CARE TRANSITIONS: IMPLICATIONS & OPPORTUNITIES FOR …CARE TRANSITIONS: IMPLICATIONS & OPPORTUNITIES...
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CARE TRANSITIONS: IMPLICATIONS & OPPORTUNITIES FOR CASE MANAGERS Helen Hayes Hospital May 9, 2013 Margaret Leonard, MS, RN-BC, FNP Sr. Vice President for Clinical Services Hudson Health Plan Chair, NTOCC Public Policy Task Force Page 1 www.NTOCC.org
Transcript of CARE TRANSITIONS: IMPLICATIONS & OPPORTUNITIES FOR …CARE TRANSITIONS: IMPLICATIONS & OPPORTUNITIES...
CARE TRANSITIONS: IMPLICATIONS &OPPORTUNITIES FOR CASEMANAGERS
Helen Hayes Hospital
May 9, 2013
Margaret Leonard, MS, RN-BC, FNP
Sr. Vice President for Clinical Services
Hudson Health Plan
Chair, NTOCC Public Policy Task Force
Page 1www.NTOCC.org
Page 2www.NTOCC.org
Hudson Health Plan•• New York Medicaid Not-For-Profit Managed Care organization
• Founded in 1985 by four Community Health Centers
• Offers three state-subsidized managed care programs - Medicaid, Family Health Plus and Child Health Plus.
• Serves over 120,000 members in New York’s Hudson Valley(4,000 sq. mi. service area)
Page 3www.NTOCC.org
““To promote and provide accessTo promote and provide access
to excellent health servicesto excellent health services
for for all all people.people.””
HudsonHudson’’s Mission Statements Mission Statement
Hudson Core Values
Page 4www.NTOCC.org
TODAY’S HEALTHCAREENVIRONMENT
“It's about better care: care that is safe, timely, effective,efficient, equitable and patient-centered.”
Source: http://www.ama-assn.org/amednews/2010/12/20/prse1221.htmPage 5www.NTOCC.org
Thoughts For Today!
Transitional and community-based care is oftendisorganized and haphazard with patients shuffledfrom one post-acute environment or provider toanother with little advocacy, no establishedtransitional care plan, and absolutely no idea that itshould not be that way.
Patients often move from door to door; episode ofcare to episode of care without a champion tocoordinate that care.
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More Thoughts!
This starts a downward trajectory of their healthstatus that not only can prompt readmissions toan acute care facility but also cause physical,emotional, and financial compromise that mayinterfere with the patient’s quality of life.
Patients are confused. Families are in crisis. And,your intervention may be the one action thatdecreases anxiety and prevents negativeoutcomes!
Page 7www.NTOCC.org
Some Words from Secretary Kathleen Sebelius
Source: http://www.hhs.gov/news/press/2011pres/04/20110412a.htmlPage 8www.NTOCC.org
“Americans go the hospital to get well,
but millions of patients are injured
because of preventable complications
and accidents. Working closely with
hospitals, doctors, nurses, patients,
families and employers, we will
support efforts to help keep patients
safe, improve care, and reduce costs.
Working together, we can help
eliminate preventable harm to
patients.”
Establishing the Goals
On March 22, 2011, the U.S. Department of
Health and Human Services released its National
Strategy for Quality Improvement in Health Care(National Quality Strategy).
The Affordable Care Act required the Secretary of
HHS to establish a national strategy to improvethe delivery of health care services, patient health
outcomes, and population health. This strategy is
designed to guide federal, state, and local healthinitiatives.
Source: http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdfPage 9www.NTOCC.org
Three Broad Aims of the National Quality Strategy:
Source: http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdfPage 10www.NTOCC.org
Prevention and Treatment of Leading Causes of Mortality
Supporting Better Health in Communities
Making Care More Affordable
Making care safer by reducing harm caused in the delivery of care
Ensuring that each person and family members are engaged as partners intheir care
1
2
3
4
5
Promoting effective communication and coordination of care6
Better Care, Healthy People/Healthy Communities, and Affordable Care.
Six Strategies to Advance these Aims include:
What is “Transition of Care” ?
The movement of patients from one health care practitioner or setting toanother as their condition and care needs change
Occurs at multiple levels
Within Settings
Primary Care Specialty Care
ICU Ward
Between Settings
Hospital Sub-acute facility
Ambulatory clinic Senior center
Hospital Skilled nursing Home Hospital
Across Health States
Curative care Palliative care/Hospice
Personal residence Assisted living
Source: Coleman E. http://www.caretransitions.org/definitions.aspPage 11www.NTOCC.org
Transition Issues Dramatically ImpactPatients & Their Caregivers
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PatientPatient&&
CaregiveCaregiverr
ERER ICUICU
In-PatientIn-Patient
Patient &Patient &CaregiveCaregive
rr
OUTPATIENT:OUTPATIENT:•• HomeHome•• Home Care Home Care•• PCP PCP•• Specialty Specialty•• Pharmacy Pharmacy•• Case Mgr. Case Mgr.•• Caregiver Caregiver•• Hospice Hospice
SNFSNF ALFALF
Patient &
Caregiver
ER ICU
In-Patient
Patient &
Caregiver
OUTPATIENT:• Home• Home Care• PCP• Specialty• Pharmacy• Case Mgr.• Caregiver• Hospice
SNF ALF
NOMedication
Reconciliation
NOPersonal
Medicine List
NOCoordinated
Care Plan
NODischargeCare Plan
NOCare Plan
NO MedicationReconciliation
NO PersonalMedicine List
NOCare Plan
NO MedicationReconciliation
NO PersonalMedicine List
Transition Issues Dramatically ImpactPatients & Their Caregivers
To Date We Have Not HadConsistent and Accepted Transition Tools
Medication Reconciliation Elements
Comprehensive Care Plan
Health or Clinical Status
Transition Summary
Patient & Caregiver Tools & Resources
Consistent Performance Measures That Apply to All Health Care Settings
Accountability for Sending & Receiving Information
Aligned Payment Incentives
Source: National Transitions of Care Coalition. http://www.ntocc.orgPage 14www.NTOCC.org
Rehospitalizations: Medicare Fee-for-Service
Page 15www.NTOCC.org
Summary Analysis
19.6% (nearly 1/5) wererehospitalized within 30 days
34% were rehospitalizedwithin 90 days
50.2% of those rehospitalized within30 days after a medical dischargethere was no bill for a visit to aphysician office
• Analysis of Medicare Claims data from 2003-2004• Includes the 11,855,702 Medicare beneficiaries discharged from the hospital
Source: Jencks FS et al. N Engl J Med 2009;360:1418-28.
“The Billion Dollar U-Turn”
• Frequent - 17.6% of all Medicare hospitalizations are 30-dayrehospitalizations
• Costly - $12B in Medicare spending; est. $25B across allpayers annually
• Actionable for improvement• 76% potentially avoidable
• Heart failure, pneumonia, COPD, acute MI lead the medical conditions
• CABG, PTCA, other vascular procedures lead the surgical conditions
• Performance highly variable• Medicare 30-day rehospitalization rate varies 13-24% across states
• Variation greater within states
Page 16www.NTOCC.org
MedPAC Report to Congress, Promoting Greater Efficiency in Medicare. June 2007Mark Taylor, The Billion Dollar U-Turn, Hospitals and Health Networks, May 2008Commonwealth Fund State Scorecard on Health System Performance. June 2007
Our healthcare system operates in
“silos” and information queues– incapable of reciprocal operation with other related
management systems & different departments of organizations
© Eric A. Coleman, MD, MPH
WORKING TOADDRESS THE ISSUES
Page 18www.NTOCC.org
Diverse Organizations and ProfessionalsAdvise and Support NTOCC
Page 19www.NTOCC.org
These groups represent over 200,000 health care professionals, 11,000 employersThese groups represent over 200,000 health care professionals, 11,000 employersand 30,000,000 consumers throughout the United States.and 30,000,000 consumers throughout the United States.
Patient and Family Caregiver Tool Development
Page 20www.NTOCC.org
HEATH CARE TOOLSHEATH CARE TOOLS
NTOCC Provides Tools & Resource Developmentfor Patient and Family Caregivers
Tool Highlights
Guidelines for aHospital Stay withHelpful DefinitionsFor Patient, Family, &Caregiver
Taking Care of MYHealth CareFrançais & Español
My Medicine ListFrançais & Español
Additional NTOCC Tools & Resources
Page 22www.NTOCC.org
Additional NTOCC Resources
Health Information Technology Position Paper
Updated Public Policy Concept Paper
Electronic Compendium – Collection of Transitions of Care Models
Elements of Excellence for Safe Transitions of Care – Cross Walk ofCommon Interventions
Patient and Family Caregivers Bill of Rights
Transition of Care Web-Based Evaluation Tool
Page 23www.NTOCC.org
NTOCC Considerations
Improve communication during transitions with providers, patients, andcaregivers
Support the implementation of electronic medical records that includestandardized data elements
Increase the use of case management and professional care coordination
Expand the role of the pharmacist in transitions of care
Establish points of accountability for sending & receiving
Implement a payment system that aligns incentives
Develop performance measures to encourage better transitions of care
NTOCC. Improving Transitions of Care.The Vision of the National Transitions of Care Coalition. May 2008.
Page 24www.NTOCC.org
TOC Compendium
The TOC Compendium is acollection of resources suchas white papers, journalarticles, and websites that a"Transitions of Care"professional or interestedconsumer might find usefulin their practice or medicalsituation.
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Explore theTOC Compendium at:
www.NTOCC.org/Compendium
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Page 27www.NTOCC.org
Page 28www.NTOCC.org
Compendium: Browsing Results
Seven Essential Intervention Categories
Source: http://www.NTOCC.org/compendium (2011)Page 29www.NTOCC.org
Medications Management
Transition Planning
Patient and Family Engagement / Education
Information Transfer
Follow-Up Care
1
2
3
4
5
Healthcare Providers Engagement
Shared Accountability across Providers and Organizations
6
7
Improving Communication
Source: National Transitions of Care Coalition (NTOCC) Measures Workgroup.Transitions of care measures. 2008.
Page 30www.NTOCC.org
The Integrated Team
Physicians
Wellness or Health Coaches
Lab and Radiology Professionals
Rehab personnel
Skilled Case Managers
Patient
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Pharmacists
Specialists
Hospitalists
Nurses
Therapists
Behavioral Health
Family Caregivers
Social Workers
Transition Connector
Collaborative Team
Patient
Physician
Pharmacist
Nurse
Social Worker
Case Manager
Allied Health
– Respiratory Therapist
– Dietitian
– Physical Therapist
– Educator
Page 32www.NTOCC.org
Community Team
PCP
Specialist
Skilled Nursing Facility
LTC Services
Pharmacy
Community Clinic
Home Care
GCM/CM
Rehabilitation
Hospice
Community Resources
Health Plan
Medical Home
WHOIS
THECONNECTOR?
SNFSNF ALFALF
ERER ICUICU In-PatientIn-Patient
OUTPATIENT:OUTPATIENT:•• Home Home•• Home Care Home Care•• PCP PCP•• Specialty Specialty•• Pharmacy Pharmacy•• Case Mgr. Case Mgr.•• Care Giver Care Giver•• Hospice Hospice
PatientPatient
My Med List
MedicationReconciliationData Elements
+Care / Case
Transition Process
Improving CommunicationWill Improve Transition Issues
Page 33www.NTOCC.org
Care Models, Policy, Advocacy, & PerformanceMeasures
Page 34www.NTOCC.org
Care Transitions Intervention : Dr. Eric Coleman - Transition Coachinghttp://www.caretransitions.org
Transitional Care Model: Dr. Mary Naylor - Advanced NursePractitionershttp://www.nursing.upenn.edu/media/transitionalcare/Pages/default.aspx
Guided Care: Dr. Chad Boult - Guided Care Nursehttp://www.guidedcare.org
Project RED : Dr. Brian Jack - Boston University Medical Center - Re-engineering Discharges http://www.bu.edu/fammed/projectred/
Project BOOST: Society of Hospital Medicinehttp://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm
Implementation of the program at one Georgia hospital lead to a reductionin 30 day readmission rates in those under age 75 from 25.5% to 8.5%
Patients who received intervention had a 33.9% lower cost than thosewho did not receive intervention, translating into a savings of $412 perpatient
An annual net savings of $75,000 per nurse or $1364/patient
Total health care savings for intervention vs. control patients at 24 weekswere$300/patient. In patients with heart failure, the mean savings at 52weeks was $5000 per patient
The anticipated cost savings of one Transitional Coach (responsible for350 chronicallyill adults) after an initial hospitalization, over a period oftwelve months, is $330,00
Transition of Care Models
Care Transitions Intervention: Dr. Eric Coleman - Transition Coachinghttp://www.caretransitions.org
Transitional Care Model: Dr. Mary Naylor - Advanced Nurse Practitionershttp://www.nursing.upenn.edu/media/transitionalcare/Pages/default.aspx
Guided Care: Dr. Chad Boult - Guided Care Nursehttp://www.guidedcare.org
Project RED: Dr. Brian Jack - Boston University Medical Center, Re-engineering Discharges http://www.bu.edu/fammed/projectred/
Project BOOST: Society of Hospital Medicinehttp://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/CT_Home.cfm
Page 35www.NTOCC.org
The Pharmacy Opportunity
Leadership role in interdisciplinary efforts toestablish accurate and complete medicationlists
Hospital admission and discharge
Any change in level of care
Encourage community-based providers andhealth care systems to collaborate inmedication reconciliation efforts
Educating patients and their caregivers ontheir role in retaining a current list ofmedications
Assisting patients and caregivers through theprovision of a personal medication list
ASHP. Medication Therapy and Patient Care: Organization and Delivery of Services–Positions. 2009.Page 36www.NTOCC.org
AFFORDABLE CARE ACT
We Are Perched at the Beginning of the Middle!
Patient Protection andAffordable Care Act
Improving Quality & Efficiency ofCare
Reduction of HospitalReadmissions
Provisions for Medical Home
Provisions for Medication TherapyManagement
Access to Care
The Patient Protection and Affordable Care Act. 42 USC 18001 (2010).Page 38www.NTOCC.org
Provisions for Care Coordination
Community-Based CareTransition programs
Chronic Care DiseaseManagement
Transitional Care Provisions
Wellness Programs
Shared Decision Making
Bundled Payments
Case Manager will be the "linchpin“of Accountable Care Success
Many "naive policymakers, out-of-touch regulators, inflexible legal
experts and physician-leader apparatchiks" contend primary care
physicians can manage all the elements of an ACO. Jaan Sidorov, MD,
publisher of ACO Watch and The Disease Management Care Blog,
disagrees. "Docs don't mind being ultimately responsible, but they have
little interest in reviewing, recruiting or educating lists of patients. They
are happy to delegate such tasks to case managers.” In other words, the
case managers will be the linchpin to assuming ACO success. Where the
rubber hits the road. Where the light shines. Where the action is. Where
the return on investment will be achieved." (ACO Watch)
http://acowatch.wordpress.com/2011/06/20/the-5-imperatives-of-accountable-care/Page 39www.NTOCC.org
What Causes Hospital Readmissions?
Page 40www.NTOCC.org
Determinants of Preventable Readmissions
Patients with generally worse health and greater frailty are morelikely to be readmitted
Identifying determinants does not provide a single interventionor clear direction for how to reduce their occurrence
There is a need to address the tremendous complexity ofvariables contributing to preventable readmissions
Importance of identifying modifiable risk factors (patientcharacteristics and health care system opportunities)
Preventable hospital readmissions possess the hallmarkcharacteristics of healthcare events prime for intervention andreform > leading topic in healthcare policy reform
Page 41www.NTOCC.org
Case StudyMrs. Johnston is an 87 year old woman in good
health. She has GERD, minor urinary incontinence,
and severe arthritis in her right knee. She has
prescription medication to treat these ailments. She is
relying more on pain medications for her knee. Her
leg is beginning to turn outwards and has given way
on several occasions. She is a widow and lives by
herself in her own home in a Midwest suburb. She
swims five days a week, eats healthy balanced meals,
volunteers at her church, plays bridge, quilts, and
keeps up with current events and politics. She has
four adult children, three who live in the city and one
in a neighboring state. Mrs. Johnston is scheduled for
a right knee replacement.
Page 42www.NTOCC.org
Case Study 1 – Making A Difference?
PCP sent medical information to the Surgeon for 1st visit
Patient had a Medicine List and FAQ for 1st visit
Surgeon provided written instructions or office health coaching
Admission medication reconciliation & transition medication reconciliationwere completed with patient and family caregiver health coaching
Health coaching about urinary incontinence issues and care plan options
Timely transition summary, care plan, and transition medicationreconciliation were available to the PCP, home health agency andPhysical therapist on transition from hospital
Follow transition call with patient & family scheduled 24-48 hours aftertransition with possible home visit at day 4 or 5
Scheduled follow up transition set prior to transition home
Page 43www.NTOCC.org
Case Study: Hospital to LTC“Elise”
82-yer-old woman with T2DM admitted from LTC to the hospital for astroke and complicated UTI
T2DM for 15 years, body mass index 31. History of CVD, lower extremityedema, limited ability to perform ADL
Elise was taking metformin for her diabetes
A1C at admission of 8.6%. Metformin discontinued and basal/bolusinsulin regimen was initiated to manage hyperglycemia during hospitalstay
Elise will be discharged to LTC facility on basal insulin
Page 44www.NTOCC.org
Case Study: Hospital to LTC“Elise”
What is the role of thecase manager in the transition of care
relating to Elise’s diabetestreatment and monitoring in LTC?
Page 45www.NTOCC.org
Case Study: Hospital to LTC“Elise”
Standardized “TOC” discharge order set is completed and acomprehensive medication reconciliation is performed
T2DM medications
Metformin (per outpatient dose)
Basal insulin 16 units SQ once daily at bedtime
Medium dose correctional insulin
Monitoring of BG at meals and bedtime (4 × per day)
Follow up consult scheduled with endocrinologist within 1 week ofpatient’s return to LTC
Page 46www.NTOCC.org
Case Study: Hospital to LTC“Elise”
Page 47www.NTOCC.org
Back at the LTC facility, Elise’s care is beingdiscussed and optimized based on the TOC dischargerecommendation and the subsequent endocrinologyconsultation…
Communication
http://www.usatoday.com/yourlife/health/healthcare/studies/2010-12-06-1Adoctalks06_ST_N.htmPage 48www.NTOCC.org
Communication
When physicians have more personalizeddiscussions with their patients and encouragethem to take a more active role in their health,both doctor and patient have more confidencethat they reached a correct diagnosis and agood strategy to improve the patient's health.That approach can help eliminate or reduceunnecessary and costly testing and referrals tospecialists.
Source: Bertakis KD et al. J Amer Board Fam Med 2011;24:229 –39.Page 49www.NTOCC.org
Facilitating A Safe Transition
Page 50www.NTOCC.org
Medication reconciliation at discharge
Comprehensive discharge planning
Post-discharge support (e.g. Pharmacist call,home care.) in specific conditions is essential!
Transitional planning
Transitioning The Continuum of Carewith Bi-Directional Communication
Page 51www.NTOCC.org
PharmacyEmployer
PCP/MedicalHome
Specialist
PatientTOC Manager
Hospital
Community HealthCenter
Health Plan
AdherenceAssessment & Support
Health Promotion
Motivational Advocacy
Prescri
ption
Assessm
ent & Care
Plan
Motivational InterventionsAdvocate
AssessmentMedication Reconciliation
Care Plan
AdherenceAssessment & SupportCoordination & Care Plan
Non-Adherence
Behavior Health Change
Facilitation
IncreaseProductivity
LTC
Home Care
Hospice
Assessm
ent & Support
SupportCoordination
Providers & Patients with Tools Working Together &Improved Communication…Means Better Transitions of Care
Page 53www.NTOCC.org
Medicare Transitional Care Act
The Medicare Transitional Care Act would provide Medicarebeneficiaries that are at highest risk for hospital readmissionsaccess to evidence based transitional care services that areprovided by an eligible transitional care entity, such ashospitals, skilled nursing facilities and community based-organizations.
The bill would also provide incentives for the use of technologyand other tools to improve care transitions.
Page 54www.NTOCC.org
Medicare Transitional Care Act
NTOCC Recommended changes incorporated into bill:
“Findings” which include multiple care transition models and referencesNTOCC’s work on care transitions issues
An expanded definition of “eligible entities and providers” (ensures casemanagers, pharmacists, social workers etc. are eligible to provide services)
Broadens the definition of “Transitional Care Services” to supportevidence-based care transition models which align with NTOCC’s sevenessential elements.
Includes language to require the documentation of a family caregiverduring the plan-of-care process.
Requires the development of measures to address and hold accountableboth the sending and receiving side of the transition.
Page 55www.NTOCC.org
Medicare Transitional Care Act ***For Immediate Release*** ***Media Contact***
September 14, 2012Lindsay Punzenberger at (202)-446-4721
Legislation Introduced that Seeks to Fill Care TransitionGapsMedicare Transitional Care Act of 2012 designed to improvetransitions of care for high risk Medicare bene<iciaries
WASHINGTON, D.C.— Today, Representatives EarlBlumenauer (D-OR), Thomas Petri (R-WI), Allyson Schwartz(D-PA) and Jan Schakowsky (D-IL) introduced the bipartisanMedicare Transitional Care Act of 2012, legislation that seeksto improve transitions of care for Medicare beneficiaries athighest risk for readmission as they move from the hospitalsetting to their home, skilled nursing facility or next point ofcare. The National Transitions of Care Coalition (NTOCC)believes the bill is an important step forward to improvingpatient outcomes and reducing unnecessary health-relatedexpenses.
References
O’Reilly, K. Health Reform Law Will Boost Care Quality. Amednews.com.
DHHS. Partnership for patients to improve care and lower costs for Americans .http://www.hhs.gov/news/press/2011pres/04/20110412a.html April 2011.
DHHS. National Strategy for Quality Improvement in Health care.http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdfMarch 2011.
Coleman E. http://www.caretransitions.org/definitions.asp
Jencks SF, Williams MV, Coleman EA. Rehospitalization among patients in theMedicare fee-for-service program. N Engl J Med 2009;360:1418-28.
MedPAC Report to Congress, Promoting Greater Effeciency in Medicare. June2007.
Taylor M. The Billion Dollar U-Turn, Hospitals and Health Networks, May 2008.
Commonwealth Fund. Aiming higher. Results from a state scorecard on healthsystem performance. June 2007.
Page 57www.NTOCC.org
References
ASHP. Organization and delivery of services. Medication Therapy and PatientCare. http://www.ashp.org/DocLibrary/BestPractices/OrganizationPositions.aspx
The Patient Protection and Affordable Care Act. 42 USC 18001 (2010).Available at http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
Sidorov J. The 5 Imperatives of Accountable Care.http://acowatch.wordpress.com/2011/06/20/the-5-imperatives-of-accountable-care June 2011
Weise E. Survey finds gap and doctor-patient communication.http://www.usatoday.com/yourlife/health/healthcare/studies/2010-12-06-1Adoctalks06_ST_N.htm December 2010.
Bertakis KD et al. Patient-centered care is associated with decreased healthcare utilization J Amer Board Fam Med 2011;24:229 –39.
Page 58www.NTOCC.org
References
National Transitions of Care Coalition (NTOCC). Improving transitions of care.The Vision of the National Transitions of Care Coalition. May 2008. Available athttp://www.ntocc.org/Portals/0/PolicyPaper.pdf
National Transitions of Care Coalition (NTOCC) Measures Workgroup.Transitions of care measures. 2008. Available athttp://www.ntocc.org/Portals/0/TransitionsOfCare_Measures.pdf
The Patient Protection and Affordable Care Act. 42 USC 18001 (2010). Availableat http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf.
National Quality Forum (NQF) - Endorsed Definition and Framework forMeasuring Care Coordination. Available athttp://www.qualityforum.org/projects/care_coordination.aspx.
US.NMH.10.09.004Page 59www.NTOCC.org
