Care Coordination and Aging

Transcription

1 Care Coordination and Aging September 3, 2014 Robyn Golden, LCSW Director of Health and Aging Rush University Medical Center

2 Our nation faces significant challenges when it comes to ensuring all Americans have access to needed health care services. We are woefully unprepared. The U.S. health care system is in denial about the impending demands. Innovative new approaches to delivering care to older adults have been shown to be effective and efficient, but most are not implemented widely and instead left to languish on the shelf Institute of Medicine report Retooling for An Aging America

3 Framing the issue Baby boomers + increased longevity 12% of US population to 20% Disproportionate share of health services. Older adults make up 12% of US population, but use: 26% of all physician visits 35% of all hospital stays 34% of all prescriptions 38% of all emergency medical response services 90% of nursing home use 50% of older adults have multiple chronic conditions Individuals w/ chronic conditions see average of 12 physicians/year and take 4-8 meds

4 Medicare spending by # chronic conditions 4 Chronic Conditions 12% 5+ Chronic Conditions 68% 3 Chronic Conditions 10% 2 Chronic Conditions 6% 0 Chronic Conditions 1% 1 Chronic Condition 3% Source: R Berenson, A Call for Clarity in Care Coordination, PowerPoint Presentation to the American Society on Aging New York Academy of Medicine National Forum on Care Coordination. 17 March 2009.

5 Fragmentation as a Major Obstacle Siloed health and social service systems Funding streams Delivery systems Eligibility rules Training programs Terminology Person- and family-centered, coordinated care with links to the community are rare in care models, but are critical Mental health often forgotten Not bilingual or bicultural to bridge medical and social systems

6 Care coordination after hospital After hospital discharge, particular need for care coordination ( transitional care ) New care plans, new medications New provider organizations Change in ability to complete tasks Lack of hospital community collaboration Little post discharge follow up Outpatient and inpatient care disconnected Clients/caregivers take responsibility of care at home External providers (ex: home health agency) assumed to be providing care as ordered/needed Lack of follow up on community service referrals Little to no accountability for problem resolution between providers

7 What are the risks of a poor transition? 19% of clients experience an adverse event within 3 weeks of hospital discharge 1 17% of Medicare beneficiaries are readmitted in 30 days 2 75% of readmissions were preventable 3 Each older adult readmission costs CMS an average of $9,600 4 According to CBO, 43% of Medicare costs can be attributed to 5% of Medicare s most costly beneficiaries 5 1 Forster, A.J., Murff, H.J., Peterson, J.F., Gandhi, T.K., and Bates, D.W. (2003). The incidence and severity of adverse events affecting clients after discharge from the hospital. Annals of Internal Medicine, 138(3): CMS Medicare Medicaid Research Review Data Shows Reduction in Medicare Hospital Readmission Rates During MedPac and AHRQ report 4 CMS 5 Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008; Friedman, B., & Basu, J. (2004). The rate and cost of hospital readmissions for preventable conditions. Medical Care Research and Review (2),

8 Who s providing care? Aging Network Hospital Primary Care Physician Nontraditional Resources Older Adult Home Health Pharmacy Community Based Agencies Skilled Nursing Facility Caregivers

9 Amidst the press of acutely ill patients, it is difficult for even the most motivated and elegantly trained providers to assure that patients receive the systematic assessments, preventive interventions, education, psychosocial support, and follow-up that they need. - Wagner et al. Milbank Quarterly 1996:74:511

10 Meeting the Demand Care needs to include: Prevention Care coordination The social determinants of health It takes a village Need a team to meet the needs of increasingly complex, older patient population Responsibility cannot solely reside with the MD Importance of interprofessional education

11 What s Needed for Chronic Care Opportunities for improving care for people with chronic care needs Comprehensive primary care Assessment of client and caregiver long-term services and supports (LTSS) needs LTSS home and community-based or institutional care that support ability to complete daily activities Coordination of LTSS and medical care Collaboration between care coordinators, PCPs, patients, families Supportive care transitions Commitment to person- and family-centered care Georgetown Health Policy Institute report

12 Care Coordination Care coordination is a person- and family-centered, assessment-based, interdisciplinary, multicultural approach to integrating health care and social support services in a cost-effective manner in which an individual s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an evidence-based process which typically involves a designated lead care coordinator. -National Coalition on Care Coordination

13 Key Components of Effective Care Coordination Models Target high risk patients Frequent in-person contacts by care coordinator Timely information on hospital/er admissions Co-location of care coordinators and physicians Same care coordinator for all of physician s patients Strong patient education, guidance on taking Rx s Social supports for those who need it Source: Carol O Shaughnessy Principal Policy Analyst, Weaving Together Health Care and Community Support Services: Searching for Seamless Connections: National Health Policy Forum, March 29, 2012 Randall Brown. Mathematica, Inc. Presentation to the National Health Policy Forum, Coordinating Care for Adults with Multiple Chronic Conditions: Searching for the Holy Grail, March 27,

14 Initiatives to meet demand Federal initiatives Demonstration projects in Center for Medicare and Medicaid Innovations Accountable Care Organizations Community-based Care Transitions Program Independence at Home Demonstration Bundled Payment for Care Improvement Initiative Hospital Readmissions Reduction Program Capitation Medicare Advantage Post-acute care contractors Program of All-Inclusive Care for the Elderly (PACE)

15 more initiatives Federal initiatives (cont.) Primary Care Medical Homes Medicare-Medicaid Plan (IL s plan: MMAI) Chronic care payment to Medicare PCPs Aging and Disability Resource Center (ADRC) funding

16 State and community-led efforts States-wide initiatives Senior Care Options (Massachusetts) Vermont Blueprint for Health: Support and Services at Home (SASH) Community-driven efforts: developing, evaluating, and disseminating programs to meet needs of older adults and their caregivers Geriatric Resources for Assessment and Care of Elders (GRACE) Comprehensive Care Program (HealthCare Partners) Mercy Health System Care Management Plus (Oregon) Bridge Model of transitional care

17 Bridge Model of transitional care Pre-Discharge Referral Assessment Information gathering Community resources Post-Discharge Assessment Connection to providers Advocacy Clinical intervention 30-day followup Confirm long-term support structure Collect data Outcomes of Bridge intervention: Decreased readmissions Decreased mortality Increased physician follow-up Increased understanding of medications and discharge plan of care Decreased client and caregiver stress

18 Opportunities for change Disconnects between health care, LTSS, community services providers exist, and addressing the disconnects has huge potential to improve care and individual outcomes, and slow costs Increase knowledge of community services by health care providers Foster interdisciplinary team approach by providers Support community providers to increase capacity for 24-hour care upon patient discharge Engage family caregivers in care plan Focus on health care literacy when working with patients and caregivers Promote primary care provider follow-up after a hospitalization or upon nursing home entry Find/create alternatives to ERs in medically underserved areas Engage and invest in the range of community providers/services

19 Challenges Care coordination Medicare pilots haven t shown great results in cost savings 2009 Jama (Peikes et al): 0 of 15 sample Medicare care coordination demo sites saved $; only 1 reduced hospitalizations 2008 AARP (Berenson et al): nearly 30 years of FFS and capitation demos w/ various approaches to care management/coordination showed some improvement in quality but negligible savings Different definitions of care coordination, chronic care management, case management, etc. Targeting care coordination interventions for different population and patient needs Cognitive decline needs different supports than a chronic disease that limits physical ability Source: R Berenson, A Call for Clarity in Care Coordination, PowerPoint Presentation to the American Society on Aging New York Academy of Medicine National Forum on Care Coordination. 17 March 2009.

20 Other challenges to meeting needs of older adults Economic security of older adults Housing, transportation Long-term services and supports Over reliance on and lack of support for family caregivers Fewer family caregivers will be available in future Future economic security of family caregivers Shortage of geriatric professionals From frontline workers to social workers to MDs Rural service delivery and provider coverage

21 The moral test of a government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy, and the disabled. - Hubert H. Humphrey, 1976