option d adrc evidence based care transitions grant program

Option D ADRC Evidence Based Care Transitions Grant Program

Evaluator Workgroup CallNovember 14, 2011

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL [email protected] | WEB www.aoa.gov

Agenda

• Welcome and Introductions

• Option D Grantee Spotlight: Florida

• Future Work Group Calls

• Resources

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL [email protected] | WEB WWW.AOA.GOV

Question for Option D Grantees

from California

Are any states implementing a streamlined online data collection process?


Hawaii*

Alaska *

MT

ID*

WA†

CO†

WY

NV

CA*†

NMAZ

MN

TX†

KS*

IA

WI

IL†KY

TN†

IN†OH

MI

ALMS

AR

LA

FL†

SC*

WV VA

NC*

PA†

VT

RI†

NH†OR*

UT

SD

ND

MO*

OK

NE

NY†

CT†MA†

DC

Care Transitions Activities

DE

Guam

NorthernMariana Islands

35 States with ADRC program sites currently conducting care transitions through formal intervention (Total of 97 active sites with an additional 49 sites within active states currently planning to conduct care transitions)

10 States with ADRC program sites currently planning to conduct care transitions through formal intervention (Total of 13 sites currently planning care transitions activities within states with no active sites)

GA

9 States not reporting current or planned care transition activities

Puerto Rico* Indicates state with current CMS Hospital Discharge Planning Model grant

†Indicates state with 2010 ADRC care transitions grant

MD*†

NJ

ME†

Option D Grantee Spotlight: Florida

• Presenters– Randy Hunt, CEO Senior Resource

Alliance– Steve Paquet, RN, MS, Hospital to Home

Project Director/Transitions Coach– Sarah Duncan, RN Transitions Coach– Sandi Smith, Community and Support

Services, Florida DOEA

Medicare Readmission Reduction ProgramEvidence-Based Care Transitions Intervention with

Home and Community-Based Services

A Hospital/ADRC Partnership

Problem Statement

Arbaje AI et al. Postdischarge Environmental and Socioeconomic factors and the Likelihood of Early Hospital Readmission Among Community-Dwelling Medicare Beneficiaries. The Gerontologist. 2008;48(4):495-504.

Program Goals

• Reduce potentially preventable Medicare readmissions in patients age 60 and older

• Increase awareness of the ADRC core functions– To “effectively navigate their health and other long-term

support options.” (Source: ADRC Program Overview)

• Influence health policy at the national level by:– Connecting health and community-based aging social

services through the hospital discharge planning process– Post-discharge “stabilization” or health recovery

Program ModelIntervention Combines:

The Care Transitions InterventionSM Evidence-Based Program

• Transitions Nurse (RN) Coach– 30-day transition support program– www.caretransitions.org

SRA - Aging and Disability Resource Center (ADRC)• Person-Center Transition Support and Options Counseling• Connection to Home and Community-Based Services• Information, Referral and Program Awareness

Target Population • Case Manager referred patients on Medicare, age 60 and older • CHF, AMI or Diabetes (complex co-morbidities)• Discharged to home in the Tri-county area.

Program FundingCHiC Grant - Initial Demonstration Grant •Two-Year Funding period: March 2010 - March 2012•Transition Coach/Program for Florida Hospital Orlando, East Orlando, and Winter Park Campuses

U.S. Administration on Aging- Option D: Evidence-Based Care Transition Expansion Grant•Two-Year Funding Period: February 2010 - September 2012•Added second Transition Coach/Program for Florida Hospital Altamonte, Celebration and Kissimmee

•SRA was the only active Hospital/ADRC Care Transitions project in Florida eligible to apply and receive this grant

Patient Sources· Case Management

Referrals· Self-Referrals· Caregiver

Referrals· ADRC Referrals

PROGRAM ELIGIBILITY CRITERIA· Medicare participants, age ≥ 60· Cardiovascular and/or Diabetes-Related Admission Diagnosis

(AMI/CHF and related)· NOT admitted from an institution· Orlando, Winter Park or East Orlando campuses· English Speaking or Caregiver Interpretation (reading, verbal

communication skills required for self-management)· Has Telephone and Physical Address· No Prior Diagnosis of Dementia for Self-Management CTI or

Responsible Caregiver if cognitive deficit is documented· Resident of Orange/Seminole/Osceola County· Discharge Care Plan to Home

CTI Evidence-Based Only

· Four Pillars Education

· 3 Follow-up Calls

· ADRC information

CTI Evidence-Based + HCBS

· Four Pillars Education

· 3 Follow-up Calls

· HCBS Services Ordered

· 701A Completed

· ADRC Resource Specialist Assigned

Enroll in Transitions Program

Hospital Visit(s)Orientation to Program

Discharge Plan MonitoringHCBS Need Assessment-

701 A, if applicable

Transitions Program Call and Introduction

· To Determine Patient/Caregiver Interest in Hospital to Home Transition Support Program after Discharge

Yes

Patient Discharged to

Home?

No Accepts

Follow-up Calls/Information Program

· CTI and ADRC Information· Provide 3 Follow-up Calls over

30 Days to Assess for Changes in Needs and Encourage Participation in CTI Pillars

ADRCOptions Support

· Assessment 701A· Follow-up for Long-term

Care Needs Through Assigned ADRC Resource Specialist

No Needs

Home Visit, Assess HCBS

needs?

Declines

Yes

HCBS Needs

Yes

Discharge to Home from Hospital?

Hospital to Home: Transitions Support Program Aging and Disability Resource Center (ADRC) with Evidence-Based Care Transitions Intervention

Targeting High-Risk Medicare Patients

No 30 Day ProgramFollow-up Calls: Check CTI StatusChange in Needs?

Enrollment EndsRefer to ADRC, if

needed

Enrollment Ends30 Days Post-

Discharge Unless Patient is Readmitted

No

Day 3 CallRequest Home

Visit?

Made possible through a grant from the Florida Hospital Foundation -- Community Health Impact Council

Accept Follow-Up

Calls Only?

Enrollment EndsRefer to ADRC Resources, if

needed

NoYes

Measurement of Outcomes

March 2010 - Sept 2011 Preliminary Analysis

Intervention Program Activity

CHiC (3 Hospitals) Target Total %

CM Referrals 720 359 50

Not Eligible 45 6Decline (Hospital Visits) 63 9Total Enrollment 360 251 70

AoA (3 Hospitals) Target Total %

CM Referrals 720 236 33

Not Eligible 12 2

Decline (Hospital Visits) 72 10

Total Enrollment 360 152 42

February 2011 - Sept 2011 Preliminary Analysis


March 2010 - Sept 2011 Preliminary Analysis

Intervention Program Activity

Intervention Type Total CHiC % AoA %

CTI 200 73 37% 127 64%

CTI Plus (CHiC Only) 120 120 100% 0 0%

ADRC (CARES/Triage) 59 56 95% 3 5%

Other 24 2 8% 22 92%

Total 403 251 62% 152 38%

Assigning Home and Community Based Services DOEA 701A

701A Scores for IADLs at 3 or more

Clients may receive more than one service


701A Scores for IADLs at 3 or more

*Clients may receive more than one service

“Other” will require DOEA data analysis/evaluation

CTI Plus - Funded Home and Community-Based Services March 2010 to September 2011 (CHiC Only)

Services Total 2010 2011 % Costs

1. Home-Delivered Meals 85 61 24 49% $ 8,147.50 2. Transportation 43 32 7 25% $ 4,732.78 3. Homemaker 45 38 11 26% $ 7,705.20 4. Other ADRC Programs Total* 173 131 42 100% $20,585.48

Average of $120 per client for 30-day transition period


FLORIDA HOSPITAL DRG Readmissions

Revenue Management Sep 10 - Mar 11

Admit Date Readmits Total Admissions Readmit RateSep 10 0 25 0.00%Oct 10 1 20 5.00%

Nov 10 1 15 6.67%

Dec 10 2 19 10.53%

J an 11 3 25 12.00%Feb 11 0 14 0.00%Mar 11 0 12 0.00%

Total 7 130 5.38%

Revenue Management Analysis- 130 Hospital to Home Admissions September 2010 to March 2011

CHiC Grant Only - Readmission Rate – 5.38%

Lessons Learned

Hospital Partnership•Identifying and keeping support of hospital administrative “champions” for the project

– Leadership changes– Need to communicate regularly

•Keeping the flow of referrals constant and time involved in acquisition and enrollment

– Case management turnover and workload• Need for constant education/re-education

– Case management leadership support is critical– Include Nurses and Nursing departments


Lessons Learned

ADRC Process•Integrating with ADRC under current workload of ADRC staff•“Transitions Support Network”

– Importance of education– Sub-Contracting


Lessons Learned

Patient-Centered Lessons•Importance of home visit AND follow-up calls•Lack of awareness of OAA, its programs and Aging Network•Improved quality of transition

– Stress reduction for patients and caregivers•Intervention becomes more than only 30-day transition support •Need of services after discharge vs. waiting lists•Avoidable vs. unavoidable readmissions


Lessons Learned

Care Transitions Process•Evidence-based intervention not always “cookbook”

– Patient factors– Caregiver factors– Hospital factors– Home Health factors


Questions for Florida team?


Future Work Group Calls

• Focus on sustainability• Current schedule (monthly)• Quarterly schedule?

– Intermittent ad-hoc topic-specific calls

• Other ideas?


Question from California

• Are any states implementing a streamlined online data collection process? – Currently, CA’s data collection process

involves an Access database• Request from the sites is to move it to an

online data collection process.

• Have other sites adopted this approach?– If so, what did you find beneficial or not?


Care Transitions Resources and Upcoming Events

• Innovation Advisors Program– Select and develop as many as 200

individuals from across the nation– Deadline to submit applications: November

15, 2011

• Health Literacy: New Skills for Health Professionals (IHI)– November 17, 2011, 2:00– 3:00 PM Eastern– Register

Care Transitions Resources and Upcoming Events

• Upcoming Work Group Call (combined with General Care Transitions Work Group)– December 12, 2011 at 1:00 PM Eastern– Register


Questions? Contact Caroline Ryan:

[email protected]


option d adrc evidence based care transitions grant program

Documents

care transitions activities

adrc care transitions

adrc program sites

care transitions10 states

department of health

support services

active states

human services