A I S. San Diego s ADRC CARE TRANSITIONS INTERVENTION (CTI) 9/19/2011

Transcription

1 CARE TRANSITIONS INTERVENTION (CTI) Brenda Schmitthenner, MPA Aging Program Administrator (858) A I S RSVP Veterans Health Promotion Info & Assistance Outreach & Education Senior Dining & Home Delivery Call Center Care Mgmt Adult Day Care Caregiver Intergenerational IHSS APS Ombudsman Project Care Senior Team San Diego s ADRC The ADRC is a highly visible and trusted place where people of all incomes and ages can turn for information on the full range of long term support options and a no wrong door access to public long term support programs and benefits. 1

2 C Core Functions of the ADRC AIS Call Center Information and Assistance (I&A) Short Term Service Coordination Options Counseling Care Transitions History Of The ADRC Timeline 1999 LTCIP began 2004 ADRC established 2007 First AAA ILC partnership 2010 Awarded ADRC Enhancement and MIPPA Grants 2010 CA Awarded Option A, B, C, D AoA/CMS Grants MIPPA Options Counseling Nursing Home Transition & Diversion Evidence Based Care Transitions 2011 ADRC funded for all 4 grants and Tech4Impact Grant AIS Health Improvement Programs Chronic Disease Self Management (Healthier Living) Diabetes Self Management (Healthier Living with Diabetes) Fall Prevention TEAM SAN DIEGO 2

3 How Are We Building A Better System? Care Transitions Intervention (CTI) Pilot Partnership between AIS ADRC and Sharp Memorial Hospital August 2010 December 2011 Evidence based Coleman Model to coach, not do, using Four Pillars Establish and maintain a PHR Establish and maintain a Medication List Prompt follow up with specialists Recognition of Red Flags How Are We Building A Better System? Care Transitions Intervention (CTI) Pilot Enrolled 138 patients as of June 30, 2011 Diffusing use of technology to support chronic disease self management through Tech4Impact Teaching use of Web Resources Using electronic tools PHR Medication List CTI Pilot Early Outcomes TIMEFRAME: August 12, 2010 to June 30, 2011 POPULATION: 88 patients who completed the fourweek CTI program, were 90 days post discharge, and were readmitted to Sharp Memorial Hospital for the same diagnosis. 24.3% 25.0% 20.0% 12.6% 17.0% 15.0% 10.0% 5.0% 2.3% 5.7% 8.0% 0.0% Within 30 Days Within 60 Days Within 90 Days CTI Readmission Rate SMH Readmission Rate for 2009 Pilot costs $157,557 Pilot cost savings $556,928 Per patient savings $6,329 3

4 Working Together Across All Providers And Settings It s All About Improving Quality Of Life CTI Aligns with AIS Mission and Vision Integration efforts since 1999 Competencies of AIS staff Partnerships Interdisciplinary Teams Service Coordination Enhanced Follow Up Patient Activation Making a difference in the lives of those we serve and supporting their selfsufficiency Improving Health Outcomes And Quality of Life Community based Care Transitions Program (CCTP) $500 M CMS funding under Sec of ACA Improve quality, reduce cost and improve patient experience for Medicare beneficiaries (including duals) through partnerships Target Medicare beneficiaries with multiple chronic conditions including CHF, AMI, PNEU and at high risk for readmission 4

5 Community Based Care Transitions Program Preferred Applicants: AoA funded ADRCs partnering with multiple hospitals Hospitals with high readmission rates partnering with CBOs Program runs for 5 years 2 year agreement initially Rolling application process began April 12, 2011 Bridging Health And Social Services Develop a blended rate that includes all services in comprehensive care transitions program the cost of care transition services provided at the patient level the cost of implementing broader systemic changes at the hospital level ADRC paid blended rate on a per eligible discharge basis for targeted Medicare beneficiaries ADRC can share fee with hospitals and CBOs, based on proposed interventions Improving Health Outcomes And Quality of Life Evaluation Performance Measures Outcome Measures: 30 Day Risk Adjusted All Cause Readmission Rate 30 Day Unadjusted All Cause Readmission Rate 30 Day Risk Adjusted AMI, HF, and PNEU Readmission Rate Process Measures: Primary Care Provider follow up within 7 days of discharge Primary Care Provider follow up within 30 days of discharge 5

6 The Road Ahead Building Partnerships Presented CCTP opportunity to hospitals Identified hospitals interested in partnership Drafted proposed model Established County Tiger Team Engaged Consultants Engaged QIO and Beacon Community Questions 6