A Bridge Back Home: Care Transition Coaching for the Post-Acute Heart Failure Patient

February 8, 2018

Partners in Care (Partners) A Mission-Driven Organization

Our Mission • Partners shapes the evolving health system by developing and spreading high-value

models of community-based care and self-management

Our Partnership • Partners collaborates with hospitals, physician groups, health plans, community-based

organizations, and government agencies to deliver services that support adults with complex health and social services needs and their caregivers and families

• Evidence-based programs demonstrated to significantly reduce costly hospital readmissions, ED visits, and nursing home placements

Our Focus on Innovation • We shift the emphasis from illness care to preventive care, reducing costs and improving

quality of life for those with chronic conditions • NCQA accredited for Complex Care Management as defined by CMS.

www.PICF.org

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CBOs Can Affect 60% of US Premature Deaths

Genetic Predisposition,

30%

^Behavioral Patterns, 40%

[CATEGORY NAME], [VALUE]

^Social Circumstances,

15%

Shortfalls in Medical Care,

10%

^ Indicates a modifiable risk factor in the social services domain

Adapted from McGinnis JM, Williams-Russo P, Knichman JR. The case for more active policy attention to health promotion. Health Affairs (Millwood) 2002;21(2):78-93.

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Partners in Care Foundation Service Overview

Health Self-Management

Short-Term In-Person Services

Long-Term Services & Supports

(LTSS)

Health Self-Management Multi-session workshops such as Chronic Disease Self-Management (or pain or diabetes versions), Diabetes Prevention Program, Arthritis Walk with Ease, A Matter of Balance, Tai Chi

Short-term (mostly) In-Home Services

Care Transition Choices: Coaching or telephonic social work support (Bridge) after discharge from hospital

HomeMedsPlus: Psychosocial, functional, cognitive & home safety assessment & service coordination

TCM/CCM: Medicare fee-for-service physician billing codes for transitional care management & chronic care management.

LTSS MSSP: Services to keep people at home (nursing home diversion) Community Care Transitions: Returns people home from nursing home (“repatriation”)

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Partners in Care/Providence Saint Joseph

Care Transition Choices

• 3 Evidence-Based Interventions:

– Eric Coleman MD’S Care Transitions Interventions

– Partners in Care’s HomeMeds

– Rush Medical Center’s Bridge Intervention

• For people outside service area or who refuse home visit

• Experienced, culturally/linguistically appropriate coach in each

ministry

• Target population: Medicare patients identified as high risk of

readmission

– Fragile health; care is complex and costly

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Coleman Care Transitions Intervention (CTI)

• Develop patient/family skills for self-care and connecting with community

resources to recuperate safely at home.

• Hospital visit to introduce program and gain consent

• Home visit by coach (social worker) within 72 hours of discharge

– Review red flags for disease exacerbation

– Plan what to do if signs/symptoms get worse

– Patient activation for self-care and self-management

– Instruct on use of Personal Health Record, including medication list

– Reminders and coaching to schedule follow-up medical appointments, with transportation

if needed

– HomeMeds medication risk screening & pharmacist intervention can be added

– Ensure DME, prescriptions, diet-compliant meals, etc. available as ordered

– Refer to longer term self-management programs as appropriate

• Telephonic follow-up for 30 days

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HomeMeds: Coach + Pharmacist = Improved medication safety

www.PICF.org

• Inventory all meds being taken: out of system meds, drugs from other countries, borrowed, and OTC

• Assess for potential adverse effects; e.g., BP, pulse, falls, dizziness, confusion

• Document adherence issues and understanding

• Algorithm identifies targeted potential medication-related problems (MRPs)

• Pharmacist reviews potential MRPs & makes recommendations for resolution, contacts provider and/or patient

• Telepharmacy available in home

Adherence Inquiry:

1. Why do you take this (purpose)?

2. How much do you take at one time?

3. How often do you take it?

4. Does it seem to work for you? If NO, why?

5. Do you have any side effects? If YES, what are they?

6. How long have you been taking the medication (months or years)?

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The Bridge Model

• Transitional support through intensive service coordination that starts in the hospital and continues after discharge to minimize the risk of complications.

• Hospital visit to introduce program and determine needs

• Telephonic service coordination by social worker

• Arrange for services and follow-up appointments as needed after discharge

– Also address caregiver issues

• Refer to longer term self-management programs as appropriate

• RCT outcomes:

– Participants were more likely to make and keep follow-up appointments,

– Lower mortality at 30 days, and

– 24.4% fewer readmissions at 60 days

– Less caregiver burden

– Faster access to community-based support services

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Track Record in Care Transitions

• Coleman CTI for IEHP in 2010

– 11.7% readmission rate for intervention group.

– 19.8%. readmission rate for referred, not served

• CMS-funded Community-based Care Transitions Program (CCTP) 2013-2017

– 32,000 pt. at 11 hospitals; average reduction in readmission rate = 34%

– Internal UCLA study of CCTP: Readmission rate for intervention=10.6%; rate for referred but not served was 28% (same risk level)

– CMS lauded performance as top decile in country (140 CCTP sites)

• HomeMedsPlus (adds in-home psychosocial assessment & service coordination) for UCLA Medicare Advantage/ACO/Med Group

– 3% lower population-level readmission rate (net of low-risk decrease)

– 10.6% of intervention group readmitted vs. 26.9% of high-risk, not served

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CMS Innovation Results

Best in CA

Source: HSAG, CA QIO, November 2016

Program to Date through October 2016

1 Baseline (Pre): All-Cause, All-Condition, Medicare FFS: Westside & Glendale = Jan – Dec 2012; Kern = Apr 2012-Mar 2013 2 CCTP (Post): Medicare High-Risk FFS Population, Readmission Rate to Date (Westside= May 2013 – Jul 2016; Glendale = May 2013-Mar 2016; Kern = Nov 2013 – Jul 2016

CCTP Collaborative Participants Served % Reduction in Readmissions

# Readmits Averted Program to Date

Westside 14,086 28% 831

Glendale 6,745 29% 391

Kern 10,508 41.5% 904

21.1% 20.2% 20.7%

15.2% 14.4%12.1%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Westside(3Hospitals) Glendale(3Hospitals) Kern(5Hospitals)

ReadmitRate

ResultsbyCCTPSite

ReadmitPre ReadmitPost

Source: Final CMS Quarterly Monitoring Report, Released March 21, 2017

28% reduction2

29% reduction2

41.5% reduction2

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31.3

26.9

15.1 13.7

[VALUE]

10.6

Pre June 2013 - May 2015 Post June 2015 - Jan 2017

% R

ead

mis

sio

n r

ate

HomeMedsPlus: Population-level readmission outcomes in

Medical Group/Medicare Advantage

High-Risk (LACE≥11) Others (LACE≤10) Intervention

“Background” 1.4% pre-post decrease among low-risk patients

Pre-Post 3% Absolute Decrease among entire high-risk population; Net of

“background” decrease

Intervention group 66% relative decr.

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HomeMeds Summary/Results

• Nationally recognized; chosen for research quality: Aging & Disability Programs & Practices and AHRQ

– http://www.acl.gov/Programs/CDAP/OPE/ADEPP.aspx – https://innovations.ahrq.gov/profiles/care-managers-use-software-aided-medication-review-protocol-frail-community-dwelling

• RCT Vanderbilt; consensus panel led by Mark Beers, MD – Targeted problems chosen for availability of alternatives – Typically 40-60% of those screened need changes to meds

• Implemented in 20 states for about 7,000 older adults each year

• HealthCare Partners post-acute results – After pharmacist review 63% needed intervention – 12.8% reduction in rate of ED visits within 30 days of d/c – 22% reduction in rate of 30-day readmissions

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CM Work Flow

1. CM to review list of potential referrals and send daily to

Partners via EPIC using “Community Services”

2. CM to notify Partners of anticipated DC date. Preferably

within 2-3 days of discharge

3. CM goes with Partners Transition Coach to patient room and introduces Coach to patient

Patient Leave Behind to be printed by CM

department and stored in the

department for Transition coach

CM Department to print a copy of the

CM assignments daily for Transition Coach

to pick up

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Coach Work Flow

6. Coach will then follow patient home (or to SNF then Home) and provide 30 day coaching program Care Transitions Intervention (CTI; in-home) Bridge Care Coordination (telephonic)

5. Transition Coach enters MD appt date/time and Date of Home Visit on the AVS, writes it on whiteboard in patient room and on back of Patient Leave Behind

4. Coach will: • Explain the program • Schedule Home Visit • Schedule F/U MD visit

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Patient Success Story

• 74 year old Caucasian female admitted to St. Joseph for shortness of breath

• Medical conditions include congestive heart failure, pulmonary hypertension, and pneumonia

• Home visit helped identify:

– patient needed a caregiver; access to low-cost prescriptions and low sodium meals; patient was at risk for isolation

• Outcome:

– Secured caregiver, who assisted with preparing low-sodium meals and housekeeping, plus other services as needed

– Applying for grant to assist with paying for medications

– Connected with local senior centers, community activities and volunteer opportunities

– Patient empowered to take charge of her own health

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Chronic Disease Self-Management Program Healthier Living

• Six-week program

• 2.5 hours, one day per week

• Target Audience – 12-16 participants – Individuals with different chronic conditions

• Workshop Format – Lead by two trained leaders – Group discussions – Activities – Short lectures – Action Planning

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Learning Self-Management Skills

Physical Activity

Medications

Decision Making

Action Planning

Breathing Techniques

Understanding Emotions

Reduce Fear of Falling

Problem-Solving

Using Your Mind

Social Activity

Strength, Mobility, and Balance

Communication

Healthy Eating

Weight Management

Working with Health Professionals

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In-Person, On-line or Tool-Kit

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Chronic Disease Self-Management Program (CDSMP) Clinical Outcomes

• Population: 571 union members w/chronic conditions in MCO

• Intervention: CDSMP + monthly meetings + incentives (discounted medication co-pays)

• Outcomes:

– Compared to baseline, after 12 months

• Self-rated health good or excellent: 60% vs. 32% at baseline

• BMI 1 point

• A1C 1 point

• Systolic BP 11 points

• Depression score from 5.8 at baseline to 3.2

• Pain from 3.2/10 to 2.0/10

– Compared to baseline, after 12 months

• aerobic exercise from 51 to 75 minutes per week

• stretching/strength exercise from 21 to 35 minutes per week 2/27/2018

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2013 National Study IMPROVEMENTS:

National Retrospective Study Health Outcomes

*Brady, Teresa J. Executive Summary of ASMP/CDSMP Meta-Analyses. CDC, May 2011. http://www.cdc. gov/arthritis/docs/ASMP-executive-summary.pdf *Ory, Jiang, Lorig, Laurent, Whitelaw, and Smith, 2013.

CDC Meta-analysis of 20 studies: CDSMP contributes to improvements in

Psychological & physical health status

Self-efficacy, and

Selected health behaviors

Depression 21%

Managing Sleep Problems 16%

13% Physical Activity

10% Fatigue Management

11% Pain Management

12% Medication Compliance

9% Communication with Physicians

Reduction in ER and Hospital Stays, resulting in $714 of savings per person

2/27/2018

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