Hospital to Home: Improving Quality and Savings Through Innovative Transition Care

Transcription

1 The Philips Healthcare Reimbursement Simplified Webinar Series Presents Hospital to Home: Improving Quality and Savings Through Innovative Transition Care May 12, :00 1:15 pm ET Mary Naylor, Director of the New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing Denise Levis Hewson, Director of Clinical Programs and Quality Improvement, Community Care of North Carolina Scott Mader Clinical Director, Rehabilitation and Long Term Care Division Portland VA Medical Center For the latest information on payment and coverage, visit Laurel Sweeney, Moderator Senior Director, Global Reimbursement Policy, Philips Healthcare 1

2 Mary D. Naylor, PhD, RN, FAAN Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions and Health University of Pennsylvania School of Nursing 2 Philips Healthcare s Reimbursement Simplified Webinar Series May 12, 2010

3 Transitional Care Transitional care range of time limited services and environments that complement primary care and are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and across settings. 3

4 The Case for Transitional Care High rates of medical errors Serious unmet needs Poor satisfaction with care High rates of preventable readmissions Tremendous human and cost burden 4

5 Context for Transitional Care: Acute Care Episode Adapted from the National Quality Forum committee on Measurement Framework: Evaluating Efficiency across Episodes of Care 5

6 Quality Cost Transitional Care Model (TCM) 6

7 Unique Features Care is delivered and coordinated by same advanced practice nurse in hospitals, SNFs, and homes seven days per week using evidence-based protocol with focus on long term outcomes 7

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9 Core Components Holistic, person/family centered approach Nurse-led, team model Protocol guided, streamlined care Single point person across episode of care Information/communication systems that span settings 9

10 Across RCTs, TCM has Increased time to first readmission or death Improved physical function and quality of life* Increased patient satisfaction Decreased total all-cause readmissions Decreased total health care costs *Most recently completed RCT only 10

11 11 1 Naylor MD, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, & Pauly MV. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994;120: Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281: Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:

12 TCM's Impact on Total Health Care Costs* at 52 weeks*** $7,636 $12,481 TCM Group at 26 weeks** $3,630 $6,661 Control Group Dollars (US) 12 * Total costs were calculated using average Medicare reimbursements for hospital readmissions, ED visits, physician visits, and care provided by visiting nurses and other healthcare personnel. Costs for TCM care is included in the intervention group total. ** Naylor MD, Brooten D, Campbell R, Jacobsen BS, Mezey MD, Pauly MV, & Schwartz JS. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281: *** Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, & Schwartz JS. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:

13 Barriers to Widespread Adoption Organization of current system of care Regulatory barriers Lack of quality and financial incentives Culture of care 13

14 Translating TCM into Practice Penn research team formed partnerships with Aetna Corporation and Kaiser Permanente to test real world applications of research-based model of care among at risk elders. Funded by The Commonwealth Fund and the following foundations: Jacob and Valeria Langeloth, The John A. Hartford, Gordon & Betty Moore, and California HealthCare; guided by National Advisory Committee (NAC) 14

15 National Advisory Committee VHA Penn Home Care & Hospice Services 15

16 Project Goals (Aetna) Test TCM in defined market Document facilitators and barriers Provide for ongoing NAC input Present findings to Aetna decision makers Widely disseminate findings 16

17 Tools of Translation Patient screening and recruitment Orientation of nurses (web-based modules) Documentation and quality monitoring (clinical information system) Quality improvement (case conferences grounded in root cause analysis) Evaluation 17

18 High Quality + Satisfaction Reductions in Acute Readmissions (Costs) = TCM as High Value Proposition for Aetna 18

19 Progress to Date Aetna expansion proposed as part of Aetna s Strategic Plan Kaiser data collection/analyses ongoing University of Pennsylvania Health System adopted TCM (Blue Cross reimbursing) QIOs working with NJ and NY Other health care providers 19

20 Ongoing Efforts Advancing the science Promoting widespread adoption of TCM Using findings to promote policy changes 20

21 21 Would cognitively impaired hospitalized older adults and their caregivers benefit from TCM? Funding: Marian S. Ware Alzheimer Program, and National Institute on Aging, R01AG023116, ( )

22 22 What do we know about effects of transitions in health among elderly long-term care recipients over time? Funding: Rand-Hartford Center for Interdisciplinary Geriatric Health Care Research ( ); National Institute on Aging, National Institute of Nursing Research, R01AG025524, ( )

23 HR3590- Patient Protection and Affordable Care Act Quality Incentives Center for Innovation Pilots of Health System Redesign Financial Incentives and Disincentives 23

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27 Community Care of North Carolina Joins other community providers (hospitals, health departments and departments of social services) with primary care physicians Designated primary care medical home Creates community networks that assume responsibility for managing recipient care in concert w/ medical homes 27

28 Community Care of North Carolina Infrastructure Focuses on improved quality, utilization and cost effectiveness of chronic illness care 14 Networks with more than 4000 Primary Care Physicians (>1300 medical homes) Over 1 million enrollees Community-based care managers supporting population management activities 28

29 Some Statistics Driving Transitional Support Approximately 18% of patients are readmitted within 30 days Up to 30% or readmissions occur at different hospitals 40% of patients are discharged with one or more tests pending 25% of discharged patients need additional workup or testing More than 1/3 of prescriptions provided to patients at discharge are never filled Multiple chronic conditions, including mental health issues

30 COMPONENTS AND GOALS OF TRANSITIONAL CARE Medication Management Self management Notebook Follow-Up Red Flags G O A L S Patient/Care Giver know about medications and have a medication management system in place Maintain a Self- Management Notebook (SMN) to facilitate communication and ensure continuity Patient schedules and completes follow-up visit with the PCP/ Specialist knowledge about symptoms that indicate their conditions are getting worse and what to do 30 Modified Coleman guidelines

31 Community Care has done the following: Forged links with all the hospitals, getting timely information about hospitalized enrollees Visit patients in the hospital, when possible Follow-up home visits to perform medication reconciliation and self-management support Build relationships and share information with community providers (health care team) Care managers are the conduit for information exchange 31

32 TIME FRAME FOR TRANSITIONS: Optimally, the program is initiated during an inpatient admit with the following progression: o 1 or more CM contacts prior to discharge o Face to face CM contact within 72 hours / 3 business days following discharge. The primary goal of this contact is for MEDICATION RECONCILIATION. o 3 or more follow-up phone calls / contacts based on patient need 32

33 Standardized SCREENING Criteria 1. Aged Blind and Disabled designation 2. 2 or more Chronic Conditions (including MH) 3. Patient is UNSTABLE as defined by evidence of 2 or more of the following: > 1 Inpatient admit within the past 6 months > 3 or more ED visits within the past 6 months > 8 Rxs over the past month or 24 over 3 mos > 3 or more Outpatient Providers over 6 months No PCP visit within the past year > 2 ADL deficits requiring hands-on assistance 33

34 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 / CG 34

35 How can we make an impact?

36 Best Practices and Early Results All networks are getting real time data from hospitals Embedded care managers in the large tertiary hospitals Embedded care managers in practices with large numbers of aged, blind and disabled (high cost and high risk) Most recent data shows an 8 % reduction in 30 day re-admission rates 36

37 QUESTIONS?

38 Home Hospital Care Project At Home a study of care for older persons Program At Home... an alternative to hospitalization Scott L. Mader scott.mader@va.gov 38

39 Admissions by year FY02-44 (Project at Home Research year) FY Home begins) FY04-92 FY05-61 FY06-61 FY07-89 FY FY Total=654 39

40 Why develop a home hospital? Hospital can be a difficult environment for older persons Demographics Economics Local-Portland VA bed shortage Support and vision from John A Hartford Foundation/Johns Hopkins/VA New Clinical Initiatives 40

41 Home a study of care for older persons The model: Patients 65 and older who would otherwise require hospital admission for specific diagnoses (CHF, COPD, Cellulitis, CAP) A period of continuous nursing followed by twice daily RN visits. Daily MD visits 41

42 42 Portland VA Intervention Year Model (11/01-9/02) Eligible patient in ECU who requires admission to the hospital (occas CDU, clinic, home) 7am-10pm 7 days/week (hours of our ECU attd) Evaluation, consent, & transport home Continuous nursing for minimum 8hrs then BID intermittent visits Daily and prn MD visits by dedicated provider,with Geriatrics MD coverage Rx: IV Meds, O2, Nebulizers, etc Answering service, Lifeline

43 43 Summary of Outcomes Leff et al. Ann Int Med 143: 798, 2005 ; Leff B et al., JAGS 54: , 2006; Leff B et al., JAGS 56:117-23, 2008 Acceptable model for older persons/caregivers 60% chose care at home if offered Clinical safety of HH care Decreased delirium rates, sedative use, bowel cx Satisfaction of patients & caregivers Higher for pts and caregivers than hosp care Overall stress levels lower Costs of care in HH vs acute hospital Costs lower Feasibility of HH model in integrated health system Implementation was difficult Recruitment lower than expected

44 Unofficial Summary of Outcomes Smokers like home hospital Medication errors Med errors, compliance, NSAIA use Depression Lack of adequate caregiver support Need for ongoing home care Not any home, their home Resistant CHF patients difficult to manage Utility of assessment and care in the home Easier to do in VA healthcare system Used bladder US, but not Xray, Echo, EKG 44

45 Transition from Home to Home Portland VA had funds for transition to a non-research model 45 Feedback from our users Patients/families Emergency room Inpatient teams Primary Care Home Hospital MDs Home Care Program

46 Home an alternative to hospitalization Modified program treated the same dx (CHF, COPD, CAP, cellulitis), but: Accept patients of all ages Accept early hospital discharges (now about 75%) Provided a single daily RN visit Provide a one-time MD visit with daily MD oversight Sometimes accept for the next day 46

47 47 Home an alternative to hospitalization Admit patients 8 AM 4:30 PM, 7 days/week Ability to manage late admissions the following day Daily skilled RN visits 24/7 MD oversight and coverage One MD home visit, and others as needed Private answering service Medical equipment Nebulizers, Oxygen Prepaid cell phone (Lifeline-not used) Medical Services IV medication (qd antibiotics, diuretics) In-home lab draws and specimen delivery ($40K/year) Patient transport to and from hospital if needed Bladder US In-home X-Ray and EKG available (rarely used)

48 Home Mader et al. JAGS 56: 2317, 2008 Demographics number of admissions 290 number of unique patients 225 mean age 68.7 (46-93) % who lived alone-30.3 % with DNR status during their episode of care-20.0 Referral Location % VA inpatient-54 % VA ER-23 % VA outpt-8 % Other Diagnoses % chf-51 % copd-20 % pneumonia-11 % cellulitis-25 % other-2 Other Obesity Sleep apnea Elevated creatinine

49 Clinical measures Mader et al. JAGS 56: 2317, 2008 median LOS (days) 3 range 1-14 % receiving IV therapy 58 % receiving neb therapy 34% receiving oxygen 48 % receiving new oxygen 20.3 RN visits 4.7 (range 1-22) MD visits 1.1 (range 1-3) blood draws 2.9 (range 0-33) 30 day readmission rate 25% % with home care referral after discharge-55 49

50 Estimated Costs (120 patients/yr) Personnel (added to existing home care program) 0.5 MD, 1.0 home care nurse, 0.5 clerical support, on call $280K Services IV, O 2, nebulizer, cab transportation, ambulance, blood draw, X-ray, EKG $100K Equipment Laptops, cars, cell phones, two-way pagers, answering service, misc. $20K TOTAL $400K 50

51 Estimated Benefits Benefits: Decreases hospital divert time/adds acute care capacity Saves 300+ bed-days-of-care and ECU visits/revisits Allows 7 day/week homecare program for staff and patients Supports ECU, inpatient, and primary care programs Patient satisfaction/excellence in patient care Slight direct cost savings: 300 $1700/BDOC = $510K vs $400K VA incentive for non-institutional care 51

52 Future Activities Determine optimal size/responsiveness/cost More expensive to take ECU/late/sicker admissions Provider continuity impacts length of stay Role of admission avoidance vs early discharge Readmission rates Additional diagnoses How can we use/expand the infrastructure for other activities-integration into patient-centered medical home Incorporate into educational programs Fellow training, health care professionals Disseminate model to other VA and non-va health care systems 52

53 Questions? Please type your questions into the video player window. The moderator will pose questions to the panelists. We would like to hear your views on today s webinar. Go to For more information on reimbursement, please visit the Philips Healthcare Reimbursement Website at 53

54 Speaker Bios Mary D. Naylor, PhD, RN, FAAN Dr. Naylor is the Marian S. Ware Professor in Gerontology and Director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania, School of Nursing. Since 1990, Dr. Naylor has led a multidisciplinary program of research designed to improve the quality of care, decrease unnecessary hospitalizations and reduce health care costs for vulnerable, community-based elders. Dr. Naylor is the National Program Director for the Robert Wood Johnson Foundation sponsored Interdisciplinary Nursing Quality Research Initiative. She was elected to the National Academy of Sciences, Institute of Medicine (IOM) in She also is a member of the RAND Health Board, the National Quality Forum Board of Directors and Chair of the recently established Long Term Quality Alliance. 54

55 Speaker Bios Denise Levis Hewson, RN, BSN, MSPH Denise received her Bachelors of Nursing and Masters of Science in Public Health from the University of North Carolina in Chapel Hill and has spent most of her career researching, developing and implementing community-based medical home initiatives targeting vulnerable populations. Denise has been involved in North Carolina s Medicaid initiatives since the mid 80s and has consulted with other States as they explored opportunities to better manage and improve the quality of health care delivered to their target populations. She is the Director of Clinical Programs and Quality Improvement for Community Care of North Carolina a Medicaid medical home program serving over 1 million enrollees through 14 participating community based networks with over 1350 practices and 3500 primary care providers. Denise has consulted with many states and organization on quality improvement, practice re-design, enhanced medical home, chronic care model, care and disease management, data and health informatics, system delivery re-design and population management. 55

56 Speaker Bios Scott Mader, MD Dr Scott Mader is the Clinical Director of the Rehabilitation and Long Term Care Division at the Portland VA Medical Center, and a Professor of Medicine at Oregon Health & Science University. He received his medical degree from Case Western Reserve University in Cleveland Ohio. He did Internal Medicine training at Strong Memorial Hospital in Rochester in NY, and Geriatric Fellowship training in Los Angeles at the UCLA/VA Medical Centers. In addition to his interest and clinical work in Home Hospital Care, he is an active, practicing Geriatrician and has additional research programs in orthostatic hypotension and age-related changes in blood vessel relaxation. 56