adrcs role in care transitions - advancing states · 2013-03-12 · 6 adrcs history with care...
TRANSCRIPT
ADRCs Role in Care TransitionsHCBS Conference
Atlanta, Georgia
September 26, 2010
www.adrc-tae.org 2
Care Transitions
The process of engaging
consumers and their
informal caregivers in
the discharge planning
process to ensure they
have the post-discharge
care instructions and
resources they need to
avoid unnecessary
hospitalization or
institutionalization.
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Common Care Transitions Activities
Medication Management
Assessing Patient's Understanding/Ability to Follow Care Pla
Discharge Support
Coaching for Primary Care Physician Visit
Use of Home Visits
Screening for Cognitive Ability
Use of Centralized Health Record
Involving Family and Informal Caregivers
Arranging Community-Based Support Services
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Why focus on care transitions?
Episodes of illness often result in multiple transitions between settings, particularly for individuals with chronic conditions and functional impairment
Transitions can = fragmented care
Duplication of services
Inappropriate or conflicting care recommendations
Medication errors
Patient/caregiver distress
Higher costs of care
In 2006, 6% of Medicare beneficiaries had two or more hospital stays within 60 days and account for 24% of health spending for Medicare benes
~$60,000 per person on average; ½ associated with inpatient events
Medicare beneficiaries with chronic and functional impairment 40% more likely to have rehospitalizations
Medeicare beneficiaires with some chronic condition and ADL/IADL impairments were twice as likely to be rehospitalized
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Medicare Quality Improvement Organizations 9th Scope of Work Included Care Transitions
A „subnational‟ QIO Theme – 14 sites competitively awarded
Started August 1, 2008
Coordinate care and promote seamless transitions across settings, including from the hospital to home, skilled nursing care, or home health care.
Reduce unnecessary readmissions to hospitals that may increase risk or harm to patients and cost to Medicare.
Three levels of measurement
1. Degree of dissemination
2. Effect of disseminated intervention on targeted driver
3. Effect of intervention on utilization (readmission/ED use)
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ADRCs History with Care Transitions
2003 - Federal ADRC initiative began Intervention in critical pathways was emphasized
2009 – Person-Centered Transitions added as core ADRC program component Information, referral, and awareness
Options counseling and assistance
Streamlined eligibility determinations for public programs
Person-centered transitions
Quality assurance and continuous improvement
2010 - Health reform and AoA/CMS ADRC solicitation Care transitions appears in several section of Affordable Care Act
Handful of states will receive dollars to implement specific care transitions interventions
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Additional Health Reform Provisions
Community-based care transitions program (Sec. 3026). Provides funding to hospitals and community-based entities that furnish evidence-based care transition services to Medicare beneficiaries at high risk for readmission.
Hospital readmissions reduction program (Sec. 3025). This provision requires CMS to adjust Medicare hospital payments based on the hospitals‟ readmission rate. This law gives hospitals new incentives to strengthen their care transitions procedures to reduce readmissions. These incentives go into effect in October 2012.
Extending and expanding Money Follows the Person (Sec. 2403). PPACA extends the demonstration through 2016 and expands the target population to make more nursing facility residents eligible to qualify under the program.
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Overcoming the Aging Network’s Challenges
Strategic focus and guidance from the Federal level regarding
Influencing medical providers Be opportunistic about institutions to approach
Gaining access to medical records Federal influence on included entitles in RIOs
Establishing credibility Use of evidence-based models & reporting outcomes
Increasing visibility Consistent & effective messages and adequate resources
Role in Care Coordination & Transitions Across Settings
ADRC networks can play a critical supporting and bridging role in care coordination and
transitions, especially for high cost individuals with chronic conditions and functional
impairment that can benefit the most.
Avenues include – ADRCs, CLP, I&A, NFCSP, HCBS case management
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Examples of Evidence Based Models
Hospital-to-home care transitions models
Care Transitions Intervention (CTI)
Transitional Care Model (TCM)
BOOST (Better Outcomes for Older Adults through Safe Transitions)
Bridge Program
Practice-based Care Coordination Models that include Care
Transitions Elements
Guided Care
Geriatric Resources for Assessment and Care of Elders (GRACE)
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Central Texas ADRC
ADRC or AAA name: Central Texas ADRC
Service Area: Bell, Coryell, Hamilton, Lampasas, Milam, Mills, and San Saba counties
Hospital Partner: Scott & White Hospital (Hospital is employer of record for ADRC employees within the hospital)
Model used:
Care Transitions Intervention (CTI or “Coleman Model”) for short-term intervention
REACH II Intervention for the family caregiver, which is a longer term intervention supported by the Community Living Program.
Intervention: ADRC Care Transition Specialists coach consumers and their caregivers to ensure that consumers are empowered to successfully:
understand their health conditions
communicate their needs to health system (including primary care provider);
manage their medications;
maintain a simple centralized health record;
find relevant community-based supports and services; and
achieve health goals
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Other ADRCs Involved in Care Transitions
Massachusetts Aging
Implementing the Care Transitions Intervention (CTI) in both ASAPs/AAAs and CILs
Northeast Georgia ADRC
Currently provides “transition coaching,” options counseling, and promotes use a patient health record utilizing aspects of the CTI
For profiles of these states and additional information, see:
http://www.adrc-tae.org/tiki-index.php?page=CareTransitions
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ADRCs Plans to Support Care Transitions Interventions
Which of the following services does your ADRC plan to
provide within your care transitions program?
Arranging community-based support services 16 100%
Conducting telephone follow-ups 16 100%
Informal caregiver support/education 14 88%
Making sure consumers understand their medical care plan 11 69%
Coaching consumers before follow-up primary care appointments 9 56%
Helping consumers keep track of their medical records 8 50%
Conducting home visits 7 44%
Medication management 6 38%
Source: Care Transitions Workgroup Survey. ADRC Technical Assistance Exchange. December, 2009
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Key Design and Implementation Questions for Discussion
Please rate your network’s capacity on a scale of 1 to 10 (10 highest)
Current relationship with critical pathway providers (hospitals, physician
offices, etc.)
Strategy for engaging critical partners (QIO, hospitals, etc.) – can you join
forces with existing efforts?
Capacity to handle increased referrals
Staff training (coaching, medication reconciliation, etc.)
Capacity to conduct home visits
Informal caregiver support/education resources
Structure for evaluating the program
Others?
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Care Transitions Resource Topic
on www.adrc-tae.org
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Technical Assistance Exchange
www.adrc-tae.org
Lori Gerhard
202-357-3443
Lisa Alecxih
703-269-5542
Cindy Gruman
703-269-5501