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Home and Community Innovative Strategies for Safe Transitions and Care
W. June Simmons, CEOPartners in Care FoundationApril , 2013Care Coordination for your Older Patient Symposium
1
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
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)
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
Stratify Services for Increasing Needs
Community Agencies = crucial partners
Networks for Integrating Healthcare with Community-based Organizations
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
New Self Management Priorities
• New Medicare Peer Led Diabetes Program• Chronic Pain Management• New Target Populations for Spread– Veterans– UniteHere
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
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
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
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
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
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
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
Regional Model = centralized, cost- effective, efficient and experienced!
Individual Hospital Approach Each hospitals must hire, train,
manage and pay transitions directors and health coaches
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
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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
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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
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
22
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
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
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
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%.
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.
SNF Intervention: Enhanced Care Program
27
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)
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
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
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)
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.
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 .
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.
The Time is Now – drive the change
For more information contact:-June Simmons, Partners in Care Foundation-jsimmons@picf.org (818) 837-3775
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