Speaker Disclosures Care Transitions Interventions: The Sussex County Transitional Care Program Dr. Wang has disclosed that he has no relevant financial relationship(s). George C. Wang, MD, PhD Medical Director, Sussex County Transitional Care Program Director, Center of Excellence in Geriatric Medicine, Newton Medical Center Assistant Professor of Medicine, Johns Hopkins University School of Medicine Learning Objectives By the end of the session, participants will be able to: Define and express the rationale for transitional care Recall the goals of the Partnership for Patients initiative Recognize different models of transitional care Identify common strategies for reducing avoidable hospital readmissions Transitional Care: Rationale New Jersey 30-day hospital readmission rates (Jan Jun 2013)*: All settings: 19.53% Discharged to SNF: 23.11% Discharged to Rehab: 19.99% Discharged to home without home health care: 16.91% Discharged to home with home health care: 21.60% Hospice patients: 2.52% Patient Protection and Affordable Care Act (PPACA): improved care coordination and outcomes for hospitalized patients a major goal to reduce fragmentation of care and Medicare cost *Data source: HQSI, the Medicare Quality Improvement Organization for New Jersey, under contract with the Centers for Medicare and Medicaid Services (CMS) Outline Transitional care: rational Models of transitional care Sussex County Transitional Care Program (SC-TCP): a model of public-private partnership Main partners in the SC-TCP SC-TCP Interventions Outcomes data In New Jersey, which of the following care settings has the highest rate of 30-day hospital readmission? A. Rehab B. SNF C. Home without home health care D. Home with home health care E. Hospice 1
Transitional Care: Rationale New Jersey readmission rates (Jan Jun 2013)*: All settings: 19.53% Discharged to SNF: 23.11% Discharged to Rehab: 19.99% Discharged to home without home health care: 16.91% Discharged to home with home health care: 21.60% Hospice patients: 2.52% Patient Protection and Affordable Care Act (PPACA): improved care coordination and outcomes for hospitalized patients a major goal to reduce fragmentation of care and Medicare cost *Data source: HQSI, the Medicare Quality Improvement Organization for New Jersey, under contract with the Centers for Medicare and Medicaid Services (CMS) Transitional Care: Rationale PPACA specifies incentives and penalties to hospitals and health systems based on readmission rates. The Centers for Medicare & Medicaid Services (CMS) penalizes hospitals with severity-adjusted readmission rates exceeding those expected for Medicare beneficiaries with CHF, pneumonia, or AMI. Starting in Oct 2013, maximum penalty increased to 2% and topped top out at 3% in 2014. In alignment with the Partnership for Patients initiative to reduce avoidable readmissions and reduce health care expenditures, the implementation of transitional care strategies aims to improve the care transition process across settings. Focusing efforts in the community, instead of isolating them to hospitals, has been proposed to be the best target for intervention. Partnership for Patients (PP) Initiative Nationwide public-private partnership to improve quality, safety, and affordability of health care. Two major goals: (1) Reduce harm caused to patients in hospitals. Reduce preventable errors in hospitals by 40% and reduce hospital readmissions by 20%. 10 core patient safety areas of focus: adverse drug events, catheter-associated UTIs, central line associated blood stream infections, injuries from falls and immobility, obstetrical adverse events, pressure ulcers, surgical site infections, venous thromboembolism, ventilator-associated pneumonia, readmissions (2) Improve care transitions. Key elements: The Hospital Engagement Networks 26 State, regional, national and hospital system organizations serve as Hospital Engagement Networks (> 3,700 hospitals) Help identify solutions already working to reduce hospital-acquired conditions, and work to spread them to other hospitals and health care providers The Community-based Care Transitions Program Created by Section 3026 of the Affordable Care Act, tests models for improving care transitions and reducing readmissions for high-risk Medicare beneficiaries. 102 sites awarded to test models for improving care transitions Each site constitute a collaborative community effort including community-based organizations such as social service providers or Area Agencies on Aging, multiple hospital partners, nursing homes, home health agencies, pharmacies, primary care practices, and other types of health and social service providers serving patients in that community Which of the following models of transitional care specifically provides a set of tools and strategies to assist nursing home staff in the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities? A. Coleman Care Transitions Intervention B. Naylor Transitional Care Model C. BOOST (Better Outcomes by Optimizing Safe Transitions) D. Project Re-engineered Discharge (RED) E. INTERACT II (Interventions to Reduce Acute Care Transfers) Transitional Care Model (TCM) (Mary Naylor, PhD) Nurse-developed, nurse-led intervention Comprehensive discharge planning for older adults with chronic illnesses hospitalized for common conditions Hospital planning and home follow-up Coordination of care by an APN Transitional Care Nurse Visits patients within 24-48 hrs of admission, and every 48 hrs thereafter Calls and visits patient at home after discharge Accompanies patient to follow-up visit Increased patient and caregiver understanding and management of health problems Early identification and response to potential problems Reduced hospital readmissions (2-week: 4% vs 16%, P=0.02; 6-week: 10% vs 23%, P=0.04), and rehospitalization and post-discharge service costs No difference in post-discharge acute care visits, functional status, depression, or patient satisfaction 1. Enderlin CA, McLeskey N, Rooker JL, et al. Review of current conceptual models and frameworks to guide transitions of care in older adults. Geriatr Nurs 2013;34:47-52. 2. Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med 1994;120:999-1006. 3. Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. Jama 1999;281:613-20. Care Transitions Intervention (Eric Coleman, MD, MPH) 4 pillars: Assistance with medication self-management Patient-centered record owned and maintained by the patient to facilitate cross-site information transfer Patient empowerment for timely follow-up with primary or specialty care List of red flags indicative of a worsening condition and instructions on how to respond to them. Transitions Coach Provide older patients and caregivers with tools and support to encourage more active role in their care transitions Provide continuity across care settings Meet with patient in hospital before discharge, establish rapport, arrange home visit, ideally within 48-72 hours For patients transferred to SNF: telephone or visit at least weekly to maintain continuity, facilitate preparation for discharge (attention to self-care), arrange home visit Home visit: reconcile medications, impart skills for effectively communicating care needs during subsequent encounters with health care providers, rehearse communication strategies with patient, review red flags After home visit, 3 phone calls over 28 days post discharge (determine whether received appropriate services, review progress toward goals, support patient s role in chronic illness self-management) Lower 30-day (8.3 vs 11.9, P=.048) and 90-day (16.7 vs 22.5, P=.04) readmission rates, lower hospital costs Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med 2006;166:1822-8. 2
BOOST (Better Outcomes for Older Adults through Safe Transitions Better Outcomes by Optimizing Safe Transitions) (Society of Hospital Medicine; PI, Mark Williams, MD) Grant from the John A. Hartford Foundation Mentors hospital teams to map current processes and create and implement action plans for organizational change Provides a suite of evidence-based clinical interventions that can be easily adapted and integrated into each unique hospital environment Interventions incorporate 5 principles: patient centeredness, empowerment, risk appropriateness, team orientation, bridging. Project BOOST Mentoring Program. Participating sites receive: Day long training sessions (fee-based) Year-long coaching/mentoring program (free, courtesy of grant from the John A. Hartford Foundation) >180 participating sites as of Jan 2014 BOOST Data Center: Resources to help sites implement best practices BOOST Collaboration: Care transitions discussion communities Early data from 6 sites: Reduced 30-day readmission rates from 14.2% to 11.2% Project Re-engineered Discharge (RED) (Brian Jack, MD) For general medical patients: Patient-centered education, comprehensive discharge planning, postdischarge reinforcement. Original trial did not enroll patients admitted from or discharged (planned) to an institutional setting. 3 core elements: Nurse discharge advocates (DA) carried out all aspects of in-hospital intervention. After-hospital care plan (AHCP), containing provider contact info, appt and test dates, appt calendar, color-coded medication schedule, list of tests with pending results at DC, illustrated description of DC dx, info about what to do if a problem arises. DA used a teach-back methodology to review contents of AHCP with patient. On day of discharge, AHCP and DC summary were faxed to the PCP. Follow-up phone call Clinical pharmacist called patient 2-4 days after discharge to reinforce DC plan, reviewed meds, and addressed medication-related problems; communicated issues to PCP or DA Virtual patient advocates currently being tested in conjunction with the RED, with computergenerated instructions. Lower rate of hospital utilization (incidence ratio, 0.695, P = 0.009), lower total cost per patient, higher rate of seeing PCP for F/U within 30 days. http://www.hospitalmedicine.org/am/template.cfm?section=home&contentid=27659&template=/cm/htmldispl ay.cfm. Accessed Jan 2, 2014 Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009;150:178-87. Re-Engineered Discharge (RED) Toolkit. March 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/hospital/toolkit/index.html. Accessed Jan 2, 2014. INTERACT II (Interventions to Reduce Acute Care Transfers) (Joseph G. Ouslander, MD) Reduce avoidable transfers of SNF residents to the acute hospital. Set of tools and strategies to assist NH staff in early identification, assessment, documentation, and communication about changes in status of SNF residents. 3 strategies: Identifying, assessing, and managing conditions proactively to prevent them from becoming severe enough to require hospitalization (e.g., dehydration, exacerbation of CHF). Managing selected conditions in NH when the resident does not meet specific criteria that suggest the need for acute hospital care (e.g., respiratory and urinary tract infections, fever). Improving advance care planning and considering a palliative care plan as an alternative to acute hospitalization for residents at the end of life (e.g., end-stage dementia or Parkinson s disease with recurrent aspiration pneumonia). Leadership education, facility champion, NH staff education. Evaluated in 25 NHs in 3 states in a 6-month quality improvement initiative. Average cost of 6-month implementation $7,700 per NH. Projected savings to Medicare in a 100-bed NH ~$125,000/year. 17% reduction in self-reported hospital admissions (24% for engaged NHs, 6% for not engaged NHs). Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc 2011;59:745-53. http://interact2.net/#. Accessed Jan 2, 2014. Summary of Transitional Care Models Common themes: Partnership approach, which actively involves older adults and their caregivers in the management of their illnesses Discharge planning Early identification of potential problems Tools for health professionals Patient and family education Visits in the hospital or home Follow-up phone calls Model of Public-Private Partnership Sussex County Transitional Care Program (SC-TCP) Objective: Improve care transitions for citizens of Sussex County, NJ, and reduce avoidable, unnecessary hospital readmissions for high risk patients Brief History And in the beginning there was a theory: Through a publicprivate partnership, the Sussex County Department of Human Services (SC-DHS) could provide leadership in the County, in partnership with the community hospital, primary care physicians, and other providers to reduce unnecessary hospital readmissions for high risk patients. Dr. Daryl Kim of Premier Health Associates instrumental in the conceptualization and implementation of SC-TCP Sussex County Transitional Care Program (SC-TCP) Oct 2011 - Community-based Care Transitions Program grant; unsuccessful. SC-DHS held a community educational forum to discuss transitional care on Feb 8, 2012. Mary D. Naylor, PhD, RN, FAAN Sussex County Community College Performing Arts Center 3
Model of Public-Private Partnership 2012: formal partnership agreements executed by SC-DHS, Premier Health Associates (PHA), Newton Medical Center (NMC), Bridgeway Behavioral Health, and Karen Ann Quinlan Hospice Risk-sharing model in which SC-DHS is a sharing partner with ACO Funding: $200,000 matched cash investment by County and NMC, $200,000 in-kind investment by PHA and 3% revenue sharing partner of PHA s Sussex County Regional ACO contract, 3% of per member per month incentive payment $60,000 in grants from State of NJ, $15,000 Title III funding In-kind Sussex County contribution for accounting, counsel, and program administration 2013: Medical Director, George Wang, MD, PhD Active collaboration with Health Qualities Strategies, Inc., the Medicare Quality Improvement Organization for New Jersey, under contract with CMS Staff certified as Transitions Coaches (Care Transitions Program, Coleman model) Received grants from the Grotta Fund to further develop the Sussex County Transitional Care Program Model of Public-Private Partnership Key ingredients for successful partnership formation: Recognition of the importance of the public-private partnership Bringing the right public and private partners together Buy-in from decision makers Sussex County Board of Chosen Freeholders Premier Health Associates President and Board of Directors Newton Medical Center leadership Community SC-TCP main partners: Sussex County Department of Human Services Regional acute care hospital Newton Medical Center, Newton, NJ Regional rehabilitation and skilled nursing facilities Community healthcare providers in Sussex County, New Jersey Backbone of SC-TCP Transitional care nurse coordinator Care Transitions Coaches (social workers) Geriatrician medical director Elements from the Naylor Transitional Care Model, the Coleman Care Transitions Intervention, and Project RED were incorporated into a county-specific program. High-risk patients identified using standardized form are referred to TCP on admission to Newton Medical Center. SC-TCP Interventions Transitions Coaches Visit patient in the hospital usually within 24 hours of admission Following discharge to subacute rehabilitation/skilled nursing facility (SAR/SNF): Call and/or visit patient, participate in discharge planning at SAR/SNF on an individual basis as necessary to facilitate post-discharge arrangements Available 24 hours a days, 7 days a week by phone (though patient encouraged to call between 8 am and 4:30 pm) throughout the patient s entire SAR/SNF stay Following discharge to home: Make home visits (at least 1) Make follow-up phone calls weekly Assist with completion of a Personal Health Record Identify personal goal Perform medication reconciliation Coordinate follow-up visits to PCPs and specialists Accompany patient to first post-acute, PCP visit, as necessary Assist with identifying additional services needed to be successful at home Identify Red Flags Available 24 hours a days, 7 days a week by phone (though patient encouraged to call between 8 am and 4:30 pm) for 30 days after discharge to home SC-TCP Interventions Transitions Coaches Are positioned full-time in hospital for direct patient access Coordinate with hospitalists, social workers, case management, community PCPs Immediately notify PCPs of any TCP patient admission, discharge, or transition in care Attend monthly TCP Six Sigma committee meetings Directly access EMR of PHA and document TCP nurse visits patients only on Saturdays on an as-needed basis SC-TCP Interventions In-Home Services Home health assistance, chore services, meal delivery Caregiver support Transportation Sussex County provided transport Community and youth services Benefits/Insurance Counseling SHIP (State Health Insurance Assistance Program) Medicare (A and B), secondary insurance counseling, Medicare Part D prescription benefit, Prescription Assistance to the Aged and Disabled (PAAD) Hospice Options counseling, coordination of services Social Services Jersey Assistance for Community Care giving Global Options Medicaid Screenings for Supplemental Nutrition Assistance Program (SNAP) 4
Questions for my Primary Care Doctor: 1 My Health Conditions: Personal Goal Notes: 2 3 4 5 Case Examples SAR/SNF Intervention 30-Day Medicare Re-Hospitalization Data: New Jersey Medicare All-Cause County-Specific 30-Day Total Readmission Rates (%) NJ state total readmission rate Sussex County total readmission rate 25 20 18.66 18.82 20.08 19.05 18.36 17.42 17.28 15 10 5 0 Jan10-Jun10 Jul10-Dec10 Jan11-Jun11 Jul11-Dec11 Jan12-Jun12 Jul12-Dec12 Jan13-Jun13 Six-Month Period *Data source: Healthcare Quality Strategies, Inc. (HQSI), the Medicare Quality Improvement Organization for New Jersey, under contract with the Centers for Medicare and Medicaid Services (CMS) 5
SC-TCP Enrollment January 2014 December 2014 Patients enrolled into TCP (no.) 845 Home visits (no.) 601 Telephonic care management calls (no.) 3,569 Total completed Personal Health Records (no.) 412 January 2015 July 2015 Patients enrolled into TCP (no.) 524 Home visits (no.) 339 Telephonic care management calls (no.) 1,950 Total completed Personal Health Records (no.) 297 SC-TCP Data Variables Collected Data Variables Collected for Each Participant Admission Diagnosis Discharge Diagnosis Hospital Visit by Social Worker Discharge Destination SNF/SAR Visit by Social Worker Discharge Instructions Received Hospital Follow-up Appt. with PCP Specialist Follow-up Appt. Patient Phone Calls Provider Phone Calls Home Visits Personal Health Record (PHR) Discharge Medications Filled 30 Day Readmissions Medical Insurance Referrals to Community Services Comorbid Conditions Age/Date of Birth Race Sex SC-TCP Outcomes Data January 2014 December 2014 Live discharges (no.) 845 30-Day Readmissions (all DRGs) (no.) 59 30-Day Readmission rate (%) 6.98% 90-Day Readmissions (all DRGs) (no.) 99 90-Day Readmission rate (%) 11.72% January 2015 June 2015 Live discharges (no.) 524 30-Day Readmissions (all DRGs) (no.) 45 30-Day Readmission rate (%) 8.58% 90-Day Readmissions (all DRGs) (no.) 67 90-Day Readmission rate (%) 12.79% *Readmission data includes readmissions directly from SNF/SAR facilities to the hospital 6