Improving Care Transitions and Decreasing Readmissions

through Public and Private Partnerships

11th Annual Small & Rural Hospital Conference November 9, 2011

What is “Transition of Care”

The movement of patients from one health care practitioner or setting to another as the individual’s condition and care needs change

Occurs at multiple levels Within Settings

ICU Ward

Between Settings Hospital Home or Hospital Long Term Care Facility

Across health states Curative care Palliative care/Hospice

(c) Eric A. Coleman, MD, MPH

Ineffective Transitions lead to Poor Outcomes

Wrong treatment Delay in diagnosis Severe adverse events Patient complaints Increased length of stay Increased healthcare costs

Increase in Care Transitions

53% increase in patients discharged from hospital to home health

25% increase in patients discharged from hospital to nursing homes or rehab facilities

50% of older adults discharged from the hospital

to long term care facility experienced 4+ transitions to another institution over 12-months

Understanding Rehospitalizations

Who is at risk of Rehospitalizations? According to IHI…Individuals with:

Chronic Illnesses (heart disease, COPD) Frail Elderly In Nursing Homes or Receiving Home Health End-of-Life Psychiatric Illnesses Substance Abuse Complex Social Challenges (poverty)

20% Medicare Beneficiaries readmitted within 30 Days

33% readmitted within 90 Days

Hospitalizations account for 33% of total Medicare $

Readmissions result in $17.4 Billion annually

76% of Medicare readmissions potentially avoidable

Estimated $12 Billion Preventable Expenditures

Readmissions: By the Numbers

The Challenge

“If re-hospitalizations are frequent, costly, and able to be reduced,

why haven’t they been?”

Hospital-level barriers Community-level barriers

State-level barriers

How does our community navigate this transition?

Nursing Home

Assisted Living

Rehabilitation Continuing Care

Retirement Community

Home

County Council/

Department on Aging

Area Agency

on Aging

Cooperative Extension

Mental Health

Provider

Community Resource Connection

Home Health Care

Senior Center

Adult Day Services

Faith Community

County Social

Services

?

New Models of Care

There are a number of proven & promising models to improve outcomes during transitions:

Common Elements:

Interdisciplinary Communication/Collaboration Transitional Care Staff Patient Activation Enhanced Follow-up (by phone / home visit)

Transitional Care Models Care Transitions Intervention (www.caretransitions.org)

Transitional Care Model (www.transitionalcare.info )

Project RED (www.bu.edu/fammed/projectred)

Project BOOST (www.hospitalmedicine.org/BOOST)

Resources National Transitions of Care Coalition’s Compendium

(www.ntocc.org) “Health Care Leader Action Guide to Reduce Avoidable Readmissions” (www.commonwealthfund.org)

4 Steps for Hospital Leaders

1. Examine your hospital's current rate of readmissions

2. Assess and prioritize your improvement opportunities

3. Develop an action plan

4. Monitor your hospital’s progress

Evidence-Based Strategies Hospitalization

Risk screen patients Tailor Care Communication “Teach-back” Education Interdisciplinary Teams End-of-life Wishes

At Discharge

Discharge Planning

“Teach-back” Education

Schedule F/U Appts.

Medication Management

Instructions for NH

Partnerships with NH

Post-Discharge

Self -Management Conduct Home Visit

F/U by Telephone

F/U with LTC Facilities

Personal Health Info

Community Networks

Aging & Disability Resource Centers: ADRCs The federal ADRC initiative began with 3 core

functions: Awareness, Assistance & Access

The set of expectations has grown over time to include improving care transitions

AoA and CMS are viewing ADRCs as the platform to catalyze broader systems change

Health reform adds new fuel to the fire! $500M - Section 3026: Community-Based Care Transitions Program

ADRCs - Local Core Collaborators Consumers Aging Services Agencies Disability Services Agencies In-Home services Senior Centers Community Agencies Dept. of Social Services Area Agencies on Aging Community Health Centers Hospitals

Anson

Beaufort

Bertie

Brunswick

Carteret

Columbus

Craven

Duplin

Gaston

Gates

Greene

Halifax

Harnett

Hertford

Hoke

Hyde Johnston

Jones

Lee

Lenoir

Lincoln

Martin

Moore

Nash

Northampton

Onslow

Pender

Pitt

Robeson

Sampson

Scot- land

Tyrrell

Union

Wayne

Wilson

Alam

ance

Alleghany Ashe

Caldwell

Caswell

Catawba

Chatham Davidson

Davie

Forsyth Franklin Guilford

Iredell

Person

Randolph

Rockingham Stokes Surry Warren

Watauga Wilkes

Yadkin

Wake

Avery

Cherokee Clay

Graham Henderson

Buncombe McDowell

Macon

Polk

Rutherford Swain

Madison

Mont- gomery

Stanly

Cabarrus

Rowan Burke

Orange

Durham

Bladen

Dare

North Carolina: Community Resource Connections (CRCs)

CRCs in Operation

Program Areas where CRC Development is in process with launches in mid-2012

Programs Areas Launching or Expanding Fall 2011

DHHS Office of Long Term Services & Supports

South Carolina ADRCs

Person-Centered Hospital Discharge Planning Model Enhance the ability of community organizations to

plan for person-centered hospital discharges

Develop models that ensure that individuals have maximum options to return home

Create processes for communities to share tools, resources, outcomes & lessons learned

Lessons Learned

Identify a Change Agent

Bring Stakeholders Together & Make the Case

Encourage Collaboration: Public & Private

Celebrate Early & All Successes

Demonstrate Impact (Now vs. Future)

Choose Intervention – Outcomes – Fit

Capture the Data

Sustainability is Critical!

A Community-Based Approach

“Communities across the US are

beginning to consider transitions of care as a community–based challenge that requires shared ownership and close collaboration across settings.” (Institute for Healthcare Improvement)

Community Care of North Carolina (CCNC) Transitional Care Highlights

Jennifer Cockerham, RN, BSN, CDE Director of Chronic Care and Quality Improvement jcockerham@n3cn.org Communitycarenc.com

North Carolina Medicaid 1,516,803 Medicaid Recipients

Medicaid Managed Care *Community Care of NC (CCNC) 1,127,958 Enrollees 1542 Practices 4500+ Providers *Carolina Access I (CA I = 57,092) Straight Medicaid (331,753)

Community Care Networks

Cherokee

Graham

Swain

Clay Macon

Jackson

Haywood

Madison

Buncombe

Henderson

McDowell

Rutherford

Polk

Burke

Cleveland

Watauga

Caldwell Alexander

Catawba

Lincoln

Gaston

Ashe

Wilkes

Alleghany

Surry

Yadkin

Iredell

Mecklenburg

Union

Stanly Cabarrus

Rowan

Davie

Stokes

Forsyth

Davidson

Anson

Rockingham

Guilford

Randolph

Montgomery

Richmond

Caswell

Chatham

Orange

Person

Lee

Moore

Hoke

Scotland

Robeson

Cumberland

Harnett

Wake

Franklin

Warren

Johnston

Sampson

Bladen

Columbus

Brunswick

Pender

Duplin

Wayne

Wilson

Nash

Halifax

Northhampton

Edgecombe

Pitt

Greene

Lenoir

Jones

Onslow

Craven

Pamlico

Beaufort Hyde

Martin

Bertie

Hertford

Gates

Washington Tyrrell

Dare

Alam

ance

Durham

Granville

Hanover

Chow

an

a r

Legend AccessCare Network Sites Community Care Plan of Eastern Carolina AccessCare Network Counties Community Health Partners Community Care of Western North Carolina Northern Piedmont Community Care Community Care of the Lower Cape Fear Northwest Community Care Carolina Collaborative Community Care Partnership for Health Management Community Care of Wake and Johnston Counties Community Care of the Sandhills Community Care Partners of Greater Mecklenburg Community Care of Southern Piedmont Carolina Community Health Partnership

CCNC Infrastructure

14 Networks - private, non-profit organizations Community-based, physician-led, emphasis on

medical homes Local partners = hospital, health department,

DSS, specialists, etc Partner with the state to better manage Medicaid

population = improve quality and contain cost Enhanced pmpm to Medical Home

FOCUS of CCNC

improved quality, utilization and cost

effectiveness of chronic illness care

Chronic Care Model Over time, visits/interactions (planned and acute) will

meet patient needs and assure the delivery of proven clinical and behavioral elements of care.

INFORMED PREPARED ACTIVATED PROACTIVE PATIENT TEAM IMPROVED OUTCOMES http://www.improvingchroniccare.org

Care Management Support to the Medical Home

Improved Care

Process Improvement

Evidence-Based Guidelines

Provider Impact

Improved Utilization

Outcome Improvement

Education, Referrals, Follow-Up

Patient Impact

Care Manager

Chronic Disease Prevalence of NC’s ABD Medicaid Population

3 or More Major Co-morbidities

43% 3 or More Major Co-morbidities

Major Co-morbid Conditions

Within the 200,000 ABD Medicaid Recipients 45% Hypertension 24% Diabetes 14% Asthma 14% COPD 13% Ischemic Vascular Disease 12% Neurological Disorders 6% Chronic Kidney Disease 3% Heart Failure 41% Mental Health conditions p

$0 $1K $2K $3K $4K $5K $6K $7K $8K $9K $10K $11K $12K $13K $14K $15K $16K $17K $18K $19K $20K

Expected Preventable Inpatient Costs for this CRG

Actual-to-Expected Difference

Treo PPL

All individuals within the same Clinical Risk Group (CRG)

ED and Inpatient Utilization of ABD Population (over 6 month period)

At Least 1 ED Visit At Least 1 Hospitalization

41%17%

t

Susan

10 y.o. with asthma ED visit on the weekend Multiple ED visits over

the last 6 months for asthma

More prednisone fills than pulmicort fills in previous year's drug claims

No Asthma Action Plan

Susan

Informatics Center ED & Hospital Visit Report Patient contact - left message for mom to call PCP

and make an appointment PCP RN notified CM of appt date/time CM conference with MD prior to appt CM met with Susan, parents, and MD MD completed AAP while CM provided asthma

education and resources

TARGET : Tool for Adjusting Risk - A Geriatric Evaluation for Transitions 7 P Risk Scale: 1. 1. Prior Hospitalization 2. 2. Problem Meds (Coumadin, insulin, Digoxin)

3. Punk (depression) 3. 4. Principal diagnosis 4. 5. Polypharmacy 5. 6. Poor health literacy (50% higher risk) 6. 7. Patient support

Project BOOST (Better Outcomes for Older Adults thru Safe Transitions)

www.hospitalmedicine.org/BOOST

Hospital Readmits

17.6 % are readmitted within 30 days of discharge 6% in the first week

50% had not followed up with PCP or

any physician before being readmitted 25-30% occur at a different hospital

Institute for Healthcare Improvement t

Medication Management Issues

o High Risk Meds (Coumadin, insulin, digoxin)

o Polypharmacy o 20% of pts D/C’d from hospital at least 1

medication discrepancy (UCHSC) o 1/3 of meds prescribed at D/C are not

taken (Beers et al) o New meds at D/C not noted in outpt.

record 50% of time

Transitional Care

“ A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location”

Source: Position Statement from the American Geriatrics Society, 2003

CCNC Transitional Care 02/2011

I

Charlie 62 y.o. with developmental

disability and multiple chronic conditions

Very little family support Dependent on CAP-DA and

other in-home services prior to admit

2 month hospital stay wound care and unstable conditions

Multiple team meetings during inpatient stay to coordinate discharge plans

Linked to multiple services - CAP-DA, Home Health, Palliative Care, DME, Specialists

Charlie

Discharged home on Labor Day Home Visit by CCNC Care Manager Home Health for B.I.D. dressing changes had not

yet begun No dressing change supplies Pain regimen had been denied by Medicaid had

not been communicated, resulting in 3 days without pain med

CAP-DA was unable to resume services until 3 days after discharge, resulting in no assistance with personal care

CCNC Transitional Care Process

1)Notification/identification of hospitalized patients 2)Screening & Assessment Process 3)Hospital Visit 4)Facilitate Optimal Hospital Stay and Discharge

Plan 5)Home Visit with Medication Reconciliation/med

management 6)Medical Home Linkage 7)Disease Management, Red Flags, Community

Linkages, improved self-management

FACE -TO-FACE INTERACTIONS

Hospital Home Medical Home

The Primary Role of the CCNC CM in the Transitional Care process is to:

facilitate interdisciplinary collaboration across transitions

encourage the patient and caregiver to play a central and active role in the formation and execution of the plan of care

promote self-management skills and direct communication between the patient/caregiver, primary care provider, and other service providers

achieve medication reconciliation through consultation with network pharmacist, the hospital, the PCP, the Specialists, and the patient

Self-management Tasks of Chronic Care Patients

Medical management of condition (MEDICAL) Creating and maintaining new

meaningful life roles (SOCIAL) Coping with anger, fear, frustration of

having chronic condition (EMOTIONAL)

Based on work by Clark, Corbin, Strauss and Glaser

Highlights of our Progress

Real-Time data, Hospital & ED reports in IC, ADT CM embedded in hospitals CM & Pharmacists teams Process for Face-to-Face encounters with patient Support to Medical Home/PCP follow-up appointments Work with hospitals to obtain more complete D/C Instructions Strong linkages with Mental Health Providers Provider Portal & Care Alerts Addition of Psychiatrists & Behavioral Health Pharmacist Palliative Care Physician Champions Value of Home Visits Enhanced features in CMIS to track and evaluate Transitional Care The value of Community Partnerships

Embedded Staff

Care Managers 118 practices 48 hospitals Pharmacists 14 practices 18 hospitals

What we are learning…

Complexity of the population – medically & socially Majority have either a dominant or moderate chronic

condition, a malignancy, or a catastrophic health condition

Motivational Interviewing techniques are key for positive patient engagement

Population management appears to be having a positive impact on access to care, ED, and inpatient utilization

2011 cumulative Medicaid costs for enrolled ABD population (dual and non-dual combined) were $196 lower per member per month for the fiscal year as compared to fiscal year 2008.

Challenges…

Defining the “impactable” patient & interventions

Incorporating palliative care, mental health & other new info without creating more silos

Challenges obtaining Real-Time Hospital Data

Unable to locate the patient

Narrow time frame for the most beneficial intervention

Promoting effective self-management

Growing population and level of complexity

Building capacity in the Medical Homes

Competing agendas

Susan

“It was a positive experience. Mom said the ED told her to call and schedule a follow-up visit, but she had forgot until she received my voice message. The family is looking forward to Susan being in better control of her asthma than she has been.”

- CCNC Care Manager

THANK YOU

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Care Transitions and

Readmissions at Chatham Hospital

Small and Rural Hospital Conference November 9, 2011

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Chatham Hospital Facts

• Critical Access Hospital • Owned by the UNC Health Care System • Located in Siler City, NC • Contract with UNC Health Care System for Emergency

Room and Hospitalist physician coverage

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Caswell Person Granville

Vance Warren

Franklin

Northampton Halifax

Durham

Wake Chatham

Nash Edgecombe

Wilson

Johnston

Wayne Lee

Moore Harnett

Sampson

Duplin

Pender

Brunswick

Columbus

Bladen Robeson

Cumberland Hoke

Scotland

Guilford

Randolph

Montgomery

Richmond

Stokes

Forsyth

Davidson

Rowan

Stanly

Anson Union

Mecklenburg

Cabarrus

Iredell Davie

Yadkin

Surry

Alleghany Ashe

Wilkes

Alexander

Catawba

Lincoln

Gaston Cleveland

Burke

Caldwell

Watauga

Avery

McDowell

Rutherford

Polk

Mitchell

Yancey

Buncombe

Henderson

Transylvania

Haywood

Madison

Swain

Jackson

Macon

Graham

Clay Cherokee

Onslow

Jones

Lenoir

Greene

Pitt

Martin

Bertie

Hertford

Gates Camden

Pasquotank

Dare Tyrrell

Washington

Beaufort Hyde

Craven

Pamlico

Rockingham Currituck

Perquimans Chowan

Carteret

Orange

New Hanover Chatham Hospital

Chatham County

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Why is this a priority?

Partnership for Patients • Keep patients from getting injured or sicker • Help patients heal without complication

We need to fix things in our hospital that are not working Payors are paying more attention and are incentivizing We are all in this together because we share patients It is the right thing to do

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There are many causes of readmissions

• Exacerbations of conditions

• Complications of care

• Medication issues

• Missed (or missing) follow-up appointments

• Confusion regards discharge instructions

• Patient non-compliance

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Small Hospital Challenges

Small patient volumes Hospital has limited resources Generally less advantaged patients

• Lower income • Less education

Fewer community options

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What is Chatham Hospital’s 30-day readmission rate?

Patients Too few to analyze 68 100 Readmits 15 18

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Chatham Hospital Status Focus on appropriate transition placement and prevention of

unnecessary readmissions

Majority of patients are elderly

Frequent ED visits from nursing home and assisted living residents

Hospitalists rotate from UNC Hospitals • Accustomed to pressure to discharge quickly • Chatham Hospital length of stay dropping • Readmissions are increasing ??

Many inpatients discharged to local nursing homes or assisted living facilities

Implementing CPOE with new discharge instruction software

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Efforts to Reduce Readmissions and ED Returns

Determine baseline readmission and ED returns

Obtain buy-in from local nursing homes and assisted living facilities

Evaluate “Hand Off’ between Chatham Hospital staff and Nursing/Assisted Living staff

• Evaluate nursing home/assisted living documentation provided to hospital

• Interview nursing home/assisted living staff

Develop an educational program based on evaluation findings

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UNC Hospitals Partnership

Pilot study with Vendor for patient-centered hospital to home program

• Discharge care plan aligned with hospital medical record

• Personalized transition liaison services

• Medication management and guidance

• Compliance monitoring

• 24-hour nurse assist line

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Questions or Comments? What is happening at your facility?

Heather Altman

Carol Woods Retirement Community haltman@carolwoods.org / 919-918-2609

Jennifer Cockerham

Community Care of North Carolina jcockerham@n3cn.org / 919-696-8880

Carol Straight

Chatham Hospital CStraight@ChathamHospital.org / 919-799-4001

THANK YOU!