Transcript of National Readmission Conference May 7 th, 2014 June Simmons, CEO Partners in Care Foundation Care...
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- National Readmission Conference May 7 th, 2014 June Simmons,
CEO Partners in Care Foundation Care Transitions: Strategies that
are Working
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- Partners in Care Foundation Who We Are Partners in Care
Foundation is a non-profit center of innovation whose mission is to
change the shape of health care. We pursue our mission by
developing and advancing transformational models of care that
promote health, independence and quality of life
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- Health Reform: Moving From Volume to Value Infrastructures and
reimbursement are transforming; emphasis on prevention Major
consolidation unpredictable future The roles of hospitals,
physicians and payers are blurring The role of the community agency
is growing New broader partnerships are essential
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- Social Factors and Health Outcomes Societal-level social
determinants have individual-level impact 1 Gallant MP. The
influence of social support on chronic illness self-management: a
review and directions for research. Health Educ Behav.
2003;30(2):170-95.; DiMatteo MR. Social support and patient
adherence to medical treatment: a meta-analysis. Health Psychol.
2004;23(2):207-18.; Krieger J, Higgins DL. Housing and health: time
again for public health action. Am J Public Health. 2002;92(5):758-
68.; American Public Health Association. The hidden health costs of
transportation.
http://www.apha.org/NR/rdonlyres/A8FAB489-BE92-4F37-BD5D-
5954935D55C9/0/APHAHiddenHealthCosts_Long.pdf. Published February
2010. Accessed January 10, 2012.; Centers for Disease Control and
Prevention. CDC health disparities and inequalities report U.S.
2011. Atlanta, GA: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention, 2011.; Robert Wood
Johnson Foundation. Overcoming obstacles to health care.
www.commissiononhealth.org/PDF/ObstaclesToHealth-Highlights.pdf.
Published February 2008. Accessed January 10, 2012.; Shi L, Singh
D. The Nations Health. 8 th ed. Sudbury, MA: Jones and Bartlett
Learning, LLC; 2011. IssueOutcome Low education, lack of social
support, and social exclusion Poor self-management 2 and reduced
care plan adherence 3 Housing 4 and transportation 5 issues
Increased health care costs and utilization Health disparities and
psychosocial issues Preventable hospitalizations 6 and mortality
7
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- Low Ratio of Social to Health Service Expenditures in U.S.
Bradley E H et al. BMJ Qual Saf 2011;20:826-831 Copyright BMJ
Publishing Group Ltd and the Health Foundation. All rights
reserved.
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- Health Cares Blind Side RWJF Survey of 1,000 PCPs: 86% said
unmet social needs are leading directly to worse health. 80% not
confident in their capacity to address their patients social needs.
76% wish the healthcare system would cover cost of connecting
patients to services to meet health-related social needs. 1 of 7
prescriptions would be for social supports, e.g., fitness programs,
nutritious food, and transportation assistance. Health Cares BLIND
SIDE - The Overlooked Connection between Social Needs and Good
Health, Robert Wood Johnson Foundation, December 2011,
http://www.rwjf.org/content/dam/farm/reports/surveys_and_polls/2011/rwjf71795
http://www.rwjf.org/content/dam/farm/reports/surveys_and_polls/2011/rwjf71795
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- Because of the Concentration of Risk and Spending, Home and
Community Care Principles and Practices are Central to Improving
Quality and Reducing Cost
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- CBOs as part of the healthcare system CBOs need to play a new
role connecting the home with the healthcare system Home provides
unique perspective otherwise unavailable to healthcare providers.
Quality measures for health plans and providers relate to issues
such as medication use and fall prevention HEDIS, Medicare
Advantage Star Ratings Meds are major factor in readmissions home
is key New focus on population health identifying and proactively
addressing health for high-risk patients
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- Home and Community Based Services (HCBS) are High Value
Improves quality: Staying home is concordant with peoples goals.
Evidence-based interventions like HomeMeds, Stanford
self-management programs and care transitions programs reduce ED
& hospital use Based on 25 State reports, costs of Home and
Community-Based LTC Services less than 1/3 the cost of Nursing Home
care.
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- Health Care + CBO/Social Services = Better Health, Lower Costs
Address social determinants of health Personal choices in everyday
life Isolation, family structure/issues, caregiver needs
Environment home safety, neighborhood Economics affordability,
access Social service agencies have advantages Trust, time to
probe, different authority Cultural/linguistic competence Lower
cost staff & infrastructure High impact evidence-based
programs
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- Readmissions: Social Issues Compassionate admissions elder with
no caregiver Gentleman with mild cognitive impairment tries to be
adherent by taking all meds including sleepers at breakfast starts
falling Appointment made by hospital but daughter cant make it no
transportation Cant afford meds No food in home especially none
that matches diet orders
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- Role of Agencies like Partners in Care Eyes and ears in the
home Skilled at building trust and relationships Gather data and
information that is not shared in a medical setting or encounter
Link in medication issues with evidence based intervention Cultural
competence in local communities Comprehensive psychosocial &
environmental evaluation Attention to caregivers special services,
support, respite
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- Major Causes of Readmissions and what CBOs can do about them
Patient and family lack of understanding about managing patient
conditions Provide information about red flags and self-care Missed
post-discharge physician appointments Transportation assistance;
consider family schedules Medication errors Misunderstanding,
language barriers, affordability, multiple prescribers meds already
in the home, OTCs Lack of communication among providers after the
discharge Patients coached to share information with PCP Lack of
food or inappropriate diet Arrange home-delivered meals for special
diet
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- Care Transitions Coaching & Support Evidence-based home
& social services models proven to reduce readmissions
Medication Review: HomeMeds SM or HomeMeds-Plus to include
comprehensive psychosocial & environmental evaluation Coaching
(Coleman Care Transitions Intervention) for those who are capable
(or have caregivers) Social services (Rush U. Med Center Bridge
Program) for those who are not Connect patients to services and
supports for recuperation, rehabilitation, education
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- Partners HomeMeds SM -Plus Program
DescriptionOutcomes/Experience Comprehensive assessment Meds, ADL,
PHQ-2/9, cognitive, sensory, social & behavioral health
indicators Comprehensive report, service plan for LTSS,
self-management & behavioral health HomeMeds SM Pharmacist
review Contact with members physician and other health providers
Compared to those who screened in and didnt get the intervention:
Readmission rate 22% lower ED use rate 12.7% lower ROI = 53% (net)
63% post-acute had med-related problems. 77% had a home safety
issue 54% had other issues (financial, caregiver, depression, etc.)
9% had depression
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- Medications & Care Transitions 72% of post-discharge
adverse events are related to medicationsand close to 20% of
discharged patients suffer an adverse event. * 35% of Medicare
patients taking 5 or more medications experience adverse drug
events* HomeMeds program a social work solution *Mary Andrawis,
PharmD, CMMI, presentation to Drug Safety Panel, May 10, 2011
(Forster et al., Annals of Internal Medicine. 2003; 128: 161-167./
CMAJ FEB 3, 2004;170-3)
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- HomeMeds - Bridge between Home and Healthcare HomeMeds is
designed to enable community agencies to keep people at home, out
of hospital & nursing home, by addressing medication safety
Practice change with workforces that already go to the home more
cost effective use of existing effort Targets problems for
significance, accessibility to in-home staff, and likelihood of
positive prescriber response. Focuses on adverse effects (falls,
confusion, dizziness, vitals) then determines if medications may be
part of the cause. Cost-effective use of geriatric pharmacist for
complex problems
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- HomeMeds-Plus Targeting Criteria 1.Age 65+ and 2.ED/hospital
use in 6 months, plus 2 or more: a)Hospital LOS > 6 days; or
b)Six or more prescribed meds; or c)Warfarin/antiplatelet or
insulin/diabetes meds; or d)Dx CHF, COPD, depression, anxiety,
bipolar, psychosis; or e)DX of diabetes, dialysis, hemodialysis,
renal failure, CKD, ESRD, CAD, COPD or CHF; or f)Mild cognitive
impairment; or g)Recent treatment for fall or confusion; or h)Age
80+; or i)Limited caregiver support
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- Adherence Problem: 4 prescriptions patient says yes when
pharmacy calls for refill obviously not taking meds Meds in the
Home 101
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- Spanish speaker English labels Neighbor helping Bottles get
moved Trouble ahead! Meds in the Home 101
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- Patient stored all morning meds in the same container Meds in
the Home 101
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- The Role of Caregivers Family Caregivers 1 Adult children,
spouses, other relatives, friends/neighbors Older adult spouses at
risk for physical & mental health issues 46% of family
caregivers perform medical/nursing tasks for relative with multiple
physical and cognitive conditions 78% manage medications 60% report
learning how to manage medications on their own 47% said they NEVER
received training from any source. Paid Caregivers 60% in recent
study could not fill pill box correctly 1/3 had difficulty reading
and understanding health information 1.Home Alone: Family
Caregivers Providing Complex Chronic Care. AARP. October 2012
2.Inadequate Health Literacy Among Paid Caregivers of Seniors. J
Gen Intern Med. 2011 May; 26(5): 474479.
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- Addressing Readmissions through a Comprehensive, Coordinated
Delivery System
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- Managing Readmissions Not Easy Alone HSAG finds 27.5%
readmitted to a different hospital Efficiency demands coordination
and a broader geographic approach Many issues NOT in skill set of
healthcare It takes a multi-pronged approach Hospital Home Health
SNF CBO PCP, etc.
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- Bringing Local Person-Centered Services to Large Regional
Systems National movement to change the business model of the Aging
& Disability Services Network U.S. Administration for Community
Living (ACL) Add upstream value to save downstream costs Local
knowledge, trust, experience Low-cost models Buthow do you create
an efficient system with dozens of smallish agencies?
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- A Possible Solution: Led by ACL & the John A. Hartford
Foundation Initiative Overview CBO networks to create an integrated
system of non- medical care and services Contract with healthcare
organizations (Medicare Advantage, Medi-Cal managed care, duals
plans, large medical groups, ACOs/Medicare Shared Savings,
commercial insurance) Measure & document value added National
dissemination & technical assistance
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- Care Transitions SoCal Glendale Healthier Community Coalition -
Glendale Hospital plus Partners in Care and 2 additional hospitals
Hollywood Area - AltaMed Health Services Corp plus 4 hospitals
Kern/Bakersfield: Partners in Care + 5 hospitals Orange County Care
Transitions Partnership - SeniorServ plus 4 hospitals San Diego
Care Transitions Partnership - AAA plus 11 hospitals San Fernando
Valley Transitions Coalition - LA Jewish Home plus 3 hospitals
Ventura County Care Transitions Community Partnership - AAA /
Camarillo Health District plus 5 hospitals Westside Care Transition
Collaborative - Partners in Care+3 hosp
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- My coach helped me make continuing health a priority and having
her support made me feel important despite my age. Patient Lolita
Regional network covers LA, Ventura, Orange, San Diego & Kern
Counties Hospital-to-home coaching for optimal post-discharge
recovery Patient empowerment: PCP follow-up, meds management, ER
avoidance education, healthy behaviors activation Contracted to
serve 40 hospitals Served 1,000s of patients in first year
Projected results: 20% reduction in FFS Medicare readmission
rate
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- Self-Management Support The actions that individuals living
with chronic conditions must do in order to live a healthy life.
Problem-Solving Planning Physical Activity Managing Fatigue
Medications Working with Health Professionals Family Dynamics &
Support Managing Pain & Symptoms Communication Healthy Eating
Understanding Emotions
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- High-Level Evidence-Based Programs Offered by CBOs
SELF-MANAGEMENT Chronic Disease Self-Management Tomando Control de
su Salud Chronic Pain Self-Management Diabetes Self-Management
Program PHYSICAL ACTIVITY EnhanceFitness & EnhanceWellness
Healthy Moves Fit & Strong Arthritis Foundation Exercise &
Walk With Ease Programs Active Start Active Living Every Day
MEDICATION MANAGEMENT HomeMeds FALL RISK REDUCTION A Matter of
Balance Stepping On Tai Chi Moving for Better Balance DEPRESSION
MANAGEMENT Healthy IDEAS PEARLS CAREGIVER PROGRAMS Powerful Tools
for Caregivers Savvy Caregiver NUTRITION Healthy Eating
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- Diabetes Self-Management Program Developed at Stanford by Kate
Lorig, RN, Dr.PH Patients learn to take control of their diabetes.
Peer-led workshop develops tools to: Learn about disease &
self-care & monitoring Understand and deal with emotions Manage
medications Work with health care providers Make action plans for
exercise and healthy eating One year after 6-week workshop:
Improvements in stress management, self-reported health, aerobic
exercise, health distress, self-efficacy, communication with
physicians Fewer hospital days; more PCP visits
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- Chronic Pain Self- Management Program Medication isnt the only
treatment. Developed by Stanford & Memorial Univ. of
Newfoundland Patients learn to manage & decrease chronic pain.
Outcomes: Less Pain & Lower Dependency on Others More Energy
Improved Mental Health Increased satisfaction with life More
involvement in everyday activities
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- Contact Us June Simmons, CEO Partners in Care Foundation 732
Mott St., Suite 150, San Fernando, CA 91340 Main #: 818.837.3775
jsimmons@picf.org www.picf.org www.HomeMeds.org