Toni Miles, M.D., Ph.D.

June 11, 2015

Integrating Policy and Physiology

Towards Optimal Hospital Discharge

Miles, T. P. and K. T. Washington (2011). Physical health problems: Shaping transitions of care. . Annual Review of

gerontology & geriatrics. P. Dilworth-Anderson. New York, NY, Springer Publishing Company.

Objectives: Policy and its role in hospital discharge.

Discuss person centered medical care and health care

quality for persons with complex medical conditions.

Review the Medicare Home Health Care benefit.

Discuss ‘Medicaid expansion and hospital access for

older adults.’

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It has different meanings:

Some think of it as a rule. ‘It’s the way we do things here.’

Some think of it as strategy. ‘What if….?’

Policy is a complex word.

In this session,

policy is strategy leading to health care law.

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The Affordable Care Act uses two strategies to develop

healthcare law:

Policy

Strategy One: Person-focused care.

This care is accessible, longitudinal and coordinated.

Strategy Two: Payment drives care priorities.

Pay providers to work with patients and families.

Hence, the emphasis on unplanned 30-day readmissions to hospital.

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Instructions:

Take 5 minutes to think about these statements,

Do you know someone who has…..

1. Been unable to get a timely appointment for care?

2. Gotten medications from a free clinic?

3. Had a hospital close in their area?

PATIENT CENTERED HEALTH CARE

Policy and Optimal Hospital Discharge

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Defining the Person Centered Medical Home: Role in optimal hospital discharge

Five functions and attributes:

• Comprehensive Care

• Person centered

• Coordinated care

• Accessible services

• Quality and Safety

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Sources: http://www.pcmh.ahrq.gov/page/defining-pcmh

http://www.jhartfound.org/grants-strategy/current-strategies/leadership-in-action/change-agents-initiatives/

Ambulatory Care Sensitive Conditions (ACSC): Conditions that respond to timely and effective care in the outpatient (ambulatory) setting. Example: Discharge rates

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ACSC's - Prevention Quality Indicators.

Used to evaluate the quality of primary

health care.

ACSC Discharges Formula =

[The number of ACSC's

discharges / The total number

of discharges] * 100

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What is an ambulatory care sensitive condition?

MEDICAID EXPANSION

Policy and Optimal Hospital Discharge

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The United States Health Care System

Sites of care shown by blue boxes on the right.

This is vendor centered health care.

Before ACA / Obamacare:

Medicaid financed hospital

care for the uninsured.

After ACA:

Everyone must have insurance.

To help with purchases,

premium supplement dollars are

provided

To keep cost low, ACA uses $$$

hospital received for uninsured care.

Uninsured $$$ for hospitals gone by 2019.

Bottom line:

Hospital closures are common in states that do not expand.

Closures destabilize access to hospital care for older adults.

Understanding the Effect of Medicaid Expansion Decisions in the South

JAMA 2014; doi:10.1001/jama.2014.7077

South 37%

21%

18%

West 24%

NOTE: Totals do not sum to 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of 2013 and 2012 ASEC Supplements to the CPS.

44%

Total: 115 Million Southerners

Larger context for Chronic Disease Care: Distribution of U.S. Residents by Geographic Region, 2011 – 2012. 14,703,958 Medicare Beneficiaries

United States : 309 Million Residents

56%

Texas 22%

Florida 17%

Georgia 8%

North Carolina, 8%

Midwest

Northeast

State Distribution of Southern Population

Other Southern

States

SOURCES: State decisions on the Medicaid expansion as of April 2014. Based on data from the Centers for Medicare and Medicaid Services, available at: http://medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Medicaid-and-CHIP-Eligibility-Levels/medicaid-chip-eligibility-levels.html with state updates.

Larger context for Chronic Disease Care: Status of Medicaid Expansion Decisions in the South as of April 2014

WV VA

TX

TN SC OK

NC

MS

MD

LA

KY

GA

FL

DC

DE

AR

AL

Implementing the Medicaid Expansion in 2014 (6 States, including DC)

Not Moving Forward at this Time (11 States)

Texas 22%

Florida 16%

Georgia 8%

NC 6%

LA 5%

SC 4%

Other Southern

States 16%

Midwest 11%

Northeast 6%

West 4%

NOTE: Excludes undocumented immigrants. Totals may not sum due to rounding. SOURCE: Kaiser Family Foundation analysis based on 2014 Medicaid eligibility levels and 2012-2013 Current Population Survey.

Regional Distribution of Uninsured Adults in the Coverage Gap, 2014

Total: 4.8 Million Adults in the Coverage Gap

South 79%

(3.8 Million)

HOME HEALTH CARE BENEFIT

Policy and Optimal Hospital Discharge

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Home health care is a Medicare benefit supporting persons at hospital discharge.

Can we shop for local providers of home health care?

Yes!

http://www.medicare.gov/homehealthcompare

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Home health care: How can I pick the agency that is best for me?

http://www.medicare.gov/homehealthcompare

Quality Patient Satisfaction with team

Daily activities Professionalism of the team?

Pain and treating symptoms Communication skills?

Treating wounds and preventing pressure

sores

Discussions of pain and home safety?

Preventing harm Rating of overall care

Preventing unplanned hospital care Recommend to friends and family

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Your advocacy strategy for next 10 years

The leadership performance model: This model requires an understanding of policy,

its context, and a self-awareness of your actions.

This model can guide advocacy for policies to promote

person centered health care, increasing the quality of care

for older adults.

Source: ‘The science of leading yourself: a missing piece in the health care transformation puzzle’ W.

Souba; Open J Leadership, http://dx.doi.org/10.4236/0jl.2013.23006

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Readings:

Hawes c. 2012. Nursing homes and the Affordable Care Act: A ceasefire in

the ongoing struggle over quality reform. J Aging & Social Policy 20(4):206-

220.

Miles TP (2012) Quality, Disparity, and ACA Title III. Chapter 3 in Health

Reform and Disparities. ABC-CLIO.

Centers for Medicare & Medicaid Services:

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-

Instruments/QualityMeasures/index.html?redirect=/QualityMeasures/03_Elect

ronicSpecifications.aspx

References:

Health care quality and older adults.

Q&A (with a view of the Gulf!)