TRANSITIONS : Improving Care for High-Risk Medicaid ... ACUU/C1 BIP Care Transitions...High-Risk Medicaid Beneficiaries in Tompkins County ... The “Four Pillars ... Confirm patient’s

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TRANSITIONS: Improving Care for High-Risk Medicaid Beneficiaries

in Tompkins County

Aging Concerns Unite Us ConferenceJune 7, 2016

Lisa Holmes, Tompkins County Office for the Aging

Sue Ellen Stuart, Visiting Nurse Services of Ithaca and Tompkins County

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Why Care

Transitions?

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National Data on Hospital Readmissions

New England Journal of Medicine (2009):

� Nationally, 1 in 5 Medicare beneficiaries are readmitted within 30 days following hospitalization

� Medicare cost of over $17 billion annually

� Heart failure, pneumonia, COPD were among most frequent medical diagnoses of patients readmitted

� Half of patients readmitted had no physician contact within 30 days post- discharge

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National Data on Hospital Readmissions

� Medicaid patients have readmission rates as high or higher than Medicare patients

� 25% of Medicare patients with CHF returned to hospital in 30 days; 33% Medicaid patients.

� Medicaid readmission patterns: more behavioral health conditions, socio-economic factors affecting access, substance abuse.

Agency for Healthcare Research and Quality

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Tompkins County’s Previous Care Transitions Experience

� CMS Community Based Care Transitions Program (CCTP) 2012-2014

� Goal: To reduce hospital readmissions among Medicare FFS beneficiaries by 20%

� Strategy: Collaboration of multiple community agencies facilitated and led by Tompkins County Office for the Aging: including VNS, Hospice, Cayuga Medical Center

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CCTP Partners

� Tompkins County Office for the Aging: lead agency, coordination, reporting, billing

� Cayuga Medical Center– community hospital

� Visiting Nurse Services– coaching

� Hospicare– coaching

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Care Transitions Intervention™

� Developed by Dr. Eric Coleman of the University of Colorado

� Designed to encourage older patients and their caregivers to assert a more active role during care transitions

Low cost ▪ Low intensity ▪ Easily adaptableShort – 30 days – with 1 home visit and 3 phone calls

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The “Four Pillars” of CTI

� Transitions Coach is used to build skills, confidence and to provide tools to support self-management

� Model behavior for common problems

� Practice or role play for health care encounters

� Create an accurate medication list

� Transitions Coach is used to build skills, confidence and to provide tools to support self-management

� Model behavior for common problems

� Practice or role play for health care encounters

� Create an accurate medication list

1. Medication self-management

2. Follow-up with PCP/Specialist

3. Knowledge of “red flags” or warning signs/symptoms and how to respond

4. Patient-centered medical record

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Tompkins CCTP: Challenges and Lessons Learned

� Challenge: Low patient volume� Smallest CCTP site in nation, small rural hospital

� Could only bill for Medicare FFS inservice patients

(no Medicare Advantage or observation stays)

� Restrictive eligibility based on patient diagnosis: originally CHF, COPD, Pneumonia; later CMS granted permission to broaden criteria to include additional diagnoses, age, polypharmacy and social factors

� Lesson Learned: Cast a wide net� Broaden targeting criteria to be all-inclusive

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� Challenge: Patient identification and referral� Few referrals among hospital discharge planners

� Turnover among key hospital staff and leadership

� No direct access to charts/ medical records

� Communication of protected health information between partners a challenge

� Lesson Learned: Embed transitions staff in hospital system

� Staff credentialing at hospital (this took a “champion”)

� Daily rounds

� Access to electronic medical records

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� Challenge: Too many cooks� Two agencies involved in hospital case finding and in-

home coaching

� Complex communication, information dropped

� Paid per coaching session: agencies losing money on staff time in rounds

� Lessons Learned: Streamline� Right-size program to one agency

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� Challenge: Patient acceptance of intervention

� Patients declining intervention in hospital

� Patients accepting in hospital, declining when home

� Lesson Learned: Present program as standard part of discharge

� Schedule home visit while in hospital if possible

� Utilize same person to introduce program to patient to conduct home visit when possible

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Tompkins CCTP Results

� Goal: reduce hospital readmissions of Medicare patients by 20% in 2 years

� Program served 85 patients total

� Though good results for individual patients, not enough volume to create impact

� CCTP contract period ended 5/31/14

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…From CCTP…to BIP

� BIP Innovations Fund: NYSDOH

� Target: Medicaid beneficiaries

� Goal: To increase access to community-based care options over institutional settings

� Tompkins submitted application: May, 2014

� Notification of grant award: July, 2014

� Start of service: Sept. 2014

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Structure of BIP Transitions Program

� Tompkins County Office for the Aging: lead organization, coordination, reporting.

� Cayuga Medical Center– community hospital

� Visiting Nurse Service– coaching

� CAP CONNECT– clinical integration organization, marketing, outreach, data analytics

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� Studied hospital data on Medicaid readmission patterns

� In addition to chronic diseases, behavioral health issues, substance abuse, health literacy issues, barriers in accessing community supports

� Modified model to suit needs of Medicaid patients

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� Modified Coleman approach: 1 or more home visits by an RN with physician’s order

� Importance of medication reconciliation by RN

� Medicaid-reimbursable service: sustainable after grant period ends

� Available to ALL Medicaid patients who could benefit

� Including behavioral health patients

� Including patients discharged home from 2 large skilled nursing facilities

� Referrals accepted from community physicians

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Goals of BIP Transitions Program

1) Raise awareness of Transitions Program among clinical partners/referral sources

� Outreach through CAP Connect

2) Foster case finding and patient introduction to Transitions Program

� Active involvement at daily rounds by VNS

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Goals of BIP Transitions Program

3) Improve health outcomes and reduce avoidable 30 and 90 day ED visits and inpatient admissions� Serve Medicaid beneficiaries with 1+ home visits by

Transitions nurse, using modified Coleman approach

4) Ensure program stability beyond grant period� Establish referral patterns to ensure program is

regularly utilized beyond grant period

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BIP Transitions Program Marketing

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Patient Testimonials

�Vaness

�Joanne

�Andrew

�Martha

�Vaness

�Joanne

�Andrew

�Martha

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BIP Transitions Program Implementation

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BIP Transitions Program Results

ED Utilization: Number of ED Visits Per

Enrollee Through December 2015

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1

2

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90 Days Prior 30 Days Prior 30 Days Post 90 Days Post

2.31 1.42 0.45 1.28

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1.24 1.08 0.18 0.45

Inpatient Utilization: Number of Inpatient

Stays Per Enrollee Through December

0

1

2

90 Days Prior 30 Days Prior 30 Days Post 90 Days Post

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Estimated program savings through December 31st, 2015

• ED visits per patient 90 days prior to enrollment = 2.31

• ED visits per patient 90 days post enrollment = 1.28

• Estimated ED visits prevented = 1.03 visits

• Number of patients enrolled = 137

• Average charges for a Medicaid ED visit* = $350.00

• Estimated program savings related to preventable ED visits =

$49,388.50

*This number based on the average charges for a Medicaid ED

visit based on the 2013 Medicaid fee schedule

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Estimated program savings through December 31st, 2015

• Inpatient admissions per patient 90 days prior to enrollment =

1.24

• Inpatient admissions per patient 90 days post enrollment =

0.45

• Estimated Inpatient admissions prevented per patient = 0.79

• Number of patients enrolled = 137

• Average charges for a Medicaid inpatient visit* = $3,000.00

• Estimated program savings related to preventable inpatient

admissions = $324,690.00

*This number based on the average charges for a Medicaid

inpatient visit based on the 2013 Medicaid fee schedule

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Estimated total cost savings from

September 2014 through

December 31st, 2015:

$374,078.50

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The Future of the Transitions

Program

� Program infrastructure and procedures remain in place

� Transitions will be the model used for DSRIP Care Transitions project in Tompkins County

� Program details shared with Care Compass Network for consideration throughout DSRIP PPS.

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VNS Role

1. Pt. Identification & Hospital Visit 2. Home Visits3. Follow up Phone Calls4. Referrals to other agencies5. Integrating techniques to enhance results such as motivational interviewing

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Identification of Medicaid Recipients

� Access & Review Hospital Census each morning

� Identify all newly admitted Medicaid patients

� Review identified patients at hospital rounds and discuss with discharge planning team to identify patients appropriate for the program.

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Approach Medicaid Patient in the hospital about the program

� It has been determined through the Coleman project that the program is more successful if the same person making the home visits also approaches the patient in the hospital.

� This begins to develop trust in the relationship and more success in ensuring the home visit.

� There is usually a 50% acceptance rate.

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Transitions Nurse called discharged

patient and set up visit within 3 days of discharge

� This has been a challenge for the program!

� Medicaid recipients tend to be more mobile and not as likely to answer their phones or to be reached (or found) after discharge.

� Early in the program, Transitions RN would visit even if not reached on the phone first usually without success and this practice was stopped.

� Saw on average, 39% of patients that accepted the program in the hospital.

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Home Visit

Based on Four Pillars of CTI

1. Medication self-management

2. Follow-up with PCP/Specialist

3. Knowledge of “red flags” or warning signs/symptoms and how to respond

4. Patient-centered medical record

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MEDICATION RECONCILIATION

The key for our project was medication reconciliation by an RN which differed from the Coleman Model which did not require an

RN for the coach.

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used. It is the responsibility of the nurse to Call the physician to reconcile any discrepancies

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Medication Tools for the Patient

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Steps to assure MD appointment

� Ascertain whether patient has a follow-up appointment with MD

� Confirm appropriate MD responsible managing patients

� Work with patient to schedule the appointment

� Discuss barriers to appointment including transportation and scheduling with family member, caregiver or friend

� Confirm/assist with transportation arrangements

� Provide appointment reminders and work with patient to put appointment information in a convenient place

� Confirm patient’s use of personal health record

� Use coaching to encourage patient/caregiver to understand importance of scheduling the appointment

� Confirm that patient understands to take medication list

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Physician Visit

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Knowledge of “red flags” or warning signs/symptoms and how to respond

Red Flags worksheets are disease specific

Many free resources to find Red Flags including :

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Red Flags-COPD

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Red Flags – Heart Disease

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Red Flags- High Blood Pressure

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Personal Health Record

Booklet given to Patient to take to

MD visits.

Coach Provides Assistant to

complete

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Patient Activation

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Follow Up Phone Calls

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Important Components incorporated into the Program

�Teach Back

�Motivational Interviewing

�Health Literacy

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Teach Back

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Motivational Interviewing

� Designed to enhance client motivation to change

� Especially effective for patients that are “stuck” –not making recommended health related behavior changes

� “MI is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence”

� MI helps activate the patient’s own motivations to change

� 6 Source: Rollnick, Miller, and ButlerInterview: Motivational ing in Healthcare. 2008

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Collaboration through COACHING:

•“An approach of partnering with patients to enhance self-management strategies for the purpose of preventing exacerbations of chronic illness and supporting lifestyle change”

(Huffman, 2007, p. 271).

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Health Literacy

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Health Literacy

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Health Literacy

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Resources

List of websites to access resources :� http://vnaablueprint.org/main-menu.html

� http://www.ihi.org/resources/Pages/Tools/AlwaysUseTeachBack!.aspx

� https://www.youtube.com/watch?v=IKxjmpD7vfY

� http://caretransitions.org/

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Questions?

Documents

TRANSITIONS : Improving Care for High-Risk Medicaid ... ACUU/C1 BIP Care Transitions...High-Risk Medicaid Beneficiaries in Tompkins County ... The “Four Pillars ... Confirm patient’s