Patient to Person. Transitions of Care. Colby Bearch, MA-SF, MA-M, BA, RN, CDONA Sharyn King, RN, BSN, CCM

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1 Patient to Person Transitions of Care Colby Bearch, MA-SF, MA-M, BA, RN, CDONA Sharyn King, RN, BSN, CCM

2 Transitions of Care Transitioning from school to adult services (vocational, medical day, etc.) Transitioning from pediatric care to adult providers Transitioning from unit to unit within a facility Transitioning from acute to sub-acute facility Transitioning from hospital to home

3 Why Patient to Person?

4 The Coordinating Center Not for profit care management agency Serving Maryland for 32 years 260+ co-workers Provides services across Maryland Services Care Management Consulting Service Coordination/Support Planning Health Coaching Life Care Planning Collaboratives and Partnerships

5 The Coordinating Center Community Care Coordination Medicare and Medicaid Navigation Housing & Supportive Services Managed Care Case Management Transitions of Care Hospital Readmission Reduction Programs

6 Touching Lives Across Maryland We touch over 10,000 Maryland lives per year. Currently 12 distinct CM programs Provide services across the lifespan youngest 10 days old; oldest 101 years old

7 Serving Individuals Complex Medical Needs Co-morbidities Dual Diagnoses Behavioral Health Related Conditions Technology Dependency Ventilator Dependency Oxygen BiPAP and CPAP Tracheostomy Parenteral Feeding Assistive devices for mobility Common Diagnoses Cerebral Palsy Quadriplegia Genetic disorders ESRD CHF COPD Sepsis Diabetes Injury/Spinal Cord Injury Autism

8 Person Centered

9 Transitions of Care in Maryland

10 Maryland Readmission Stats At-A-Glance Total number of discharges 629,175 Total number of readmissions 78,015 All payer readmission rate 12.4% % readmissions to different hospitals 31% Average charge per readmission $17,552 Total charges due to readmissions $1.031 billion % of readmissions that occur before day 12 50% % of readmissions <65 years of age 58% Source: Maryland Hospital Association Analysis, 2015

11 Maryland Readmission Stats At-A-Glance Greater than $1 billion in hospital charges are related to readmission events. Approximately 75% are associated with public payer sources. Dual eligible patients account for 7% of discharges, 13% of readmissions and have a 23% readmission rate. Source: Maryland Hospital Association Analysis, 2015

12 Maryland Readmission Stats At-A-Glance APR-DRG Total # Readmissions Readmission Rate % Total Readmissions Heart Failure % 4.8% Sepsis % 4.3% COPD % 3.5% Bipolar % 2.0% Pneumonia % 2.5% Renal Failure % 2.4% Source: Maryland Hospital Association Analysis, 2015

13 Maryland Readmission Stats At-A-Glance Social correlates High poverty rate: 16.7% readmission rate 90% readmissions occur in urban areas Patients with a personal history of recurrent hospitalizations: Account for 23% of all discharges 70% of all readmissions $722 million of total readmission charges Source: Maryland Hospital Association Analysis, 2015

14 Transitions of Care

15 Transitions of Care Programs Goal: Reduce avoidable ED Visits and Hospitalizations Three populations types with distinct approaches # 1 - Medicare Fee for Service population in West Baltimore # 2 - All payer population discharged from suburban hospital center # 3 - Medicaid population with chronic medical conditions already receiving CM services

16 Population #1 Focus Traits ACA Grant Partners Duration Clients typically live in West Baltimore Area Medicare Fee for Service Targeted clients at high risk for readmission. 3 Urban Hospital Systems 2012 to present Client Ages 21+ (Majority 65+) Leading Client Diagnoses CMS Risk Score (HCC Score) 2.2 CHF, COPD, DM, Depression, ESRD Region Statewide, but predominately in Baltimore City

17 Approaches Coleman Model Evidence based practice for Care Transitions Coleman-Certified Coaches (unlicensed) provide Care Transition services in the community Coleman s Four Pillars Personal Health Record Medication Review Red Flags (Identification of early warning signs) Follow-up care after discharge

18 Case Study-Ms. L. Diagnoses Diabetes Bipolar Social Issues Client s Goals No family/care providers Experiencing homelessness Frequent use of hospital services Better attitude Independence

19 Coach interventions Coaching Assisted client to identify behaviors that presented as barriers. Helped client to prioritize multiple tasks. Outcomes Secured housing. Linked client with resource for diabetes supplies (delivered). Helped client to obtain personal and medical items from last known address. Identify and engaged a Primary Care Physician Connected with mental health facility to provide transportation, individual counseling and group therapy.

20 Program Outcomes Data: Nov 1, 2013-Oct

21 Outcome Observations All cause re-admissions for all Medicare Fee For Services patients across all three hospitals were decreased by 8.7%. Reduction in ED usage over the course of the program. Increase in patient utilization of PCP services post discharge. within both 7 and 14 day time frames

22 Population #2 Focus Hospital Readmission Reduction Initiative Partners Duration Traits Clients typically live in suburban area All Payer Local Hospital Oct 2014 to present Client Ages Majority: 50+ Leading Client Diagnoses CHF, ESRD, COPD Region Central Maryland Eastern Shore

23 Model More flexible Relationship sustains often >30 days Utilizes both nurses and community health workers Nurse completes an initial assessment to determine degree of supports required by client.

24 Case Study: Ms. L. Diagnosis Barriers Client s Goal COPD with oxygen dependency Hospitalized every 2-4 weeks Knowledge deficit related to insurance benefits Lacked consultation with specialty physician providers. See granddaughter graduate from high school.

25 Interventions Identified and engaged a pulmonologist. Assisted client to secure medications. Provided educational support regarding medications, disease process and healthy lifestyle choices. Established a transportation plan. Secured DME: portable oxygen equipment Assisted client to identify red flags.

26 Population #3 Focus Clients with complex, chronic medical needs Partners Duration Traits All clients currently receiving CM by SW or RN Medicaid REM Statewide Hospitals Chesapeake Regional Information System for our Patients (CRISP) Center-based REM Liaison Feb 2015 to present Client Ages 0-65 Majority: >75% under 21 Region Statewide

27 Approaches Developed a process Utilization of a skilled liaison Develop relationships Facilitate Care Transition interventions Develop a data base with input and output capabilities Engage a system to alert CMs of client admissions to the ED and inpatient acute care across multiple MD hospitals. Determine required CM interventions. Visitation Care provider contacts MD contacts Post-discharge follow-up

28 Case Study-D.B. Client Dx: Agensis of corpus collosum Ventilator dependency Age: 17 Social Considerations Mother concurrently hospitalized. Client Goal Avoid foster care and/or long term care placement

29 Interventions Strengthened MDT collaboration. Father Hospital DONS Hospice DSS Client remained hospitalized until father received adequate training to care for client in the home. Additional nursing support was added. Established a respite schedule with Hospice.

30 Outcomes: Transitions of Care Strengthening of collaborative partnership between community care coordination and hospital discharge planning personnel. Increased organizational awareness of the value of successful Transitions of Care interventions for better client outcomes. Enhanced collaboration and client focus across multidisciplinary team. Better utilization of healthcare resources.

31 Outcomes Management Data Utilization There are multiple approaches to data and outcome analysis. Assess for the impact of specific interventions on outcomes. Investigate what made a difference. For example, consider social correlates, timing of interventions, and diagnoses as data points for evaluation.

32 Outcomes Management Data Utilization Seek opportunities to glean information: Observe the actual delivery of Care Transitions services to identify best practice and replicate. Utilize databases to obtain and organize data. Create informative visuals that relay information clearly and succinctly for rapid decision making.

33 Outcomes Management Reporting Document strategies, successes, challenges and outcomes. Use data to drive strategies for improvement. Share information and share it frequently. Include partners in information sharing and improvement strategy development.

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