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Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April , 2013 Care Coordination for your Older Patient Symposium 1

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Page 1: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Home and Community Innovative Strategies for Safe Transitions and Care

W. June Simmons, CEOPartners in Care FoundationApril , 2013Care Coordination for your Older Patient Symposium

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Page 2: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Partners in CareWho We Are…• Partners in Care is a transforming presence, an

innovator and an advocate to shape the future of health care

• We address social and environmental determinants of health to broaden the impact of medicine

• We have a two-fold approach: evidence-based models for practice change and for enhanced self-management

• Changing the shape of health care through new community partnerships and innovations

Page 3: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Active Patient Population Management

“System” Support: EHR, Data aggregation, Population Registries, Predictive Modeling, Decision Support , Practice Standards, Quality Measurement and Reporting, Accountability, Tele-Medicine, Tele-Health

Patient- Centered Shared Decision

Making

Traditional Benefit-Based Home Health

Palliative & Hospice Care

Complex Chronic Illness

Home Care & High Risk Clinic

Mild Chronic Illness & Care Support for Self Management

Episodic & Expected Care Preventive Services & Urgent Care

Self-Care & Wellness Programs & Health Education & Self-Serve Preventive Services

Hospital & Hospitalist-Extensivist Programs

Communication Care Transitions ER interventions

Efficient hospital use

SNFist and SNF

Program

Ensuring Care Implementation in the Community & at Home

• Home Social/Environmental Factors

• Patient Coaching• Transitions of Care

• Use of Community Resources• Comprehensive Care Centers

Optimal Discharge

(Hospital, ER, SNF, other)

Page 4: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Caring for the whole person – Non-medical services• Health results come from both medical

interventions and non-medical drivers• Much truth is found in the home• The non-medical drivers are powerful:– Environmental factors– Social Factors– Self-Management Factors

Page 5: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Stratify Services for Increasing Needs

Page 6: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Community Agencies = crucial partners

Page 7: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Networks for Integrating Healthcare with Community-based Organizations

Page 8: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Evidence-based programs• Stanford Chronic Disease Self-Management

(including online, Spanish, Arthritis, Pain, Diabetes, HIV versions)

• Fall Prevention– Matter of Balance & Healthy Moves

• Depression/Mental Health– Healthy IDEAS & PEARLS

• Physical Activity– EnhanceFitness, Fit & Strong

• Medication Safety– HomeMeds

Page 9: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

New Self Management Priorities

• New Medicare Peer Led Diabetes Program• Chronic Pain Management• New Target Populations for Spread– Veterans– UniteHere

Page 10: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Westside Care Transitions CollaborativePartners in Care Foundation and the UCLA Health System and Faculty Practice Group, including Ronald Reagan UCLA and Santa Monica UCLA Medical Centers, and St. John’s Health Center

Page 11: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Westside Care Transitions CollaborativeMajor Initiatives

Identify patients at high readmission risk Redesign patient flow/discharge planning functions from hospitals

Create new gap-filling resources to smooth patient transfers(e.g. Care transitions, new UCLA urgent care center for post-discharge; in-home medical care program; home palliative care)

Expand offerings of evidence-based models for self-care (e.g., Stanford University’s Chronic Disease Self-Management Program)

Develop standardized transfer tools, processes and quality monitoring for SNFs

Adopt home care best practices, including piloting and spreading a standard of one-hour response time 24/7 for home health and hospice admissions, whether discharged from hospital or ER

Page 12: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Westside Care Transitions Collaborative

A Root-Cause Analysis (RCA) found the following areas in need of improvement:

• Coordination and communication among providers

• Medication management

• Timely support for patients discharged home

• Communication with patients and families about post-hospitalization care needs and alternatives

• Patient activation to improve self-care skills

• Late life care and decision support services including advance care planning for life-limiting illness

Page 13: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

In-Home Assessment and Care Coordination• Care Transitions Interventions • Coaching vs. Care Coordination• Identification of what is needed• Determination of best location to obtain what

is needed• Natural supports• Purchased services and supports

Page 14: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

A Key Problem – Medications at Home

• Medication Errors at home are:– Serious: They cause approximately 7,000

deaths per year in the US– Costly: Annual cost of drug-related illness and

death exceeds $170 billion– Common: Up to 48% of community-dwelling

elders have medication-related problems– Preventable: At least 25% of all harmful

adverse drug events are preventable

Page 15: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

A Solution – HomeMeds

• In-home collection of comprehensive medication list, how each drug is being taken, plus vital signs, falls, symptoms, and other indicators of adverse effects

• Use of evidence-based protocols and processes to screen for risks and deploy consultant pharmacist services appropriately – chosen for physician response

• Computerized medication risk assessment and alert process with comprehensive report system

• Consultant pharmacist addresses problems with prescribers

Page 16: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Care Transitions: Buy vs. BuildHypothetical Los Angeles County Scenario

Patients discharged to geographically disparate parts of the County

Lancaster

San Pedro

Woodland Hills

Considerations: Driving distances to visit patients in home setting following discharge Arranging for local services (transportation, meals, medical supplies, etc.) Training and experience hospital (clinical) staff vs. community-based care Language / Culture Data collection / patient monitoring becomes more complex

Page 17: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Regional Model = centralized, cost- effective, efficient and experienced!

Individual Hospital Approach Each hospitals must hire, train,

manage and pay transitions directors and health coaches

Page 18: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Challenges in Providing End-of-Life Care

• Fragmentation of care• Aging population• Costs of medical care– 25% of Medicare revenue is spent on 5% who die each year – Average cost of care in last year of life is $26,000 (1996 costs)– Average cost of care in last 2 years $ 58,000

Page 19: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

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Home Based Palliative Care Model

• Bridge traditional medical care and Hospice care• In home end-of-life care for patients with one year

life expectancy• Blended model of care• Shift focus of care from hospital to home• Honor patient choices for own care

Page 20: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

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• Pain & other symptom management– comprehensive primary care to manage underlying

conditions– aggressive treatment of acute exacerbation per patient and

family request

• 24 hour phone support, visits if necessary• Volunteer & bereavement services• Transfer to hospice if appropriate

Core Components of Palliative Care

Page 21: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Unadjusted Medical Service Use (n=297)

0.290.672.2

7.34

1.773.18 4.42

9.11

30

12.39

0

5

10

15

20

25

30

Mea

n N

um

ber

of

Day

s/V

isit

s

*ED *Hospital SNF *MDOffice

*HomeVisits

PalliativeUsual Care

* P<.01

Page 22: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

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Total Service Costs

$12,670

$20,221

$0

$5,000

$10,000

$15,000

$20,000

$25,000

All Costs

Palliative

Usual Care • Adjusted costs of care for those in PC were 32.6% less than those receiving UC

• Saves $7,551

p<.001 F=16.66

n=292

Page 23: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Acute Care Service Use (n=297)

20%

32%36%

58%

0%

10%

20%

30%

40%

50%

60%

Per

cent

Usi

ng

*ED *Hospital

Palliative

Usual Care

* P<.01

Page 24: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Other Causes of Readmissions

• Discharge processes must be realigned• Skilled Nursing Facilities and Home health

caused 30% of readmits in our targeted hospitals

• Gaps in care must be identified and remedied– Innovations are emerging

Page 25: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

SNF Transitions Innovation: Results

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Discharged to SNF Home with Home Health

Baseline30-day readmission rate 25% 14%

Pilot Period30-day readmission rate 11% 7%

By engaging in robust performance improvement, Cedars-Sinai Health System identified interventions that reduced 30-day

readmissions for SNF & Home Health patients by more than 50%.

Page 26: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Root Causes for SNF Readmissions

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• Infrequent visits by a physician or advanced practice nurse

• Patient not seen by physician within first week of discharge

• SNF nursing staff unable to communicate with physician when needed

• Patient/Family not communicating Red Flags to SNF staff

• Lack of clinical oversight on weekends

• Medication Management/Reconciliation between hospital and SNF

• Patients at end of life without an Advance Directive/POLST completed

A chart review of 150 SNF patients revealed recurring factors that likely contributed to preventable readmission within 30 days.

Page 27: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

SNF Intervention: Enhanced Care Program

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Pilot 1: October/November 2011

Pilot 2: January/February 2012

A Nurse Practitioner followed 115 CSMC patients in the SNF.

• They saw the patient in the hospital

• They saw the patient in the SNF 24 hours after discharge

• They saw the patient 1-2 times per week in the SNF

• When they saw something, they said something… (to the patient’s MD, the SNF staff & to the family)

Page 28: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Cycle I: October/November 2011

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The first pilot demonstrated a 60% reduction in 30-day readmissions.During these two months, readmissions occurred mostly on weekends,

when Nurse Practitioners were not working.

Readmissions from SNF

Readmissions from SNF

Page 29: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Cycle II: January/February 2012

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The second pilot, in which NP coverage was extended to include weekends, yielded a 50% reduction in 30-day readmissions.

During this iteration, the NPs prevented 13 likely readmissions.

13 Potential readmissions averted by Nurse Practitioner • Duplicate Medication Administration averted (Warfarin)

• Patient’s family’s concerns alleviated (2 different patients)

• Patient’s medication concerns addressed

• Weekend contact with MD with lab results & Rx dosage issues

• Patient code status changed to DNR/DNI, patient expired in SNF

• POLST form completed in SNF- patient expired in SNF

Page 30: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Cycle I: Enhanced Home Health

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WHO All CSMC Discharges to a high volume Home Health agency

WHAT

In-hospital visit by nurse + 6 touch-points after discharge• Home visit within 48 hours of discharge• Friday “Tuck-in” Phone call• Weekend Visits• Medication Reconciliation• 24-hour call number staffed by a nurse

WHEN November 1 – 30, 2011

WHY To determine if more rigorous home health services can prevent readmissions. (Baseline = 19% readmit rate)

Page 31: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Root Causes for Home Health Readmissions

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• Patients & families often turn away Home Health agencies after hospital discharge

• Inconsistency in frequency of home visits post-discharge

• 45% of readmissions occurred on a Saturday or Sunday

• Patient/Family not communicating Red Flags to Home Health agency

• Medication Management/Reconciliation

• Physicians not responsive when Home Health Agencies have questions/concerns

A chart review of 45 Home Health patients revealed recurring factors that likely contributed to preventable readmission within 30 days.

Page 32: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Enhanced Home Health

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Only 6.8% of the 59 TOC patients were readmitted within 30 days of discharge.This rate is less than 50% of the baseline rate observed during FY 2011.

Patient Population Time Frame% Readmitted

(All-Cause)CSMC discharges home with Home Health (any agency) Jul 2010 -Jun 2011 19%

CSMC discharges home with TOC Home Health Agency* Jul 2010 -Jun 2011 14%

Test of Change (n=59 patients) November 2011 6.8%

* The agency selected for the Test of Change had the highest proportion of Home Health referrals from Cedars-Sinai Medical Center .

Page 33: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

Conclusions

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• Readmissions can be prevented when hospitals take the lead to collaborate with partner agencies in the community.

• Intervening during the 14 days following hospital discharge is crucial for preventing avoidable readmissions.

• Clinical resources in the community (SNF, Home Health) need to be bolstered on weekends.

• Involvement & leadership from Primary MD are key in executing improvements related to readmissions.

Page 34: Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for

The Time is Now – drive the change

For more information contact:-June Simmons, Partners in Care [email protected] (818) 837-3775