Integration of Care Coordination: Building Bridges Between ......2014/03/14  · Integration of Care Coordination: Building Bridges Between Community and the Disease Centric Islands

Integration of Care Coordination: Building Bridges Between

Community and the Disease Centric Islands of Care

National Health Policy Forum

March 14 2014

Kyle Allen, DO AGSF

VP Clinical Integration Medical Director Geriatric Medicine and Lifelong Health

Riverside Health System Newport News VA

Key Issues

• Policy, traditional medical model, history and financial incentives have created chasms in care delivery and true coordinated care

• For those with chronic illness and functional impairment the system woefully inadequate, unsafe and poor quality.

• Change will require “radical” transformational change of the health system and integration of community based services

Health-service and social-services expenditures for OECD countries, 2005, as ratio

BMJ Qual Saf 2011;20:826e831.

US level

Health Care Utilization Experience for Patients with Chronic Conditions: Current Health Care System

Poor care transitions planning and advance care

decisions (often by the family) and failure to link to care transitions program or

community programs at transition/discharge

Community-dwelling chronically ill patient with poor symptom control and coordination of care, whose

goals and advance care wishes are rarely asked or documented, and

who rarely engages in self management programs or learning

Exacerbation of chronic illness leading to ED visit and hospitalization with inherent

hospital risks for further decline and associated disability

The Expanded Chronic Care Model: Integrating Population Health

Promotion

February 26, 2014 5

Source: The Expanded Chronic Care Model, Barr, Robinson, Marin-Link, Underhill, Dotts, Ravensdale, & Salivaras, 2003

We Need Bridges and “Boundary Spanners”

February 26, 2014 6

Summa Health System Akron, Ohio

Case Study

A Comprehensive “System” Approach: The Foundation for ACO for those with Complex Illness

Summa Health System

• Serves a five county region in Northeast Ohio

• Seven owned, affiliated and joint venture hospitals

• SNF Network • Regional network of ambulatory

centers • 240+ employed multi-specialty

group • A 150,000+ member health plan • A System-level foundation • 10,000+ employees • Total Net Revenue of $1.6

Billion • Total Discharges of 61,000

8

Enhanced Care Management

Improving Care through Collaboration: Integration of the Aging Network and Acute and Post

Acute Medical Care Services

Area Agency on Aging 10B.Inc

The SAGE Project The AD-LIFE Trial

AHRQ# R01 HS014539

The PEACE Trial National Palliative Care Research Center

SummaCare Insurance Co.

The Enhanced Care Management Program

Summa Health System

Care Coordination Network

Summa Health System Care Coordination Task Force

• 26 active participating facilities (now 39) • Initial meetings to define the problems:

– Identified that 99.9% of problem was communication – Collaborative development of work plan – Commitment to 2-hour work sessions every 2 weeks – Shared learning experiences

• Developed memorandum of understanding (MOU) to formalize network

• Use meetings to advance quality, problem solving, new learning, and innovations

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February 26, 2014 11

NE Ohio Regional Impact

• Universal transitional care form created by CCN

• Instituted in 19 regional hospitals • Phase II was creation of SNF “change in

condition” form – Involved EMS and EM physicians and staff – Used by CCN facilities

• http://www.innovations.ahrq.gov/content.aspx?id=2162 • http://www.innovations.ahrq.gov/content.aspx?id=186

February 26, 2014 12

Newport News Virginia

A Health System Approach for Improving Care for Older Adults with

Complex Illness

Integrated Delivery System

Riverside Health System

ACUTE Riverside Medical Group

Lifelong Health

Engineering Health System for Older Adults and Those With Advanced Chronic Illness

Nurses Improving Care of Health System Elders

Acute Care for Elders Meeting the Challenge of Providing Quality and Cost-Effective Hospital Care to Older Adults

Programs of All-Inclusive Care for the Elderly

Transformation of Institutional Nursing Home to Household Person- Centered Care

ACE Acute Care for Elders

Hospice

Palliative

Care

POST

• All adults with progressive illness

• Projects complications • Normalizes ACP for future

decisions

Advance Care Planning *http://www.capc.org/capc-resources/capc-poster-sessions/capc-texas-2008/abstracts/posters/01-full.jpg

*NIH/National Institute of Nursing Research, R01 NR009784

Community Partnerships In Eastern Virginia and Beyond

• Hampton Road Chronic Disease Self Management Coordination Coalition

• Eastern Virginia Care Transitions Partnership • Tidewater Advance Care Planning Coalition

Chronic Disease Self Management Coalition

Provided by

and

Eastern Virginia Care Transitions Partnership: A community partnership of health systems, area agencies on aging, independent

physicians’ groups and other public and private health and human service providers.

HEALTH SYSTEMS Riverside Health System

Bon Secours Mary Washington Healthcare

Rappahannock General Hospital Sentara Health Care

AREA AGENCIES ON AGING Bay Aging – Lead Community Based Organization

Eastern Shore Area Agency on Aging and Community Action Agency, Inc. Peninsula Agency on Aging, Inc.

Rappahannock Area Agency on Aging, Inc. Senior Services of Southeastern Virginia

19

Tidewater Advance Care Planning Coalition

• Respecting Choices Model • Supported by 4 Regional Health Systems • Administered through the local AAA • Supports Executive Director and Programing • Moving ACP upstream into the community

20

Scaling to a state model for care transitions?

21

Conveners Department of Aging and Rehabilitation Services Virginia Health System and Hospital Association Virginia QIO- VHQC

Model to Scale 1. Expanding the Eastern Virginia Care Transitions Partnership 2. Western Virginia- Appalachia AAA Care Transitions Program 3. Both using Coleman CTI

MediCaring4LIFE: Making Local Improvement for Frail Elders

• CMMI Proposal 2014 • Altarum Institute’ s Center for Elder Care • 4 Communities

– Akron Area Agency on Aging & Summa Health System, Akron ,Ohio

– Riverside Center of Excellence for Aging and Lifelong Health, Williamsburg Virginia

– Providence Health, Milwaukie Oregon – North Shore –LIJ Health System, New York

Challenge: Medically Complex Patients Answer: Geriatric and Palliative Care Medicine

If geriatrics/palliative care can implement its vision: • Patients don’t get care they don’t want • Patients don’t get care which can’t benefit them • Patients suffer fewer adverse events • Patients experience fewer transitions • Caregiver burden is reduced • Costly care of marginal utility is eschewed • Society meets its responsibilities to vulnerable

population—and has money left over for other good things

Kyle R. Allen, D.O. , AGSF

Riverside Lifelong Health Services Across the Continuum

Independent 24 hour care End of life Needing

Assistance Senior Care Navigation

Wellness & Fitness Centers Inpatient Rehabilitation Center Outpatient Rehabilitation

Continuing Care Retirement Communities – Life Care at Home

Assisted Living

Memory Support

LTACH – Skilled Nursing - Care Residences

In-Home Technology

Home Health – In-Home Private Duty – Pharmacy – Home Medical Equipment PACE

Adult Day Care Hospice

Provider Group - Care Coordination - CEALH - Clinical Initiatives