Option D ADRC Evidence Based Care Transitions Grant Program Evaluator Workgroup Call November 14, 2011 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL [email protected]| WEB www.aoa.gov
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Option D ADRC Evidence Based Care Transitions Grant Program
Option D ADRC Evidence Based Care Transitions Grant Program. Evaluator Workgroup Call November 14, 2011. Agenda. Welcome and Introductions Option D Grantee Spotlight: Florida Future Work Group Calls Resources. Question for Option D Grantees from California. - PowerPoint PPT Presentation
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Option D ADRC Evidence Based Care Transitions Grant Program
Evaluator Workgroup CallNovember 14, 2011
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL [email protected] | WEB www.aoa.gov
Agenda
• Welcome and Introductions
• Option D Grantee Spotlight: Florida
• Future Work Group Calls
• Resources
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL [email protected] | WEB WWW.AOA.GOV
Question for Option D Grantees
from California
Are any states implementing a streamlined online data collection process?
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
Hawaii*
Alaska *
MT
ID*
WA†
CO†
WY
NV
CA*†
NMAZ
MN
TX†
KS*
IA
WI
IL†KY
TN†
IN†OH
MI
ALMS
AR
LA
FL†
SC*
WV VA
NC*
PA†
VT
RI†
NH†OR*
UT
SD
ND
MO*
OK
NE
NY†
CT†MA†
DC
Care Transitions Activities
DE
Guam
NorthernMariana Islands
35 States with ADRC program sites currently conducting care transitions through formal intervention (Total of 97 active sites with an additional 49 sites within active states currently planning to conduct care transitions)
10 States with ADRC program sites currently planning to conduct care transitions through formal intervention (Total of 13 sites currently planning care transitions activities within states with no active sites)
GA
9 States not reporting current or planned care transition activities
Puerto Rico* Indicates state with current CMS Hospital Discharge Planning Model grant
†Indicates state with 2010 ADRC care transitions grant
MD*†
NJ
ME†
Option D Grantee Spotlight: Florida
• Presenters– Randy Hunt, CEO Senior Resource
Alliance– Steve Paquet, RN, MS, Hospital to Home
Project Director/Transitions Coach– Sarah Duncan, RN Transitions Coach– Sandi Smith, Community and Support
Services, Florida DOEA
Medicare Readmission Reduction ProgramEvidence-Based Care Transitions Intervention with
Home and Community-Based Services
A Hospital/ADRC Partnership
Problem Statement
Arbaje AI et al. Postdischarge Environmental and Socioeconomic factors and the Likelihood of Early Hospital Readmission Among Community-Dwelling Medicare Beneficiaries. The Gerontologist. 2008;48(4):495-504.
Program Goals
• Reduce potentially preventable Medicare readmissions in patients age 60 and older
• Increase awareness of the ADRC core functions– To “effectively navigate their health and other long-term
support options.” (Source: ADRC Program Overview)
• Influence health policy at the national level by:– Connecting health and community-based aging social
services through the hospital discharge planning process– Post-discharge “stabilization” or health recovery
Program ModelIntervention Combines:
The Care Transitions InterventionSM Evidence-Based Program
• Transitions Nurse (RN) Coach– 30-day transition support program– www.caretransitions.org
SRA - Aging and Disability Resource Center (ADRC)• Person-Center Transition Support and Options Counseling• Connection to Home and Community-Based Services• Information, Referral and Program Awareness
Target Population • Case Manager referred patients on Medicare, age 60 and older • CHF, AMI or Diabetes (complex co-morbidities)• Discharged to home in the Tri-county area.
Program FundingCHiC Grant - Initial Demonstration Grant •Two-Year Funding period: March 2010 - March 2012•Transition Coach/Program for Florida Hospital Orlando, East Orlando, and Winter Park Campuses
U.S. Administration on Aging- Option D: Evidence-Based Care Transition Expansion Grant•Two-Year Funding Period: February 2010 - September 2012•Added second Transition Coach/Program for Florida Hospital Altamonte, Celebration and Kissimmee
•SRA was the only active Hospital/ADRC Care Transitions project in Florida eligible to apply and receive this grant
Patient Sources· Case Management
Referrals· Self-Referrals· Caregiver
Referrals· ADRC Referrals
PROGRAM ELIGIBILITY CRITERIA· Medicare participants, age ≥ 60· Cardiovascular and/or Diabetes-Related Admission Diagnosis
(AMI/CHF and related)· NOT admitted from an institution· Orlando, Winter Park or East Orlando campuses· English Speaking or Caregiver Interpretation (reading, verbal
communication skills required for self-management)· Has Telephone and Physical Address· No Prior Diagnosis of Dementia for Self-Management CTI or
Responsible Caregiver if cognitive deficit is documented· Resident of Orange/Seminole/Osceola County· Discharge Care Plan to Home
CTI Evidence-Based Only
· Four Pillars Education
· 3 Follow-up Calls
· ADRC information
CTI Evidence-Based + HCBS
· Four Pillars Education
· 3 Follow-up Calls
· HCBS Services Ordered
· 701A Completed
· ADRC Resource Specialist Assigned
Enroll in Transitions Program
Hospital Visit(s)Orientation to Program
Discharge Plan MonitoringHCBS Need Assessment-
701 A, if applicable
Transitions Program Call and Introduction
· To Determine Patient/Caregiver Interest in Hospital to Home Transition Support Program after Discharge
Yes
Patient Discharged to
Home?
No Accepts
Follow-up Calls/Information Program
· CTI and ADRC Information· Provide 3 Follow-up Calls over
30 Days to Assess for Changes in Needs and Encourage Participation in CTI Pillars
ADRCOptions Support
· Assessment 701A· Follow-up for Long-term
Care Needs Through Assigned ADRC Resource Specialist
No Needs
Home Visit, Assess HCBS
needs?
Declines
Yes
HCBS Needs
Yes
Discharge to Home from Hospital?
Hospital to Home: Transitions Support Program Aging and Disability Resource Center (ADRC) with Evidence-Based Care Transitions Intervention
Targeting High-Risk Medicare Patients
No 30 Day ProgramFollow-up Calls: Check CTI StatusChange in Needs?
Enrollment EndsRefer to ADRC, if
needed
Enrollment Ends30 Days Post-
Discharge Unless Patient is Readmitted
No
Day 3 CallRequest Home
Visit?
Made possible through a grant from the Florida Hospital Foundation -- Community Health Impact Council
Revenue Management Analysis- 130 Hospital to Home Admissions September 2010 to March 2011
CHiC Grant Only - Readmission Rate – 5.38%
Lessons Learned
Hospital Partnership•Identifying and keeping support of hospital administrative “champions” for the project
– Leadership changes– Need to communicate regularly
•Keeping the flow of referrals constant and time involved in acquisition and enrollment
– Case management turnover and workload• Need for constant education/re-education
– Case management leadership support is critical– Include Nurses and Nursing departments
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
Lessons Learned
ADRC Process•Integrating with ADRC under current workload of ADRC staff•“Transitions Support Network”
– Importance of education– Sub-Contracting
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
Lessons Learned
Patient-Centered Lessons•Importance of home visit AND follow-up calls•Lack of awareness of OAA, its programs and Aging Network•Improved quality of transition
– Stress reduction for patients and caregivers•Intervention becomes more than only 30-day transition support •Need of services after discharge vs. waiting lists•Avoidable vs. unavoidable readmissions
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
Lessons Learned
Care Transitions Process•Evidence-based intervention not always “cookbook”
– Patient factors– Caregiver factors– Hospital factors– Home Health factors
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
Questions for Florida team?
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
Future Work Group Calls
• Focus on sustainability• Current schedule (monthly)• Quarterly schedule?
– Intermittent ad-hoc topic-specific calls
• Other ideas?
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
Question from California
• Are any states implementing a streamlined online data collection process? – Currently, CA’s data collection process
involves an Access database• Request from the sites is to move it to an
online data collection process.
• Have other sites adopted this approach?– If so, what did you find beneficial or not?
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
Care Transitions Resources and Upcoming Events
• Innovation Advisors Program– Select and develop as many as 200
individuals from across the nation– Deadline to submit applications: November
15, 2011
• Health Literacy: New Skills for Health Professionals (IHI)– November 17, 2011, 2:00– 3:00 PM Eastern– Register
Care Transitions Resources and Upcoming Events
• Upcoming Work Group Call (combined with General Care Transitions Work Group)– December 12, 2011 at 1:00 PM Eastern– Register
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL [email protected] | WEB WWW.AOA.GOV