The Metro Care Transitions Program (CCTP)

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Transcription:

The Metro Care Transitions Program (CCTP)

OUR GOAL Build patient/caregiver confidence. Engage patients to take a more active role in self-management of chronic health conditions. Foster independence and well-being of Care Transitions participants. Improve quality of care. Reduce avoidable hospital readmissions for high risk participants. Reduce healthcare system costs associated with hospital readmissions

OUR HISTORY First patient enrolled in the program on April 16 th, 2013. Over 3400 patients served in the last 2 ½ years. Performing person-centered Coleman Transitions Intervention plus wrap-around services to Medicare Fee For Service Beneficiaries from April 2014-September 2015 under a contract with the Center for Medicare Services (CMS)

OUR COLLABORATION The Metro Care Transitions Collaborative is a joint effort of four Area Agencies on Aging (AAA), three medical systems and six hospitals. The AAA s include: Clackamas County Social Services Community Action Team of Columbia County, Multnomah Disability, Aging and Veteran s Services and Washing County Disability, Aging and Veteran s Services. The Medical systems include: Legacy Health System Hospitals (Legacy Emanuel, Good Samaritan, Meridian Park and Mt. Hood), Oregon Health Sciences University (OHSU) and Portland Adventist Medical Center.

OUR SERVICE AREA Additional service areas include: SW Washington (Vancouver, Kelso and Longview). The program currently has capacity to provide telephonic support and services to individuals living outside of the current program service area.

OUR TARGET POPULATION We have served MEDICARE and/or MEDICAID Beneficiaries, including dual eligibles Age 18 or older CHRONIC HEALTH CONDITIONS, not including active substance abuse disorder and/or acute mental health condition(s). Also those with a second inpatient admission

Eligible Diagnoses List COPD Aortic valve disease Renal failure Cardio myopathy Pneumonia Unstable angina Diabetes Congestive heart failure Orthopedic Acute myocardial infarction Coronary artery disease Deep vein thrombosis Coronary atherosclerosis Cerebral vascular accident Ischemic heart disease Second in-patient hospitalization

OUR MODEL Coleman Transition Intervention (CTI) Model One home visit within 72 hours of discharge Develop the participants Personal Health Record Identify important personal goals Make and keep doctors appointments Manage participants medication(s) Review warning signs and how to respond Identify other community resources the participant or caregiver may need Three follow-up phone calls within 30 days of discharge. Review items covered at home visit Follow up on additional needs

Plus Wrap-Around Services Home-delivered meals In-home assistance with personal care, activities of daily living, house-keeping, and more Options Counseling Connections to community services and resources, such as: behavioral health support services, Supplemental Nutrition Assistance benefits (SNAP/food stamps), family caregiver support services, transportation services, State Medicaid medical benefits, and many more. Additional home-based screenings for depression, home safety, functional capacity, and medication risk are under development

OUR OUTCOMES 60% of patients accept services offered Almost 90% complete the intervention, with one home visit and three follow up phone calls Hospital re-admission rate within 30 days of discharge reduced by 58% for those who participate compared to those who decline services (data review of 270 patients between Dec. 2014 and Feb. 2015) Decrease in overall hospital readmission rate amongst CCTP participants is greater than 50% Fewer than 12% of CCTP participants re-admit to hospital

Return on Investment The 2012 average cost per stay in Oregon hospitals was $15,200. Adults aged 45-64 were the most costly to treat, followed by adults aged 65-84. Chronic condition hospitalization cost an average of $6,000 than acute conditions. Currently, in Oregon, approximately 25% of hospitalized patients re-admit within 30 days. Assuming that the Metro Care Transitions Program serves a monthly panel of 400 patients and reduces the re-admit rate by a little over half, the Metro Care Transitions Program will save approximately $1, 441,204 per month at a cost of $220,000 per month. The approximate Return on Investment (ROI) is 6.5:1.

OUR PATHWAY TO POSITIVE OUTCOMES Daily case finding among in-patient hospital census Community Coach completes home visit with 72 hours of discharge Community Coach continues assessment and links to other services Engage patient through in-room visit in hospital Warm hand-off to Community Coach Community Coach completes three follow up phone calls over following several weeks Initiate assessment regarding additional community service needs Schedule home visit prior to discharge Close Care Transitions case

OUR FUTURE Expand services to additional populations and payer sources Expand to additional hospitals, primary care clinics and skilled rehabilitation facilities Enhance Care Transitions services by incorporating additional home-based services, such as: medication risk and home-safety assessments, depression screening, screening for cognitive impairments, and functional-needs assessment Develop collaborative partnerships with other transitional service providers Maximize opportunities to build relationships with and make vital connections for CCTP participants

OUR TEAM Hospital-Based Coaches Angela Leonardo, Legacy Emanuel and Good Samaritan Colleen Davis, Legacy Mt. Hood Marcie Liesegang, Portland Adventist Brianna Williamson, Legacy Meridian Park Jennifer Rechel, OHSU

OUR TEAM Community-Based Coaches Kati Tilton Pat Carleton Heather Johnson Jennifer Starr Laurie Alexander Amy Vlahos Bobbie Taylor Marissa Cysani Stephen O Neal Juliann Davis Dina Miller Marge Tuomi

Bethany Chamberlin Care Transitions Coordinator Bethany.Chamberlin@multco.us (503) 988-8116 Angela Leonardo Care Transitions Health Coach Angela.Leonardo@multco.us (503) 988-2405

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