Strategies for Success Under the New Medicare Waiver – Part 2
Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies
May 21, 2014
Agenda
• Expanding your portfolio of strategies
1. ED based strategies
2. Enhanced services for high risk
3. Portfolio strategy in action
• Discussion
2014 Playbook
• Section 1: Overview • Section 2: The Transitions: Handle with Care Driver Diagram • Section 3: Critically Review Your Readmission Efforts to Date • Section 4: Designing for Success: The Portfolio Strategy • Section 5: Essential Action
– Model Impact of Your Strategy – Improve Standard Care for All – Improve Transitions Across the Continuum
• Section 6: High Leverage Impact – Hospital to SNF – Hospital to HH – Hospital to Home with Services – Emergency Department Based Interventions
• Section 7: Special Topics – Medicaid Readmissions – Behavioral Health – Palliative Care and End of Life
• Glossary and Links to Resources • Online Resources • Transitions: Handle with Care Initiative Presentations and Webinars • Template Press Release • Readmission Data Analysis • Readmission Interview Protocol • Cross-continuum Team Sample Letter and Agenda • Hospital to SNF Action Planning Worksheet • Hospital to Home Health Action Planning Worksheet • Hospital to Home Action Planning Worksheet • Excel Tool: Readmission Strategy Impact Estimator
2014 Playbook - Appendices
MGH High Cost Beneficiary Demonstration Project (CMS) • Target population: most expensive Medicare FFS pts at MGH • Opportunity: Identify in ED, intervene to avoid hospitalization • Intervention: Flag in record to identify patient by registration in ED
– Patients’ full care team (SW, PCP, specialists) paged – Expectation clinicians will go to ED and avert admission
• Impact: only program in the demo that saved $$ • Lessons learned:
– May not stop patients from behavior of going to ED – These patients always “look bad” (physically, or labs) – Clinicians who know the patient know what baseline is – Partner with ED doc to reassure no substantial change is presents and
to assure that close follow up will occur
ED-based Interventions
ED to SNF Transitions • Hallmark Health System, metro Boston
– 2 hospital system, 70% admits via ED, hospitalists – 20 ED docs, 17 PAs
• ED Chief and Champion of this work explored myths of SNFs/EDs – Patients only seen once a month; can’t do IVs, etc – “ED admits everyone”
• Actions: – Discussion “why” – Education: our capacity/their capacity – Simplicity : establish contacts, standard transfer information – Feedback
• Results: increase in number of patients transferred from ED to SNF
ED-based Interventions
Adapted from presentation by Dr Steven Sbardella, System Director of Quality, Hallmark Health System, April 29 2014
Frequent ED visits for Behavioral Health patients • Non-teaching regional hospital in central/rural MA • Difficulty transferring patients to psych beds = lengthy boarding • Concept: reduce ED boarding by preventing ED visits • Opportunity: identify frequent ED BH patients in ED • Staff: PM and ED BH nurse navigator, 2 FTEs • Team: ED director, ED BH team, CNO, CIO, ED CM, cross-continuum
partners • Intervention: collaboration between community mental health provider, crisis
team, community health center, ED, documented identification, referral workflows between all 3 entities, standing orders for frequent BH ED users to facilitate med clearance; establishment of individualized care plans
• Impact: successful linkage; social work / harm reduction orientation • Time to implement: 10 weeks.
ED-based Interventions
1. Train ED staff on how to use INTERACT NH Capabilities List
2. Train ED staff on how to use INTERACT SNF-ED information
3. Meet with SNFs to discuss SNF-ED transfers & opportunities to treat and return from ED
4. Staff a dedicated admission avoidance clinician in ED to coordinate with community providers/services to facilitate d/c
5. Create a flag in ED record to identify recently d/c pts <30days
6. Create individual care plans for frequent ED users with recurrent but otherwise stable complaints
ED-based Interventions - Actions
Provide enhanced services The best “transition out” and “reception in” will not suffice for high risk
“High Risk Care Teams”
• Sometimes a “coach;” increasingly multi-disciplinary team
– Navigator – Behavioral health – Social Work – Pharmacist
• Address full complement of medical, social, logistical needs
– Affordable medications; waiving office visit copayments – Transportation – Stable housing – Navigating the healthcare system, asking questions, making appointments
• Identify using combination of clinical and non-clinical criteria
– History of high utilization, no PCP, numerous prescribers, numerous meds, behavioral health comorbidities, homeless….not “just” chronic disease
• BRIDGE – Social work-based transitional care model – Assess “person in context” – Make contact in hospital; reassess at 24-48h after going home,
as needs change/emerge; reassess periodically over 30d
– Observation: Don’t require / use additional “slush funds” for transitional care – they are adept at getting patient linked to existing services (medicaid waiver, AAA, ADRC, etc)
– Observation: Don’t medicalize social complexity – “work the case” and refer for services, follow up, advocate for the patient, but don’t “escalate” care medically when they encounter barriers
Enhanced Care: BRIDGE
Patient-Centered Community Health Worker Intervention to Improve Posthospital Outcomes A Randomized Clinical Trial; Kangovi et al JAMA Internal Medicine April 2014 • Target population: 683 low income, uninsured, Medicaid patients
– 237 (35%) declined to participate – 446 were randomized to standard care or intervention (CHW)
• CHW intervention – Engaged w/ patients during hospitalization – Developed personalized action plans – Worked with patients at least 2 weeks
• Results: – Reduced recurrent 30-day readmissions (2.3% v. 5.5%) – Among 63 pts, recurrent readmissions 40% v. 15% for CHW
Community Health Workers
Preventing 30-Day Hospital Readmissions A Systematic Review and Meta-analysis of Randomized Trials Leppin et al; JAMA Internal Medicine (online first) May 12 2014 • Review of 42 published studies of discharge interventions
• Found that multi-faceted interventions were 1.4 times more effective
– Many components – More people – Support patient self-care
• Interventions published more recently had fewer components are were
found to be less effective
46-study Meta-Analysis: What Works?
http://archinte.jamanetwork.com/article.aspx?articleid=1868538
Costlier care is often worse care. Photograph by Phillip Toledano.
What a Texas town can teach us about health care.
McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.
THE COST CONUNDRUM
The New Yorker June 1 2009
by Atul Gawande
Annals of Medicine
McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent.
Sept 2009
Jan 2010
July 2012
Sept 2012
Nov 2012
Feb 2013
Mar 2013
April 2013
July 2013 Current
Palliative Care / Hospice
Project Red – Appt. w/PCP or Clinic and FU Calls
CCTP – CTI Coach and PAC Program
Discharge Assessment within 24 hour of admission
Transitional CM
Walgreen’s Well Transition Program
Registration Identifying Possible Readmissions in the ED
WellTransitions – Program Overview
Patient identified, enrolled in program
1 Generate medication
history
2 Fill, alignment and
reconciliation of discharge medications
3 Bedside delivery of medication
and patient consultation
4
Hospital Treatment
Education follow up
initiated 48-72 hours after discharge
5 Clinical therapy review approximately 10 days post
discharge
6 Community
integration at day 25 post discharge
7
Post-discharge Care
Joint outcomes reporting with health system and IT partner 8
Readmission Decline for VBHS
• Fiscal Year 2011 = 28% Readmission Rate
• Fiscal Year 2012 = 21.1% Readmission Rate • Fiscal Year 2013 = 13.7% Readmission Rate
50% readmission reduction!
Story courtesy of Angela Blackford, Valley Baptist Health System
Valley Baptist Health System Readmission Reduction Portfolio of Efforts
• Redesign Discharge Process
• RN/SW Case Managers Start DC Plan within 24 h of Admission
• Discharge Plans for 30 days
• Transitional CM Team - Identify, Monitor, Call, Home and Nursing Home Visits, Medication Reconciliation
• Create and Foster Community Collaboration
• Increase Patient Satisfaction
• Improve Patient Safety
• Decrease Readmissions
• Eliminate Any Readmission Penalty Over Time
• Collect Data and Trend Results
1. Know your readmission data
2. Ask your patients & their families why readmissions occur
3. Inventory your current readmission reduction efforts
4. Quantify your hospital’s 1 and 5 year readmission reduction goals
5. Develop a multifaceted strategy
6. Invest resources – in staff and tools - to get the job done
6 Recommendations
Thank you
Amy E. Boutwell, MD, MPP President, Collaborative Healthcare Strategies
Advisor, Maryland Hospital Association [email protected]