11 th Annual Small & Rural Hospital Conference November 9, 2011 Improving Care Transitions and Decreasing Readmissions through Public and Private Partnerships
What is Transition of Care The movement of patients from one health care practitioner or setting to another as the individual s condition and care needs change Occurs at multiple levels Within Settings ICU Ward Between Settings Hospital Home or Hospital Long Term Care Facility Across health states Curative care Palliative care/hospice (c) Eric A. Coleman, MD, MPH
Ineffective Transitions lead to Poor Outcomes Wrong treatment Delay in diagnosis Severe adverse events Patient complaints Increased length of stay Increased healthcare costs
Increase in Care Transitions 53% increase in patients discharged from hospital to home health 25% increase in patients discharged from hospital to nursing homes or rehab facilities 50% of older adults discharged from the hospital to long term care facility experienced 4+ transitions to another institution over 12-months
Understanding Rehospitalizations Who is at risk of Rehospitalizations? According to IHI Individuals with: Chronic Illnesses (heart disease, COPD) Frail Elderly In Nursing Homes or Receiving Home Health End-of-Life Psychiatric Illnesses Substance Abuse Complex Social Challenges (poverty)
Readmissions: By the Numbers 20% Medicare Beneficiaries readmitted within 30 Days 33% readmitted within 90 Days Hospitalizations account for 33% of total Medicare $ Readmissions result in $17.4 Billion annually 76% of Medicare readmissions potentially avoidable Estimated $12 Billion Preventable Expenditures
The Challenge If re-hospitalizations are frequent, costly, and able to be reduced, why haven t they been? Hospital-level barriers Community-level barriers State-level barriers
How does our community navigate this transition? Home Area Agency on Aging County Social Services Assisted Living Cooperative Extension? Nursing Home Mental Health Provider Home Health Care Rehabilitation Continuing Care Retirement Community Community Resource Connection County Council/ Department on Aging Faith Community Adult Day Services Senior Center
New Models of Care There are a number of proven & promising models to improve outcomes during transitions: Common Elements: Interdisciplinary Communication/Collaboration Transitional Care Staff Patient Activation Enhanced Follow-up (by phone / home visit)
Transitional Care Models Care Transitions Intervention (www.caretransitions.org) Transitional Care Model (www.transitionalcare.info ) Project RED (www.bu.edu/fammed/projectred) Project BOOST (www.hospitalmedicine.org/boost) Resources National Transitions of Care Coalition s Compendium (www.ntocc.org) Health Care Leader Action Guide to Reduce Avoidable Readmissions (www.commonwealthfund.org)
4 Steps for Hospital Leaders 1. Examine your hospital's current rate of readmissions 2. Assess and prioritize your improvement opportunities 3. Develop an action plan 4. Monitor your hospital s progress
Evidence-Based Strategies Hospitalization Risk screen patients At Discharge Discharge Planning Post-Discharge Self -Management Tailor Care Teach-back Education Conduct Home Visit Communication Schedule F/U Appts. F/U by Telephone Teach-back Education Medication Management F/U with LTC Facilities Interdisciplinary Teams Instructions for NH Personal Health Info End-of-life Wishes Partnerships with NH Community Networks
Aging & Disability Resource Centers: ADRCs The federal ADRC initiative began with 3 core functions: Awareness, Assistance & Access The set of expectations has grown over time to include improving care transitions AoA and CMS are viewing ADRCs as the platform to catalyze broader systems change Health reform adds new fuel to the fire! $500M - Section 3026: Community-Based Care Transitions Program
ADRCs - Local Core Collaborators Consumers Aging Services Agencies Disability Services Agencies In-Home services Senior Centers Community Agencies Dept. of Social Services Area Agencies on Aging Community Health Centers Hospitals
North Carolina: Community Resource Connections (CRCs) Graham Cherokee Clay Swain Macon Madison Buncombe Henderson Avery McDowell Polk Rutherford Watauga Ashe Caldwell Burke CRCs in Operation Alleghany Wilkes Catawba Lincoln Gaston Iredell Surry Yadkin Davie Rowan Union Stokes Rockingham Caswell Forsyth Anson Guilford Davidson Randolph Cabarrus Stanly Montgomery Moore Alamance Scotland Chatham Lee Hoke Orange Person Robeson Durham Harnett Wake Bladen Franklin Johnston Sampson Warren Nash Wilson Wayne Duplin Pender Halifax Gree ne Lenoir Northampton Pitt Jones Onslow Martin Craven Hertford Bertie Beaufort Carteret Gates Tyrrell Hyde Dare Programs Areas Launching or Expanding Fall 2011 Columbus Brunswick Program Areas where CRC Development is in process with launches in mid-2012 DHHS Office of Long Term Services & Supports
South Carolina ADRCs
Person-Centered Hospital Discharge Planning Model Enhance the ability of community organizations to plan for person-centered hospital discharges Develop models that ensure that individuals have maximum options to return home Create processes for communities to share tools, resources, outcomes & lessons learned
Lessons Learned Identify a Change Agent Bring Stakeholders Together & Make the Case Encourage Collaboration: Public & Private Celebrate Early & All Successes Demonstrate Impact (Now vs. Future) Choose Intervention Outcomes Fit Capture the Data Sustainability is Critical!
A Community-Based Approach Communities across the US are beginning to consider transitions of care as a community based challenge that requires shared ownership and close collaboration across settings. (Institute for Healthcare Improvement)
Community Care of North Carolina (CCNC) Transitional Care Highlights Jennifer Cockerham, RN, BSN, CDE Director of Chronic Care and Quality Improvement jcockerham@n3cn.org Communitycarenc.com
North Carolina Medicaid 1,516,803 Medicaid Recipients Medicaid Managed Care *Community Care of NC (CCNC) 1,127,958 Enrollees 1542 Practices 4500+ Providers *Carolina Access I (CA I = 57,092) Straight Medicaid (331,753)
Community Care Networks Cherokee Graham Clay Ashe Alleghany Warren Northhampton Gates Surry Stokes Rockingham Caswell Person Hertford a Watauga Halifax Wilkes Yadkin Granville Forsyth Guilford Orange Franklin Bertie Madison Caldwell Alexander Durham Davie Nash Edgecombe Tyrrell Wake Washington Iredell Davidson Martin Burke Randolph Chatham Wilson Buncombe McDowell Catawba Rowan Haywood Pitt Beaufort Swain Hyde Rutherford Lincoln Johnston Lee Greene Henderson Cabarrus Jackson Harnett Polk Gaston Stanly Wayne Cleveland Moore Montgomery Lenoir Craven Mecklenburg Macon Pamlico Union Cumberland Sampson Richmond Jones Hoke Anson Duplin Scotland Onslow Alamance Chowan r Dare Robeson Bladen Pender Columbus Brunswick Hanover Legend AccessCare Network Sites AccessCare Network Counties Community Care of Western North Carolina Community Care of the Lower Cape Fear Carolina Collaborative Community Care Community Care of Wake and Johnston Counties Community Care Partners of Greater Mecklenburg Carolina Community Health Partnership Community Care Plan of Eastern Carolina Community Health Partners Northern Piedmont Community Care Northwest Community Care Partnership for Health Management Community Care of the Sandhills Community Care of Southern Piedmont
CCNC Infrastructure 14 Networks - private, non-profit organizations Community-based, physician-led, emphasis on medical homes Local partners = hospital, health department, DSS, specialists, etc Partner with the state to better manage Medicaid population = improve quality and contain cost Enhanced pmpm to Medical Home
FOCUS of CCNC improved quality, utilization and cost effectiveness of chronic illness care
Chronic Care Model Over time, visits/interactions (planned and acute) will meet patient needs and assure the delivery of proven clinical and behavioral elements of care. INFORMED ACTIVATED PATIENT PREPARED PROACTIVE TEAM IMPROVED OUTCOMES http://www.improvingchroniccare.org
Care Management Support to the Medical Home Care Manager Provider Impact Evidence-Based Guidelines Process Improvement Improved Care Patient Impact Education, Referrals, Follow-Up Outcome Improvement Improved Utilization
Chronic Disease Prevalence of NC s ABD Medicaid Population 43% 3 or More Major 3 or More Major Co-morbidities
Major Co-morbid Conditions Within the 200,000 ABD Medicaid Recipients 45% Hypertension 24% Diabetes 14% Asthma 14% COPD 13% Ischemic Vascular Disease 12% Neurological Disorders 6% Chronic Kidney Disease 3% Heart Failure 41% Mental Health conditions p
Treo PPL All individuals within the same Clinical Risk Group (CRG) Actual-to- Expected Difference $0 $1K $2K $3K $4K $5K $6K $7K $8K $9K $10K $11K $12K $13K $14K $15K $16K $17K $18K $19K $20K Expected Preventable Inpatient Costs for this CRG
ED and Inpatient Utilization of ABD Population (over 6 month period) At Least 1 ED Visit At Least 1 Hospitalization 41% 17% t
Susan 10 y.o. with asthma ED visit on the weekend Multiple ED visits over the last 6 months for asthma More prednisone fills than pulmicort fills in previous year's drug claims No Asthma Action Plan
Susan Informatics Center ED & Hospital Visit Report Patient contact - left message for mom to call PCP and make an appointment PCP RN notified CM of appt date/time CM conference with MD prior to appt CM met with Susan, parents, and MD MD completed AAP while CM provided asthma education and resources
TARGET : Tool for Adjusting Risk - A Geriatric Evaluation for Transitions 7 P Risk Scale: 1. 1. Prior Hospitalization 2. 2. Problem Meds (Coumadin, insulin, Digoxin) 3. Punk (depression) 3. 4. Principal diagnosis 4. 5. Polypharmacy 5. 6. Poor health literacy (50% higher risk) 6. 7. Patient support Project BOOST (Better Outcomes for Older Adults thru Safe Transitions) www.hospitalmedicine.org/boost
Hospital Readmits 17.6 % are readmitted within 30 days of discharge 6% in the first week 50% had not followed up with PCP or any physician before being readmitted 25-30% occur at a different hospital Institute for Healthcare Improvement t
Medication Management Issues o High Risk Meds (Coumadin, insulin, digoxin) o Polypharmacy o 20% of pts D/C d from hospital at least 1 medication discrepancy (UCHSC) o 1/3 of meds prescribed at D/C are not taken (Beers et al) o New meds at D/C not noted in outpt. record 50% of time
Transitional Care A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location Source: Position Statement from the American Geriatrics Society, 2003 CCNC Transitional Care 02/2011 I
Charlie 62 y.o. with developmental disability and multiple chronic conditions Very little family support Dependent on CAP-DA and other in-home services prior to admit 2 month hospital stay wound care and unstable conditions Multiple team meetings during inpatient stay to coordinate discharge plans Linked to multiple services - CAP-DA, Home Health, Palliative Care, DME, Specialists
Charlie Discharged home on Labor Day Home Visit by CCNC Care Manager Home Health for B.I.D. dressing changes had not yet begun No dressing change supplies Pain regimen had been denied by Medicaid had not been communicated, resulting in 3 days without pain med CAP-DA was unable to resume services until 3 days after discharge, resulting in no assistance with personal care
CCNC Transitional Care Process 1)Notification/identification of hospitalized patients 2)Screening & Assessment Process 3)Hospital Visit 4)Facilitate Optimal Hospital Stay and Discharge Plan 5)Home Visit with Medication Reconciliation/med management 6)Medical Home Linkage 7)Disease Management, Red Flags, Community Linkages, improved self-management
FACE -TO-FACE INTERACTIONS Hospital Home Medical Home
The Primary Role of the CCNC CM in the Transitional Care process is to: facilitate interdisciplinary collaboration across transitions encourage the patient and caregiver to play a central and active role in the formation and execution of the plan of care promote self-management skills and direct communication between the patient/caregiver, primary care provider, and other service providers achieve medication reconciliation through consultation with network pharmacist, the hospital, the PCP, the Specialists, and the patient
Self-management Tasks of Chronic Care Patients Medical management of condition (MEDICAL) Creating and maintaining new meaningful life roles (SOCIAL) Coping with anger, fear, frustration of having chronic condition (EMOTIONAL) Based on work by Clark, Corbin, Strauss and Glaser
Highlights of our Progress Real-Time data, Hospital & ED reports in IC, ADT CM embedded in hospitals CM & Pharmacists teams Process for Face-to-Face encounters with patient Support to Medical Home/PCP follow-up appointments Work with hospitals to obtain more complete D/C Instructions Strong linkages with Mental Health Providers Provider Portal & Care Alerts Addition of Psychiatrists & Behavioral Health Pharmacist Palliative Care Physician Champions Value of Home Visits Enhanced features in CMIS to track and evaluate Transitional Care The value of Community Partnerships
Embedded Staff Care Managers 118 practices 48 hospitals Pharmacists 14 practices 18 hospitals
What we are learning Complexity of the population medically & socially Majority have either a dominant or moderate chronic condition, a malignancy, or a catastrophic health condition Motivational Interviewing techniques are key for positive patient engagement Population management appears to be having a positive impact on access to care, ED, and inpatient utilization 2011 cumulative Medicaid costs for enrolled ABD population (dual and non-dual combined) were $196 lower per member per month for the fiscal year as compared to fiscal year 2008.
Challenges Defining the impactable patient & interventions Incorporating palliative care, mental health & other new info without creating more silos Challenges obtaining Real-Time Hospital Data Unable to locate the patient Narrow time frame for the most beneficial intervention Promoting effective self-management Growing population and level of complexity Building capacity in the Medical Homes Competing agendas
Susan It was a positive experience. Mom said the ED told her to call and schedule a followup visit, but she had forgot until she received my voice message. The family is looking forward to Susan being in better control of her asthma than she has been. - CCNC Care Manager
THANK YOU
U N C H E A L T H C A R E S Y S T E M Care Transitions and Readmissions at Chatham Hospital Small and Rural Hospital Conference November 9, 2011
U N C H E A L T H C A R E S Y S T E M Chatham Hospital Facts Critical Access Hospital Owned by the UNC Health Care System Located in Siler City, NC Contract with UNC Health Care System for Emergency Room and Hospitalist physician coverage 50
U N C H E A L T H C A R E S Y S T E M Chatham County Alleghany Ashe Caswell Person Granville Warren Northampton Gates Camden Currituck Surry Stokes Rockingham Vance Halifax Pasquotank Hertford Watauga Wilkes Perquimans Yadkin Forsyth Guilford Orange Franklin Bertie Mitchell Avery Chowan Nash Durham Caldwell Yancey Alexander Davie Edgecombe Madison Tyrrell Iredell Martin Washington Dare Burke Davidson Randolph Chatham Wake Wilson McDowell Pitt Buncombe Catawba Rowan Beaufort Haywood Swain Johnston Hyde Lincoln Rutherford Lee Harnett Greene Graham Cabarrus Jackson Montgomery Moore Wayne Henderson Cleveland Polk Gaston Craven Stanly Macon Transylvania Lenoir Cherokee Mecklenburg Pamlico Clay Cumberland Union Richmond Hoke Duplin Jones Anson Sampson Scotland Robeson Bladen Pender Onslow Carteret Chatham Hospital Columbus Brunswick New Hanover 51
U N C H E A L T H C A R E S Y S T E M Why is this a priority? Partnership for Patients Keep patients from getting injured or sicker Help patients heal without complication We need to fix things in our hospital that are not working Payors are paying more attention and are incentivizing We are all in this together because we share patients It is the right thing to do 52
U N C H E A L T H C A R E S Y S T E M There are many causes of readmissions Exacerbations of conditions Complications of care Medication issues Missed (or missing) follow-up appointments Confusion regards discharge instructions Patient non-compliance 53
U N C H E A L T H C A R E S Y S T E M Small Hospital Challenges Small patient volumes Hospital has limited resources Generally less advantaged patients Lower income Less education Fewer community options 54
U N C H E A L T H C A R E S Y S T E M What is Chatham Hospital s 30-day readmission rate? Patients Too few to analyze 68 100 Readmits 15 18 55
U N C H E A L T H C A R E S Y S T E M Chatham Hospital Status Focus on appropriate transition placement and prevention of unnecessary readmissions Majority of patients are elderly Frequent ED visits from nursing home and assisted living residents Hospitalists rotate from UNC Hospitals Accustomed to pressure to discharge quickly Chatham Hospital length of stay dropping Readmissions are increasing?? Many inpatients discharged to local nursing homes or assisted living facilities Implementing CPOE with new discharge instruction software 56
U N C H E A L T H C A R E S Y S T E M Efforts to Reduce Readmissions and ED Returns Determine baseline readmission and ED returns Obtain buy-in from local nursing homes and assisted living facilities Evaluate Hand Off between Chatham Hospital staff and Nursing/Assisted Living staff Evaluate nursing home/assisted living documentation provided to hospital Interview nursing home/assisted living staff Develop an educational program based on evaluation findings 57
U N C H E A L T H C A R E S Y S T E M UNC Hospitals Partnership Pilot study with Vendor for patient-centered hospital to home program Discharge care plan aligned with hospital medical record Personalized transition liaison services Medication management and guidance Compliance monitoring 24-hour nurse assist line 58
U N C H E A L T H C A R E S Y S T E M Questions or Comments? What is happening at your facility? 59
THANK YOU! Heather Altman Carol Woods Retirement Community haltman@carolwoods.org / 919-918-2609 Jennifer Cockerham Community Care of North Carolina jcockerham@n3cn.org / 919-696-8880 Carol Straight Chatham Hospital CStraight@ChathamHospital.org / 919-799-4001