PASS Presentation

Independent Living Systems, LLC5201 Blue Lagoon Drive, Suite 270Miami, FL 33126Tel: 305 262 1292

www.ilshealth.com|ILS Strictly Company Confidential

CARE TRANSITION INTERVENTIONS FOR ACCOUNTABLE CARE ORGANIZATIONS

Independent Living Systems, LLC5201 Blue Lagoon Drive, Suite 270Miami, Florida 33126Tel: 888 262 1292

www.ilshealth.com|

Jeffrey T. King, RN, MBA, CDESVP, Clinical Operations



Care Transition Intervention for ACOsAgenda

Introduction & ILS Overview

Overview of ACO Requirements

Care Transition Requirements

PASS Care Transition Intervention

CMS Readmission Program

Program Outcomes

Keys to Successful Care Transition Program



Care Transition Intervention for ACOIntroduction & ILS Overview

Tools

ILS offers innovative health and social support services designed to improve quality of care for health plans, provider organizations and individuals.

Experience in Managed Long-Term Care, Population Care Management & Home & Community Based Services.

Non-traditional products & services proven to directly impact outcomes: Care Transitions (Readmission Prevention) Nutrition Management & Home Delivered Meals Home & Community Based Service Coordination Managed Long-Term Care

Turnkey sustainable solutions to integrate into existing business workflows and technology infrastructures.

Independent Living systems (ILS)



Care Transition Intervention for ACOAccountable Care Organization Overview

The ability to provide, and manage with patients, the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care and possibly post acute care.

Partnerships between hospitals and physicians / healthcare professionals.

Place the patient & family in the center of all activities.

“An ACO will attend carefully to handoffs, especially as patients journey from one part of the care system to another. It won't drop the baton. It will pass the baton.” - Dr. Don Berwick, CMS

The Key Requirements




The Current Cycle

PCP

SPC

OPT / DIAGINPT

(Acute / Sub-Acute)

HHS




The Current Cycle (REALITY)

PCP SPC OPT / DIAGINPT

(Acute / Sub-Acute)

HHS




The Cycle Where It Should Be

Patient / Family /

Caregiver

PCP

SPCOPT / DIAG

INPT

HHS




The Care Transition Focus

Patient / Family /

Caregiver



Care Transition Intervention for ACOILS Care Transition Program - PASS

PASS focuses on the care transition between the institutional setting back to the home & community setting. Institutional – Acute Inpatient, Sub-Acute.

Adapted from the Care Transition Intervention (CTI) model developed by Dr. Eric Coleman, University of Colorado.

Designed to integrate into existing medical management or operational processes: Is Not a replacement for case management, discharge planning or home

health Is patient advocacy, education, communication and coordination.

Post Acute Support System - PASS




Program driven by the PASS Coach LPN, RN, LCSW Assigned by facility (Hospital) and visit that facility each day

Program Supported by PASS Care Coordinators Full-service call center Care Management & support service

PASS Coaches & PASS Care Coordinators communicate and manage patient cases via web-based PASS System

Post Acute Support System - PASS




HOSPITAL VISIT: Face-to-face introduction of the program and core pillars, relationship building with patient & caregiver.

HOME VISIT: 48 – 72 hours post discharge, visit with patient & caregiver, reinforcement of core pillars.

FOLLOW-UP CALLS: Day 2, 7, 14 & 30 post discharge, coordination of services & referrals.

PASS Interactions




PASS Core Pillars (* Original CTI Pillars)

Medication Self-Management*

Nutrition & Post-Discharge Meals

Personal Health Record*

Physician Follow-Up*

Red Flags Signs & Symptoms*

Home & Community Based Services



Care Transition Intervention for ACOCMS National Readmission ProjectTools

14 QIOs with 14 target communities 70 Hospitals, 277 SNFs, 316 HHAs, 1.1 M Medicare Beneficiaries

Florida QIO: FMQAI – Miami-Dade Community 11 Hospitals, 45 SNFs, 12 HHA, 60,000 Medicare Beneficiaries ILS subcontractor to provide Care Transition Intervention

m

Nutrition management and post-discharge meals; Florida Department of Elderly Affairs.

Home and Community Based Services; Florida Area Agency on Aging Community Living Program.

CMS Project

Added Components & Partnerships



Independent Living SystemsSample Program Outcomes – Readmission Rate

30 Day Readmission Rate (N=8282)0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00%

16.00%

18.00%

17.25%

10.15%8.65%

Before PASS (6 months ending 10/2009)

With PASS (6 months ending 6/2010)




Readmission Costs PMPM (N=8282) $-

$5.00

$10.00

$15.00

$20.00

$25.00

$30.00

$35.00

$40.00

$45.00

$43.88

$21.35

$17.93

Before PASS (6 months ending 10/2009)



Independent Living SystemsSample Program Outcomes – Readmission Costs



Independent Living SystemsProgram Outcomes – Care Transition

CTI - CMS Readmission Project0.0%

5.0%

10.0%

15.0%

20.0%

25.0%23.1%

14.5%

24.8%

7.6%

0

BaselineAccepted & Completed (N=945)Refused / Not Completed (N=339)CTI Plus (Nutrition) (N=237)CTI Plus Nutrition & CLP (N=27)



Independent Living SystemsProgram Outcomes – Care Transition

Community / Population Rate

PASS Coached Rate (Intervention)

Non-Coached Rate

Hospital 1 20.26% 8.76% (N=186) 23.26% (N=45)

Health Plan 1 17.25% 10.15% (N=8282) 13.60%

CMS (Overall) 23.10% 14.50% (N=945) 24.8% (N=339)

CMS (DOES – Nutrition) 23.10% 7.6% (N=237) 13.62% (N=57)

CMS (AoA – CLP) 23.10% 0% (N=27) N/A

Other Benefits

Reduction in SNF Utilization (transfers; discharges to SNF) 26%

Reduction in Rx Cost / Utilization 36%



Care Transition Intervention for ACOKeys to Successful Program

The “Must Haves” of the Program

Keep to the original CTI model: Hospital Visit; Home Visit; Follow-up Calls

Patient-Centered and Holistic in approach: Social Support / Home & Community Based Services

Provider Collaboration: early involvement in program development and coordination; PCP, SPC, HHA, Facilities



Care Transition Intervention for ACOKeys to Successful Program

The “Must Haves” of the ProgramTechnology & Systems: Patient tracking, data collection, communication & coordination, reporting & analysis

Community Based Organization Collaboration: Relationships with ADRCs, AAAs & other CBOs to coordinate and link HCBS

Enhanced Provider Communication & Coordination: processes for communicating CT information (PHR, Med Rec) to providers.



Thank You

Jeffrey T King, RN, MBASVP, Clinical Operations

Email: [email protected]

Documents

PASS Presentation