Community Care of North Carolina

Transcription

1 Community Care of North Carolina CCNC Transitional Care Management Jennifer Cockerham, RN, BSN, CDE Director, Chronic Care Programs & Quality Management 1

2 Chronic Care Population Within the NC Medicaid population, there are over 200,000 Aged, Blind, or Disabled (ABD) recipients enrolled in CCNC networks

3 Chronic Disease Prevalence of NC s ABD Medicaid Population 43% 3 or More Major 3 or More Major Co-morbidities

4 Major Co-morbid Conditions 45% Hypertension 24% Diabetes 14% Asthma 14% COPD 13% Ischemic Vascular Disease 12% Neurological Disorders 6% Chronic Kidney Disease 3% Heart Failure 41% Mental Health conditions p

5 The Problem ABD recipients make up approximately 30% of our Medicaid population but consume around 70% of total Medicaid expenditures

6 ED and Inpatient Utilization of ABD Population (over 6 month period) At Least 1 ED Visit At Least 1 Hospitalization 41% 17% t

7 Treo PPL All individuals within the same Clinical Risk Group (CRG) Actual-to- Expected Difference $0 $1K $2K $3K $4K $5K $6K $7K $8K $9K $10K $11K $12K $13K $14K $15K $16K $17K $18K $19K $20K Expected Inpatient Costs for this CRG Revised March 2012

8 Definition Transitional Care A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location Source: Position Statement from the American Geriatrics Society, 2003 CCNC Transitional Care 02/2011

9 TARGET : Tool for Adjusting Risk - A Geriatric Evaluation for Transitions 7 P Risk Scale: Prior Hospitalization Problem Meds (Coumadin, insulin, Digoxin) 3. Punk (depression) Principal diagnosis Polypharmacy Poor health literacy (50% higher risk) Patient support Project BOOST (Better Outcomes for Older Adults thru Safe Transitions)

10 Hospital Stays are Sentinel Events For poor patient understanding poor communication among providers disease instability a poor milieu at home lack of professional or family support inadequate or untimely outpatient care

11 Pitfalls of Hospitalization 17.6 % are readmitted within 30 days of discharge 6% in the first week 50% had not followed up with PCP or any physician before being readmitted (Institute for Healthcare Improvement) 25-30% occur at a different hospital (Steven Jencks, MD, MPH) 20% of pts. D/C d from hospital had at least 1 medication discrepancy (UCHSC) 1/3 of meds prescribed at D/C not taken (Beers et al) 50% of new meds prescribed at D/C did not get communicated back to PCP (Beers et al)

12 Dangers of Discharge In one study, 41% of inpatients were discharged with test result(s) pending 25% needed further workup on an outpatient basis Greater than 1/3 of those workups were not completed Archives IM 2007; 167;

13 Key Elements of a Successful Transition Interdisciplinary Communication/Collaboration Patient/Participant Activation Enhanced Follow up

14 Chronic Care Model Over time, visits/interactions (planned and acute) will meet patient needs and assure the delivery of proven clinical and behavioral elements of care. INFORMED ACTIVATED PATIENT PREPARED PROACTIVE TEAM IMPROVED OUTCOMES

15 Boots on the Ground TEAM APPROACH

16 Transitional Care Process 1) Notification/identification of hospitalized patients 2) Screening & Assessment Process 3) Hospital Visit 4) Facilitate Optimal Hospital Stay and Discharge Plan 5) Home Visit with Medication Reconciliation/med management 6) Medical Home Linkage 7) Disease Management, Red Flags, Community Linkages, improved self-management

17 Face-to-Face Encounters

18 MED WRECKS Medical Errors account for 44,000 to 98,000 deaths in the US each year 8 th Leading Cause of Death in the US Occur at a rate greater than motor vehicle accidents, breast cancer, or AIDS Over 770,000 patients are injured each year Errors occur in nearly 1 of every 5 doses given to patients in a typical hospital

19 o Annual National Cost of preventable adverse drug events is $2 Billion o Annual Cost of drug-related morbidity and mortality $177 Billion o Per FDA: at least 1 death per day and 1.3 million people injured each year due to medication errors o High Risk Meds (Coumadin, insulin, digoxin) o Polypharmacy o 49% of patients experience at least 1 error in medication continuity Kripalani S et al. Promoting Effective Transitions of Care at hospital Discharge: A review of Key Issues for Hospitalists. J Hos Med 2007;2: o New meds at D/C not noted in outpt. record 50% of time

20 Medication Reconciliation Definition: The process of identifying duplications and/or discrepancies between the medication lists and other sources (e.g. fill history, patient interview, PCP chart) arising from uncoordinated care or patient non-adherence Patient and/or Caregiver Interview takes place Home Clinic Telephone Medication List enhances drug use information gathering

21 Medication Reconciliation Who: RN (Optimally) Professional degrees and/or licensed professionals Must possess appropriate clinical training and adequate skill competency Unless excluded by their scope of practice as defined by their licensing entity All medication reconciliations performed by a non-rn must be approved by the supervising RN or Network Pharmacist. Pharmacist

22 Medication Review Definition: In-depth global review of the medication regimen and drug use history to identify complex problems. This is usually initiated by a referral from CM or PCP. Review includes: Cost-effective medications Duplications Side effects Contraindications Interactions Allergies Adverse event identification Evidence-based recommendations Not limited to transitional care

23 Med Management **Reconcile the discharge medication regimen with those taken before the hospitalization. **Explain what medications to take, emphasizing any changes in the regimen. **Review each medication s purpose, how to take each medication correctly, and important side effects to watch out for. **Be sure patient has a realistic plan about how to get the medications.

24 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

25 Self-management Tasks of Chronic Care Patients Medical management of condition (MEDICAL) Creating and maintaining new meaningful life roles (SOCIAL) Coping with anger, fear, frustration of having chronic condition (EMOTIONAL) Based on work by Clark, Corbin, Strauss and Glaser

26 What we are learning Complexity of the population medically & socially Majority have either a dominant or moderate chronic condition, a malignancy, or a catastrophic health condition Motivational Interviewing techniques are key for positive patient engagement Population management appears to be having a positive impact on access to care, ED, and inpatient utilization 2011 cumulative Medicaid costs for enrolled ABD population (dual and non-dual combined) were $196 lower per member per month for the fiscal year as compared to fiscal year 2008.

27 Time to First Readmission for Patients Receiving Transitional Care Versus Usual Care Lighter shaded lines represent time from initial discharge to second and third readmissions (Significant Chronic Disease in Multiple Organ Systems, Levels 5 & 6; ACRG3 = 65-66) 1 Survival Function Proportion still out of the hospital An estimated total of 634 averted readmissions over a one year period for people in this ACRG3 group (~$5 million saved) Transitional Care (N=1,966) Usual Care (N=1,035) Months since discharge from the hospital All CCNC enrolled at the time, or within 30 days, of discharge; inpatient discharges during SFY2011, excluded members dually enrolled at any point during the study period.

28 Looking Beyond the 30 Days Inpatient readmission scorecard measures typically focus on the outcomes during a very brief period of time (30 days) post discharge. While this target has merit, it s important to keep our eyes on the prize reducing likelihood of all admissions over the long run. Consequently, we examined the 365 days following discharge to estimate the long-term impact of transitional care. Transitional Care has lasting effects on likelihood of future admissions.

29 Challenges Defining the impactable patient & interventions Effectively incorporating palliative care, mental health & other resources/services without creating more silos Challenges obtaining Real-Time Hospital Data Unable to locate the patient Narrow time frame for the most beneficial intervention Promoting effective self-management Growing population and level of complexity Building capacity and TC skill set in the Medical Homes Competing agendas

30 More information? Thank You!