advancing care coordination and integration among
TRANSCRIPT
blueshieldcafoundation.org
blueshieldcafoundation.org
Advancing Care Coordination and Integration among Community Health Centers & Hospitals to Achieve the Triple Aim
Webinar #1 – August 4, 2014
Facilitator: Lisa Payne Simon, MPHPresenter: Amy Boutwell, MD, MPP
8/5/2014
blueshieldcafoundation.org
Webinar #1 - Agenda• Welcome & Introductions
Lisa Payne Simon, Rachel Wick
• AHRQ Toolkit for Reducing Medicaid ReadmissionsPresentation & Q&A - Dr. Amy Boutwell
• Care transitions models and strategies for high risk patientsPresentation & Q&A - Dr. Amy Boutwell
• Triple Aim measurement – updates and coaching resourcesAll teams update (1-2m), Q&A – Dr. Amy Boutwell
• Group Discussion: 1) What has been your team’s #1 achievement since June? 2) What was your biggest takeaway from the June 3rd Learning Session? 3) What technologies are you using to support achieving your aims?
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STRATEGIES TO IMPROVE TRANSITIONS & MEASURE THE TRIPLE AIM
Tools, Strategies & Feasible Measurement Plans
Amy E. Boutwell, MD, MPPCollaborative Healthcare Strategies
August 4, 2014
Agenda
• New Guide to Reducing Medicaid Readmissions 30m• Guide, Tools• Brief Q&A
• Care Transitions Strategies for High Risk Patients 30m• Self-Management Coaching, Social Work, Multi-disciplinary • Q&A, Discussion
• Triple Aim Measurement for Your Projects 45m• Each team shares current measures (2 minutes each)• Discussion
• Introduction• Why focus on Medicaid Readmissions?• How to Use This Guide• Overview of Guide Content• Roadmap of Tools
• Know Your Data• Inventory Readmission Efforts• Develop a Portfolio of Strategies• Improve Hospital-based Transitional Care • Collaborate with Cross Setting Partners• Provide Enhanced Services
• Tools
Available on AHRQ site any day now….
1. Data Analysis Tool
2. Readmission Review Tool
3. Data Analysis Synthesis Tool
4. Hospital Inventory Tool
5. Cross-Continuum Inventory Tool
6. Conditions of Participation Checklist
7. Portfolio Design Tool
8. Readmission Reduction Impact Tool
9. Readmission Risk Tool
10. Whole Person Assessment Tool
11. Discharge Information Checklist
12. Cross-Continuum Team How-To Tool
13. Community Resource Guide Tool
6 Key Actions
1. Know your data
2. Ask your patients, their caregivers and providers, “why”
3. Develop a portfolio of strategies
4. Improve hospital-based transitional care for all
5. Collaborate with community based providers & services
6. Provide enhanced services for high risk patients
1. KNOW YOUR DATA“We were just focusing on the “three conditions:” heart failure, AMI, and pneumonia, but now we can see those are not our highest risk patients”
All-Payer and Payer-Specific: 1. Total adult, non OB discharges2. Total number of patients3. Total # 30-day readmissions4. Overall readmission rate (3/1)5. Discharge disposition 6. # days between d/c and readmit7. Top 10 discharge dx leading to RA8. Top 10 readmission dx9. % of top 10 RA of all RA10. High Utilizer analysis
(# patients >3 admissions/12mo)(total # hospitalizations in cohort)(discharge disposition of cohort)(top 10 dx)(30-day readmission rate)
In practice: Usefulness of Own Data Analysis
Frederick Memorial
• Working on readmissions for 3 yrs• Adopt an all-payer approach• Making progress• All-payer and payer-specific
analysis revealed:• Medicaid readmission rates high• Medicaid patients d/c to home
without services (>80%) v. Medicare• 4 of top 10 RA dx were psychiatric,
versus 0 of 10 for Medicare• Led to reformulation of strategies
customized to Medicaid
Beverly Hospital
• Attending conferences on readmissions for 5 years
• 2014 launch focus on “high risk conditions” (AMI, HF, PNA)
• Funder required Data Analysis• Data Analysis revealed:
• Equal mix of chronic and acute dx• Top 20 dx accounted for 25% of RA• Low-volume Medicaid but high rates• Behavioral health pervasive
• Led to a substantial revision of strategy from case finding to “whole person” approach
2. ASK YOUR PATIENTS “WHY”
Interview patients, caregivers, providers for the “story behind the cc”
Themes: “I couldn’t get…..” “I didn’t understand…..” “I didn’t know…..”
Specific Actions: make appointments, use interpreters, engage social services
3. DESIGN A PORTFOLIO OF STRATEGIES
“There’s no silver bullet”
Develop Portfolio Strategy
Improve hospital-based transitional care processes for Medicaid patients
1. Flag discharge <30d in chart2. ED-based efforts to treat & return3. Broaden view of readmission risks; assess “whole-person” needs4. Develop transitional care plans that consider needs over 30 days5. Ask patients & support persons why they returned, if readmitted6. Ask patient & support persons what help they need; share with them their needs/risk assessment7. Use teach-back, target the appropriate “learner” 8. Customize information 9. Arrange for post-hospital follow up 10. Use a check-list for all patients
Collaborate with cross-setting partners
1. Use ADT notifications with medical and behavioral health providers2. Ask community providers what they need and how they want to receive it3. Collaborate to arrange timely follow up 4. Perform “warm” handoffs, and opportunity for clarification5. Form a cross-continuum team that can access resources your staff are unaware of6. Constantly refresh your awareness of social and behavioral health resources7. Broaden partners to include Medicaid health plans and their care managers8. Identify community partners with social work and behavioral health competencies
Provide enhanced services for high risk1. Segment “high risk” – varying types of service & levels of intensity 2. Strategy for high utilizers3. Strategy for navigating care4. Strategy for accessing resources5. Strategy for self-management 6. Strategy for frailty/medically complex7. Strategy for end-of-life trajectory8. Strategy for recurrent stable symptoms, etc individual care plans
4. IMPROVE STANDARD CARE FOR ALL
All patients, not just high risk patients
• Medicaid adult • Medicare FFS• Single• Certain zip codes• Prior ED utilization• Prior Hospital utilization• Frailty• Limitations in ADLs• Limitations in IADLs• Cognitive impairment• Low literacy• Low health literacy• Low self-efficacy• Discharge to SNF• Discharge to Home Health• Dementia, Delirium• Behavioral Health DX• Chronic dx• Acute dx• New dx• New medication• High risk medication• Complexity• Recurrent, known symptoms• End of life trajectory• Lack social support• Low Income• Homeless, marginally housed• Newly insured• Lack reliable transportation
1. Have a process
2. Know your data; track & review readmissions
3. Assess & reassess patients for post-hospital needs
4. Engage patients and caregivers
5. Teach self-care to patients & caregivers
6. Provide a written discharge plan for all inpatients
7. Communicate effectively with “receiving” providers
8. Know the capabilities of area providers, including support services
9. Arrange for post-acute services, including support services
5. COLLABORATE ACROSS SETTINGS
“Who isn’t our key partner?” “There’s so much out there”“pick up the phone” relationships
6. PROVIDE ENHANCED SERVICES
Segment by intensity, needs; not all patients are HRHC
Segment Enhanced Services
• Shorter term, lower intensity• Post discharge phone call, early post-d/c appointment, med rec
• Short term, higher intensity• BRIDGE, Multi-disciplinary care team
• Longer term, lower intensity• Community Health Worker, Peer Speciality
• Longer term, high intensity/investment• Eg Sickle Cell Clinic, High Risk High Cost Care Team
CARE MODELS AND STRATEGIES FOR HIGH-RISK PATIENTS
Care Model Overview
The Basic Models:“Coleman” “Naylor”“BRIDGE”
Models from the Field:“MGH High Cost Beneficiary Demo”“Transitional Care Navigator”“Peer Specialists”“Multi-Disciplinary Transitional Care Team”
“Coleman” aka “Care Transitions InterventionSM
• 2002-2003, University of Colorado Medical Center• 750 patients; 360 in intervention
• Exclusions: • non-English, no phone, psych admission, <65, dementia, NH
resident, outside geographic radius, hospice• Clinical criteria: CVA, CAD, PVD, arrythmia, CHF, COPD, DM, spinal
stenosis, hip fracture, DVT/PE• Intervention:
• In-hospital visit, home visit, 3 phone calls up to day 28• “4 pillars:” medication self-management, patient-held health record,
timely follow up with physician, and “red flags” and what to do• Outcome:
• 8.3% vs. 11.9% 30-day readmission rate • p=0.48, OR 0.59 (0.35-1.0)
Coleman et al. Arch Int Med 2006. 166:1822-8.
Lessons about CTISM from the field
• Mixed results
• Implementation issues• “Opt-in” vs “Opt-out” approach (scripting is important)• Low referrals from hospitals – case finding limits “view” of who is at-
risk for readmission; hospital staff can’t remember specific lists• Some patients refuse home visits• Getting working/correct phone number
• Adaptation to model is prevalent• Teams report “problem-solving” and “doing-for” patients, which is
not consistent with “self-management coaching” model
“Naylor” aka “Transitional Care Model”
• 2004, University of Pennsylvania Hospital• Nurse Practitioners (NPs) provide inpatient assessment
• Review medications• Review goals of care• Design comprehensive care plan• Coordinate plan of care with patients and numerous providers• Attend 1st post-hospital MD visit (PCP or specialist)• Direct home care for 1-3 months• Conduct home visits
• 20% v. 37% 6-month readmission rate (p<0.001)• Decreased 6-month RA by 36% and total cost by 39%
Naylor et al. 2004. J Am Geriatr Soc 52:675-84.
BRIDGE aka “Social Work Model”• Collaboration between Rush Hospital, Aging Research Department,
local aging services provider and health policy research group.
• Staffed social workers as transitional care specialists to meet the complex needs of older adults• Model uses SW to connect existing systems to better serve patients’ needs• SW meet pre-discharge, immediately after and follow up over 30 days• Flexible re: home visits v. phone-only• Seems the secret sauce is whole-person approach & problem solving to resolution
• Used in the ADRC and AAA national networks, CMS CCTP program
• Target population: most expensive 2500 Medicare FFS pts at MGH• Collectively $68M in annual spending• Average 13 medications, 3.4 hospitalizations/year, cost $24,000 annually
• Approach: • Primary-care focused• Intensify relationships with patients• Proactive clinical and “logistical” management• Supported by better IT tools
• Intervention: • Flag in record to identify patient by registration in ED• Patients’ full care team (SW, PCP, specialists) paged • Expectation clinicians will go to ED and avert admission
• Impact: 20% reduction in hospitalizations, 13% lower ED visits• 12% gross total cost of care savings; 7% net savings• For every $1 spent, program saved $2.65
MGH High Cost Beneficiary Demonstration
http://www.massgeneral.org/news/assets/pdf/cms_project_phase1factsheet.pdf
MGH High Cost Beneficiary Demonstration
• Lessons learned:
• May not stop patients from behavior of going to ED
• These patients always “look bad” (physically, or labs)
• Clinicians who know the patient know what baseline is
• Partner with ED doc to reassure no substantial change is presents and to assure that close follow up will occur
Frequent ED visits for Behavioral Health patients• Non-teaching regional hospital in central/rural MA• Difficulty transferring patients to psych beds = lengthy boarding• Concept: reduce ED boarding by preventing ED visits• Opportunity: identify frequent ED BH patients in ED • Staff: PM and ED BH nurse navigator, 2 FTEs• Team: ED director, ED BH team, ED CM, community mental health, CHC• Intervention: collaboration between community mental health provider, crisis
team, community health center, ED, documented identification, referral workflows between all 3 entities, standing orders for frequent BH ED users to facilitate med clearance; establishment of individualized care plans
• Impact: successful linkage; social work / harm reduction orientation• 1 patient who had 26 ED visits in March has had no ED visits since May!
• Time to implement: 10 weeks.
ED-based Interventions – BH
ED- based interventions• Carroll County MD, Public Health - Hospital Collaboration• Peer specialist as BH navigators across settings; based in ED
Peer Specialist Impact
Patient-Centered Community Health Worker Intervention to Improve Posthospital OutcomesA Randomized Clinical Trial; Kangovi et al JAMA Internal Medicine April 2014• Target population: 683 low income, uninsured, Medicaid patients
• 237 (35%) declined to participate• 446 were randomized to standard care or intervention (CHW)
• CHW intervention• Engaged w/ patients during hospitalization• Developed personalized action plans• Worked with patients at least 2 weeks
• Results: • Reduced recurrent 30-day readmissions (2.3% v. 5.5%)• Among 63 pts, recurrent readmissions 40% v. 15% for CHW
Community Health Workers/ Navigators
“High Risk Care Teams”• Identify using combination of clinical and non-clinical criteria
• History of high utilization, no PCP, numerous prescribers, numerous meds, behavioral health comorbidities, homeless….not “just” chronic disease
• In safety net – use a multi-disciplinary team• Navigator, behavioral health, social work, pharmacist, nurse, • “Prescriber” and in-home or urgent clinical decision maker – NP
• Address full complement of medical, social, logistical needs• Affordable medications regimens; timely prior authorization• Transportation• Stable housing• Navigating the healthcare system, asking questions, making appointments
• Don’t over medicalize – whole person, psychosocial• Start with the person’s priorities, Maslow’s hierarchy of needs
TRIPLE-AIM MEASUREMENT FOR ACCI PROJECTS
Updates & Discussion
Triple Aim Measurement Updates
1. ARCH2. CHCN3. GVHC4. Health Plan of San Joaquin5. MCHD6. MVHC7. ODCHC8. Petaluma9. Southside Coalition of CHCs
Triple Aim Measurement Technical Assistance OpportunitiesTeams may obtain coaching from Dr Amy Boutwell (up to 1 hour by phone). To schedule a call with Dr. Boutwell, please contact:
Roshani [email protected]
(650) 843-8145
In addition, teams may elect to partner with Dr. Grace Wang of AIR to develop the BSCF-funded Triple Aim Measurement Instrument. Please contact Dr. Wang for more information about this opportunity:
Grace Wang [email protected](650) 843-8191
THANK YOU!
Amy E. Boutwell MD MPPCollaborative Healthcare Strategies