition.
The Statistics Were Staggering In 2006 and Not Much Better Today! Non-adherence statistics: 45% of hospital NRxes or Rx changes are never documented in out-patient medical records 1 12% of NRxes are never filled 2 29% don t complete LOT 2 22% take < than prescribed 2 Average hospital LOS due to medication non-compliance is 4.2 days 2 Convene experts and apply evidence based clinical practice guidelines Closing gaps across the continuum Medication Reconciliation across care settings is a Joint Commission National Patient Safety Goal Poor Transitions of Care Contribute to Hospital Readmissions Mobilize resources to optimize appropriate coordination across all channels & health care states Despite wide distribution, evidence based clinical practice guidelines have not changed physician behaviors 3 National Quality Forum (NQF) endorsed 3-Item Care Coordination Measures to expand voluntary hospital consensus standards in care transitions 4,5 COALITION LAUNCH October 18, 2006 - National Transitions of Care Coalition Chicago Sanofi in Collaboration with CMSA to lead multidisciplinary coalition of experts Employers TJC - NQF SHM ACHE ASHP ASCP ASA AGS - IHI NASW - URAC
National Transitions of Care Coalition Council These groups represent over 200,000 health care professionals, 11,000 employers and 30,000,000 consumers throughout the United States.
NTOCC s Mission & Vision Vision Improving transitions of care for patients, family caregivers and providers through promotion of public policy, education and focused solutions that advance collaborative patient-centered care Mission NTOCC s mission is to improve transitions of care across the healthcare industry. www.ntocc.org
7 Considerations for Change Improve communication during transitions with providers, patients and caregivers Support the implementation of electronic medical records that include standardized data elements Establish points of accountability for sending & receiving Increase the use of case management and professional care coordination Expand the role of the pharmacist in transitions of care Implement a payment system that align incentives Development performance measures to encourage better transitions of care www.ntocc.org
TODAY S HEALTHCARE ENVIRONMENT It's about better care: care that is safe, timely, effective, efficient, equitable and patient centered. ¹ Applying integrated approaches to simultaneously improve care, improve population health, and reduce costs per capita ² 1. Source: http://www.ama-assn.org/amednews/2010/12/20/prse1221.htm 2. IHI Triple Aim Population ; http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx
Transition Issues Dramatically Impact Patients & Their Caregivers Patient & Caregiver ER ICU In-Patient OUTPATIENT: Home Home Care PCP Specialty Pharmacy Case Mgr. Caregiver Hospice SNF ALF Patient & Caregiver
Transition Issues Dramatically Impact Patients & Their Caregivers & Providers Patient & Caregiver ER ICU NO Discharge Care Plan OUTPATIENT: Home Home Care PCP Specialty Pharmacy Case Mgr. Caregiver Hospice NO Care Plan NO Medication Reconciliation NO Personal Medicine List NO Medication Reconciliation In-Patient SNF ALF NO Personal Medicine List NO Coordinated Care Plan Patient & Caregiver NO Care Plan NO Medication Reconciliation NO Personal Medicine List
To Date We Have Not Had Consistent and Accepted Transition Tools Medication Reconciliation Elements, Medication Patient List or Comprehensive Medication Review (CMR) Comprehensive Care Plan Health or Clinical Status Transition Summary Patient & Caregiver Tools & Resources Consistent Performance Measures That Apply to All Health Care Settings Accountability for Sending & Receiving Information
Our healthcare system operates in silos and information queues incapable of reciprocal operation with other related management systems & different departments of organizations Eric A. Coleman, MD, MPH
Continuum of Care & Spectrum of Services How will you coordinate care beyond your service? Enrollment Health & Wellness Specialist Home Health Skilled & LTC Palliative Care Acute Hospitalization Sub-acute Rehab Health Health Respite Care Doctor's Hospice OP Therapies Office Diagnostic Skilled Case/Disease & Nursing Management Care Treatment Center Long Term Acute Hospital
Waves of Change New models of health care delivery and reimbursement are quickly evolving Their success is contingent on effective care coordination This in turn requires interprofessional and transdisciplinary collaboration
We ve medicalized so many things, but transitions are not medical events. It s about the team working together. It s a person event. Jennifer Fels, RN, MS, Director, Southwestern Vermont Medical Center
A Different Level of Physician Engagement Todays Health System transformation call for a different level of physician engagement organizing care around the patient means working together in teams Embracing the bigger mission of the organization An engaged physician workforce is also linked to enhanced patient care, greater efficiency and lower cost and improved quality and patient safety. http://www.hhnmag.com/display/hhn-news-article.dhtml?dcrpath=/templatedata/hf_common/newsarticle/data/hhn/magazine/2014/apr/gatefold-medsynergies
Integrated Behavioral & Medical Collaborative Care Initial agreed upon clinical and functional goals First line evidence based intervention through primary care clinician Psychiatrist supervised systematic diagnostic assessment with baseline symptom documentation Comprehensive medication review, management and coordination with the pharmacist and care team Treatment to target care escalation based on follow up findings (psychiatrist involvement and treatment change) Symptom stabilization and return to primary care follow up Integrated case management professionals Psychiatric consultation team Psychiatrist led BH team assesses all medical admissions for BH comorbidity as a part of hospitalist group teams Case Management Society of America & Cartesian Solutions, Inc.
Creating the Collaborative Clinical Team Collaboration among physicians, pharmacist, nurses, case managers, social workers, allied health and supporting staff is critical to achieving the goals of the team, the organization and changing the way we deliver healthcare today http://www.crystalgraphics.com/
The Pharmacy Opportunity Leadership role in interdisciplinary efforts to establish accurate and complete medication lists Hospital admission and discharge Any change in level of care Encourage community based providers and health care systems to collaborate in medication reconciliation efforts Educating patients and their caregivers on their role in retaining a current list of medications Assisting patients and caregivers through the provision of a personal medication list CMR when appropriate and sharing the information with the patient, family caregiver and care team. ASHP. Medication Therapy and Patient Care: Organization and Delivery of Services Positions. 2009.
Case Manager Skills Are Required For Success in These New Models! Knowledge and experience with care coordination Focus on patient centered processes Assessment, planning, facilitation across care continuum Knowledge of population based care management strategies Meaningful communication with patient, family, care team
Don t Forget The Patient
Facilitating A Safe Transition Medication reconciliation at discharge Comprehensive discharge Transitional planning planning Post discharge support (e.g. Pharmacist call, home care.) in specific conditions is essential!
Continuous Quality Improvement Process https://www.google.com/search?q=continuous+quality+improvement+graphic&espv=210&es_sm=93&tbm=isch&tbo=u&source=univ&sa=x&ei=nh1buoqjjsi6kqeug4dod w&ved=0cdyqsaq&biw=1706&bih=829&dpr=1#facrc=_&imgdii=_&imgrc=yyz8wxogfby6fm%3a%3bv
Seven Essential Interventions 1 2 3 4 5 6 7 Medications Management Transition Planning Patient and Family Engagement / Education Information Transfer Follow-Up Care Healthcare Providers Engagement Shared Accountability across Providers and Organizations Source: http://www.ntocc.org/compendium (2011) www.ntocc.org
But we need to go further in recognizing that care coordination is a collaborative process supported by a multidisciplinary teams who must coordinate, communicate and transfer information with each other and their patients and family caregivers LTC PCP/Medical Home Community Health Center Advocate Motivational Interventions Assessment Motivational Advocacy Patient & Caregiver Care Plan Hospital Health Plan Health Promotion Specialist Pharmacy Hospice Employer
Continued Support for Care Coordination & Transitions of Care
Development of Care Coordination Measures AHRQ Care Coordination Measurers Atlas NQF Performance Measures for Care Coordination CMS SOW for QIOs focus on Care Transitions & Care Coordination TJC Core Performance Measures & Patient Safety Standard #8 Medication Reconciliation URAC Incorporated Transition of Care in revised CM Standards Case Management Measures NCQA Complex Case Management Standards AMA PCPI Transitions of Care ANA Framework for Measuring Nurse s Contribution to Care Coordination
Transitional Care Codes Implemented January 2013 National Average $142.96 National Average $231.11 99495: Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge 99496: Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least high complexity during the service period Face-to-face visit, within 7 calendar days of discharge.
FY2015 Medicare Physician Fee Schedule (PFS) Effective January 2015 CPT Code 99490 Chronic Care Management Codes (CCM) Focus on paying for team based care Patients with two or more chronic conditions Separate fee for managing multiple conditions 20 minutes of clinical labor time & may be provided outside of normal business hours Billed no more frequently than once a month Care management services may be provided by social workers, nurses, case managers, pharmacist Services must be available 24X7 to patients and their family caregivers Providers using the CCM code must have an electronic health record or other health IT http://www.cms.gov/newsroom/mediareleasedatabase/fact-sheets/2014-fact-sheets-items/2014-07-03-1.html
NTOCC Policy & Advocacy: Work in 2015 Care Planning Act introduced by Senators Isakson (R-GA) and Warner (D-VA). Chronic Care Management Code went into effect on January 1, 2015. Congress repealed and replaced the Sustainable Growth Rate and included directions for CMS to include more chronic care codes. NTOCC has worked with the Chronic Care Working Group during their fact finding stage and looks forward to continuing the process. The House passed 21 st Century Cures; the Senate is working on their companion legislation.
Policy & Advocacy: Opportunities in 2016 Senate Innovation for Healthier Americans Opportunity to include language around interoperability and information transfer with electronic health records Senate Chronic Care Working Group Opportunity to highlight the importance of transitional care in chronic care management Emphasis on Collaborative Teams and integration with Behavioral Health CMS Physician Payment Rule Improving the current chronic care management code and addition of more care coordination tools CMS s MACRA implementation Including transitional care in the calculation of the MACRA score CMS s IMPACT Act implementation CMS s Discharge Planning
Collaboration To work together with others to achieve a common goal Multidisciplinary Teams: Communication and Care Coordination is a collaborative process... Lies At The Heart Of Successful Practice Without collaboration, there is little hope for positive change or successful outcomes
Transitions of Care & Care Coordination Resources CAN Caregiver Action Network Family Caregiver Resources http://www.caregiveraction.org CAPS Consumers Advancing Patient Safety Toolkits www.patientsafety.org NTOCC National Transitions of Care Coalition Provider& Consumer Tools www.ntocc.org CMSA Case Management Society of America CM Medication Adherence Guidelines & Disease Specific Adherence Guidelines, CMSA Standards of Practice www.cmsa.org AMDA s (Dedicated to Long Term Care Medicine TM ) Transitions of Care in the Long Term Care Continuum practice guideline http://www.amda.com/tools/clinical/toccpg/index.html ACC and IHI Hospital to Home Reducing Readmissions, Improving Transitions http://www.h2hquality.org/ AHRQ Agency for Healthcare Research and Quality Questions Are The Answers www.ahrq.org NASW National Association for Social Workers http://www.socialworkers.org/resources VNAA Blue Print for Excellence www.vnaablueprint.org
Resources for Development Measures The Joint Commission (TJC) http://www.jointcommission.org/assets/1/18/tjc_annual_report_2014_final.pdf Agency for Healthcare Research and Quality (AHRQ) http://www.ahrq.gov/professionals/prevention chroniccare/improve/coordination/atlas2014/ccm_atlas.pdf National Quality Forum (NQF) http://www.qualityforum.org/measures_reports_tools.aspx URAC https://www.urac.org/wp content/uploads/casemgmt Standards At A Glance 10 9 2013.pdf National Committee for Quality Assurance (NCQA) http://www.ncqa.org/hedisqualitymeasurement/hedismeasures/hedis2015.aspx American Medical Association (AMA) http://www.ama assn.org/apps/listserv/xcheck/qmeasure.cgi?submit=pcpi American Nurses Association (ANA) http://www.nursingworld.org/framework for Measuring Nurses Contributions to Care Coordination
Waves of Change Changing is like Breathing And we all know what happens when we stop Breathing Questions Cheri Lattimer RN, BSN clattimer@cm-innovators.com
Region 10 Learning Collaborative Care Transitions Monthly Webinar March 17th, 2016 Provider Participant MCA Kathleen Sweeney Cook Children s - TCPH - MHMRTC Mahie Ghoraishi, Melanie Navarro, David Gunter, LeAnne Bailey, Erin Fogarty NHH Kathleen Sweeney PMC Kathleen Sweeney Huguley Anna Rabinovich THFW - THSW - THS - Ennis Regional Edwina Miner Lakes Regional - JPS Hospital Heather Beal, Stephanie Carrell, Yvonne Kyle, Meredith Oney, Lara Burnside, Ann Elsbury, Pat Alridge, Lori Muhr, Brenda Gomez, Edlyn Alridge, Lynette Blackwood, Susan Reed UT Southwestern Moncrief Cancer Institute Catherine Simpson THAZ - Helen Farabee - Wise Regional - THAM - Pecan Valley - THC - Baylor - THHEB - Dallas Children s - UNTHSC Andrew Harman JPS PG - Methodist Mansfield Stacie Anderson
Region 10 Learning Collaborative Care Transitions Monthly Webinar March 17th, 2016 Wise PG - Glen Rose - Texas Health Alliance - Other Stakeholders Provider RHP 3 NTOCC v2v Healthcare Advisors Participant Michelle Eunice, Nini Lawani Cheri Lattimer David Salsberry