HEALTH REFORMCREATES NEW CARE MODELS AND

OPPORTUNITIES FOR SOCIAL WORK

W. June Simmons, CEOPartners in Care Foundation

April 2nd, 2014

Society for Social Work Leaders in Healthcare

We Thank Our Funders

Our work in this area is made possible through the generous support of:

John A. Hartford Foundation Archstone Foundation AndAdministration for Community Living

Partners in Care FoundationWho We Are

Partners in Care is a transforming presence, an innovator and an advocate to shape the future of health care

We address social and environmental determinants of health to broaden the impact of medicine

We have a two-fold approach, creating and using evidence-based models for: provider/system practice change and enhance patient self-management

Changing the shape of health care through new community partnerships and innovations

Objectives

Participants will be able to:• Describe key Affordable Care Act issues impacting social

work/long term supports and services practice• Recognize key target populations for social work

intervention• Describe central social work strategies and interventions

in this changing environment

4

Ecological Social Work Practice Framework: A Perfect Fit for Health Reform

Community Resources & Partnerships

Institutional Practices

Other Caregivers

Patient/Family

State & National Policy

Enduring Social Work Framework

US outcomes are worse – need to spend more wisely

The Expanded Chronic Care Model: Integrating Population Health Promotion 

Social Factors and Health Outcomes

Societal-level social determinants have individual-level impact

Issue Outcome

Low education, lack of social support, and social exclusion

Poor self-management and reduced care plan adherence

Housing and transportation issues

Increased health care costs and utilization

Health disparities and psychosocial issues

Preventable hospitalizations and mortality

The Affordable Care Act: A New Opportunity for

Social Work

Robyn Golden, LCSWDirector, Health and Aging

Rush University Medical CenterChicago, Illinois

ACA, Social Work, and Care Coordination

• ACA provisions create opportunity for new social work roles• Avenues to sustainable care coordination by social

workers increasingly available

• Provisions include• Changing incentives• Changing payment structures• Moving away from fee-for-service

Health Care’s Blind Side

• 2011 Robert Wood Johnson Foundation survey of 1,000 primary care physicians• 85% feel social needs directly contribute

to poor health• 4 out of 5 not confident can meet social

needs, hurting their ability to provide quality care

• Rx for social needs, if they existed, would be 1 in 7 Rx’s written

• Psychosocial issues treated as physical concerns

• Social work operates in this blind side

Moving toward the Second Curve

Adapted from Ian Morrison

First Curve Second Curve

Option on the Health Exchange

Direct Contracts

with Employers

Medicare Advantage

Plan

Accountable Care

OrganizationsBundled Payment

Pilots

Readmission Rate Penalties

Traditional Fee-for-Service Payment System

Population Health Per Capita Payment System

Patient Protection and Affordable Care Act 2010

Reform component What it meansWhat we need to

work on

Readmissions Financial penalties for excess readmissions

Quality and patient safety

Care coordination

Evidence-based care maps

Clinical documentation

Value Based Purchasing

Payment based on performance on core measures

Hospital Acquired Conditions

1% reduction in payment if in top quartile

Patient Protection and Affordable Care Act 2010

Reform component What it meansWhat we need to

work onCoverage expansion More patients with

insuranceManage access

Alignment and partnerships

Manage quality and cost

Manage populations

Care coordination

Informatics

Bundled payments Lump sum payments to providers for 10 conditions

Accountable Care Organizations

Manage care of specified beneficiaries; quality/cost; share of cost savings

Patient-centered medical home

Services, structures and access for continuous & comprehensive care

Bundled Payments• Bundled payment pilot began 01/31/2013

• Single Medicare payment to cover all services for an episode of care to be distributed among care providers:• Acute hospital services• Physicians’ services• Care coordination & transitional care services• Post-acute services

• Home health care• Skilled nursing facility services• Inpatient rehabilitation services

• Pilot testing four variations on bundling model over 3 years to assess efficacy

Medical Homes

• Change in outpatient care delivery toward coordinated, chronic care, including the following supportive services:• Care coordination• Case management• Health promotion• Transitional care• Patient and family support• Referral to community services

• Additional funding available for coordination through greater reimbursement

Accountable Care Organizations• Medicare Shared Savings Program (3022) creates incentive

for the establishment of Accountable Care Organizations (ACOs)• Networks of physicians and other providers • Integrated, cooperative services designed to foster collective

accountability• Share savings resulting from the ACO’s coordinated care

• Reduced Medicare expenditures• Improved beneficiary health outcomes

• No consensus on vital components of an ACO• Will have to address social issues to see true cost savings• Opportunity for social work to achieve

savings and quality improvement

The CMS Innovation Center (CMMI)

• Test innovative payment and service delivery models• To reduce program expenditures • To preserve or enhance the quality of care furnished to Medicare

and Medicaid beneficiaries

• Preference given to models that improve health care coordination, quality, & efficiency• Authority to expand any model

• Funding of $1 billion per year for 10 years• Released through ongoing Funding Opportunity Announcements • Targeted distribution within priority areas• Budget neutrality requirement waived during

testing

Thrive Under Reform• Key elements to making the ACA successful

• Engaging patients• Prevention and wellness• Not transactions but a journey• Transparency of performance• Focus on burden of treatment, not illness• Cost and quality in the same breath

• Where does social work fit?

Changing Times – New Opportunities

• Following patients across the continuum• Connecting sites of care within sectors• Connecting providers of care across sectors• Articulating the value of social work• Persistence is required

Social Work and Mental Health• Social workers can be a valuable member of the mental health team

• Care manager• Therapist• Advocate and educator of the healthcare team

• BRIGHTEN: Bridging Resources of an Interdisciplinary Geriatric Health Team via Electronic Networking

• Team-based approach to mental health in primary care• Along with the social workers, the team is comprised of:

• Patient• Geropsychologist• Geropsychiatrist• Physical Therapist• Occupational Therapist• Nutritionist• Chaplain• Pharmacist• Primary Care Physician

Social Workers and Interdisciplinary Teams in Practice

• Social workers are both valuable contributors to a team and effective leaders

• This can be seen in successful models utilizing social workers as team coordinators• Social Work and Mental Health

• BRIGHTEN: Virtual interdisciplinary program integrating mental health into primary care

• Social Work and Transitional Care• Bridge Model: Transitional care model provided by MSW’s from a

biopsychosocial perspective• Social Work and Patient Centered Medical Homes (PCMH)

• Ambulatory Integration of the Medical and Social (AIMS Model): Primary-care based care coordination

Targeting Home & Community-Based Services in Active Population Health Management

Congregate Meals, Socialization, Exercise

Evidence-Based Self-Managementfor Chronic Conditions

Care Transitions &HomeMeds/Home Support

LTSS/Caregiver Support

EOLCare

Continuum of Home and Community-Based Services for Older Adults

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Examples: Hospice & home palliative care

Examples: SNF diversion, Respite Care, Home Modifications, home monitoring, daily meals, assisted transportation

Examples : Stanford Healthier Living; Diabetes Self-Management; Matter of Balance

Examples: Coaching & Patient Activation, Home-delivered Meals; Referral to Self-Management Classes

Examples: Activity programs & education @ senior center

Targeted Patient Population Management with Increasing Disease/Disability

End ofLife

Complex Chronic Illnesses w/ major

impairment

Chronic Condition(s) with Mild Functional &/or

Cognitive Impairment

Chronic Condition with Mild Symptoms

Well – No Chronic Conditions or Diagnosis without Symptoms

Hot Spotters!

Evidence Based Self-Management, Home

Assessment and HomeMeds

Home Palliative Care

Post Acute and Long Term Supports and

Services

Avoidable Readmissions Penalty

• Incentive to improve care transitions & reduce avoidable readmissions

• Lost reimbursement to drive performance improvement• Penalty for each hospital based on risk-adjusted actual 30-day

readmission rate compared to expected readmission rate• Reduced Medicare DRG payments by 1%, rising to 3% in 2015• 3 target conditions starting in FY 2012, expanding to 7 in FY

2015

• Hospital-specific readmission rates posted on Hospital Compare website for public viewing

• Expand to skilled nursing homes & Home Health agencies

Community Based Care Transitions Program (3026)

• Provides funding to hospitals & community-based entities that furnish evidence-based transition services to Medicare beneficiaries at high risk for readmission

• Preference for medically underserved areas, small communities, rural areas & AoA programs

• Services must include at least one of 5 interventions• Arranging post-discharge services• Providing self-management support (or caregivers

support)• Conducting medication management review

• 5 year program started in 2011

Bridge Model: Primary Goals Addressed by Social Work

3 guiding tasks to reach the goal of preventing avoidable adverse events post-discharge:

1. Ensure patients receive appropriate services in their home post-discharge

2. Connect patients to their physician for follow-up appointments

3. Support caregivers to reduce stress and burden

Social Work and Transitional Care: Bridge Model

• Bridge social worker serves as primary care coordinator• Manages care coordination tasks• Facilitates inclusion of other team members

• Additional team members vary by client• Inpatient case manager & attending physician• Primary care physician• Pharmacist, therapists, other medical providers• Home health care provider• Community service provider

Social Work and Patient Centered Medical Homes (PCMH)

• Role for social workers in augmenting the patient’s primary care encounter• Address gaps in care resulting from insufficient time, staff,

resources• Provide compensatory support to meet patients’ medical and

psychosocial problems• Assess patients’ psychosocial considerations and their impact on

medical status• Educate providers how to support patient self-management

• This resource is central to PCMH success• True improvement in care, health, and cost cannot be done without

addressing the factors that impede patients’ medical care plan adherence

• Ambulatory Integration of the Medical and Social (AIMS) Model at Rush

Outcomes of Social Work Involvement and Leadership

• These three examples demonstrate success as a result of social work involvement• BRIGHTEN: Lower PHQ-9 scores & depression scores• Bridge: Increased communication with physicians & keeping medical

appointments; Decreased mortality• PCMH Social Work: Increased well-being; decreased stress; more

time for medical issues at next appointment

• However, social work evidence not extensive: ongoing challenge for field

Getting to the Table

• What can social work education programs do to get social work to the table?• Find cross-institutional ways to collaborate• Learn to communicate and market social work• Frame social work from other perspectives

• Speak the language of other professions

• Vary the message to fit the mission of the team• Find ways to partner with other disciplines

• Example: Delegating tasks to community health workers so social worker can focus on skilled activities

Future of IPEP and Geriatric Social Work

• We must prove the value of social work• Make clear business case• Show return on investment from social work involvement

• Clarify how social work helps to meet the Triple Aim of better care, better health, lower cost

• Frame within social determinant of health language and not just make it a guild issue• Not social workers can do it better• Social workers can do it, too

• Comparative effectiveness research to show outcomes of not having social worker involved

The Imperative

• Critical to incorporate:• The social determinants of health• Prevention• Care coordination

• It takes a village• Need a team to meet the needs of increasingly complex, older

patient population• Responsibility cannot solely reside with the physician

• To meet this imperative, we must innovate

5% spend 50%

1% spend 21%

The Upstream Approach: What would happen if we were to spend more

addressing social & environmental causes of poor health?

Most of Costliest 5% have Functional Limitations

http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf

Concentration of Risk

• Functional Limitation• Dementia• Frailty• Serious illness(es)

Dementia and Total Spend

• 2010: $215 billion/yr• By comparison: heart disease $102 billion; cancer

$77 billion• 2040 estimates> $375 billion/yr

Source: Hurd MD et al. NEJM 2013;368:1326-34.

Dementia Drives Utilization

Dementia No Dementia

Medicare SNF use 44.7% 11.4%

Medicaid NH use 21% 1.4%

Hospital use 76.2% 51.2%

Home health use 55.7% 27.3%

Transitions 11.2 3.8

Prospective Cohort of Community dwelling older adults

Source: Callahan et al.JAGS 2012;60:813-20.

In case you are not already worried…

The Future of Dementia Hospitalizations and Long Term Services+Supports

10 fold growth in dementia related hospitalizations projected between 2000 and 2050 to >7 million.

Zilberberg and Tija. Arch Int Med 2011;171:1850.

3 fold increase in need for formal LTSS between now and 2050, from 9 to 27 million.

Lynn and Satyarthi. Arch Int Med 2011;171:1852.

Because of the Concentration of Risk and Spending, Home and Community Care Principles

and Practices are Central to Improving Quality and Reducing Cost

Surprise! Home and Community Based Services are High Value

• Improves quality: Staying home is concordant with people’s goals.

• Reduces spending: Based on 25 State reports, costs of Home and Community Based LTC Services less than 1/3rd the cost of Nursing Home care.

This is Our Expertise

• Highest risk, highest cost population is ours: functional limitation, frailty, cognitive impairment +/- serious illness

• We need a fully integrated service line that also addresses keeping people out of the top 5%

Home and Community Based Services – a Specialty Practice Expertise

• Evidence-based approaches underlie all our work• In-Home assessment and supports, long and short term –

waivers/ Care Transitions• Caregiver skills and support

Determinants of Health & Contribution to Premature Death

Source: Stephen A. Schroeder, MD. We Can Do Better. NEJM 357:12

Predisposition30%

Social Circumstances 15%

Environmental Exposure 5%

Health Care 10%

Behavioral Patterns 40%

Scope of the Problem

• 1.7 million Americans die of a chronic disease each year

• Chronic diseases affect the quality of life for 90 million Americans

• 87% of persons aged 65 and over have at least 1 chronic condition; 67% have 2 or more

• 99% of Medicare spending is on behalf of beneficiaries with at least one chronic condition

Projected “Boomers” Health in 2030

• More than 6 of every 10 will be managing more than one chronic condition

• 14 million (1 out of 4) will be living with diabetes• >21 million (1 out of 3) will be considered obese

• Their health care will cost Medicare 34% more than others • 26 million (1 out of 2) will have arthritis

• Knee replacement surgeries will increase 800% by 2030

Source:“ When I’m 64: How Boomers Will Change Health Care ”,American Hospital Association, May 2007

Building Our New Business Model: Focus AreasEvidence Based

Self-Management

Assessments, Care Coordination &

Coaching

Efficient Delivery System Provider

Networks

Chronic Disease HomeMedsEvidence-Based Leadership Council

Chronic PainAdult Day/CBAS Assessment

Care Coordination Network

Diabetes (billable) Home Safety EvaluationCare Transitions Provider Network

A Matter of Balance Home Palliative Care

Savvy CaregiverShort & Long-Term Care & Service Coordination

Powerful Tools for Caregivers

Care Transitions Interventions

Arthritis Foundation Exercise & Walk with Ease

UCLA Early Memory Loss

What is Self-Management?The actions that individuals living with chronic

conditions must do in order to live a healthy life.

Problem-Solving

Planning

Physical Activity

Manage Fatigue

Medications

Working with Health Professionals

Family Support

Managing Pain

Communication

Healthy Eating

Understanding Emotions

Better Breathing

CDSMP: The “Gold Standard”

• Improves health and quality of life• Benefits people at all SES and education levels

• Reduces health care costs• Improvements and cost savings are sustained over time• Findings documented over 20 years of research in a

variety of settings• Offered in many countries and in over 20 languages

Some Leading Evidence-Based Programs

SELF-MANAGEMENT• Chronic Disease Self-Management• Tomando Control de su Salud• Chronic Pain Self-Management• Diabetes Self-Management Program PHYSICAL ACTIVITY• Enhanced Fitness & Enhanced Wellness• Healthy Moves• Fit & Strong• Arthritis Foundation Exercise Program• Arthritis Foundation Walk With Ease

Program• Active Start• Active Living Every DayMEDICATION MANAGEMENT• HomeMeds

FALL RISK REDUCTION• Stepping On• Tai Chi Moving for Better Balance• Matter of BalanceDEPRESSION MANAGEMENT• Healthy Ideas• PEARLSCAREGIVER PROGRAMS• Powerful Tools for Caregivers• Savvy CaregiverNUTRITION• Healthy EatingDRUG AND ALCOHOL• Prevention & Management of Alcohol

Problems

Reducing Readmissions a New Priority

• Readmission penalties inspiring rapid change• CMS testing new CBO Medicare models• Moving to all cause/all payers• Integrated regional delivery system• Multiple evidence-based approaches• New innovations in broadening array of settings

Goals of In-Home Coaching Transition Programs

• Engage patients (&/or caregivers) with chronic illness and activate self-care & behavior change

• Follow post-discharge to ensure meds/services received• Teach/coach regarding medications, self-care, symptom

recognition and management• Remind and encourage patients to keep follow- up

physician appointments – ensure transportation

How to achieve these goals differs across programs

Best Practices (Coach focus group)• Identify at-risk patients

• Case managers who know patient & family provide fewer, but more appropriate patients

• Hospital-based coach who gets to know staff, schedules, how to find patients – staff trusts more and therefore refers more

• 24 hours pre-discharge is ideal time

• Room Visit• “I’m here on recommendation from”…someone patient knows –

MD, case manager

• Efficiency• Field coach & hospital coach allows everyone to see more

patients• Teamwork gives us more flexibility – cover more times of

day and languages

Coleman Care Transition Intervention• Social Worker or Health Coach (one per 40 patients)• Duration-30 days post hospital/SNF

• One visit in hospital• One Home visit post-DC or post-SNF• Three follow-up calls within 30 days

• Based on four pillars• Medication Reconciliation & Management• Personal Health Record (PHR)• Primary care and specialist follow-up• Knowledge of red flags re: symptom exacerbation

• Results*• In RCT, CTI prevented 1 readmission per 17 patients • Savings $300,000 per 350 patients (cost<$170,000)

*California Healthcare Foundation-”Improving Care Transitions” October 3, 2007

Coleman/Bridge Commonalities• Identify at-risk patients

• Unit Nurse• Care Managers or Discharge Planners• EMR system data/risk algorithm

• Room Visit• Introduce & Explain• Determine need, coachability or appropriateness• Consent• Begin assessment• Leave info• Schedule visit or calls

• Follow-Up at home or by phone• Verify discharge orders complete: meds, equipment, home health, etc. • Ensure MD visits scheduled w/ transportation if needed• Connect with resources, including meals• Verify understanding of self-care• Encourage healthy behaviors

• HomeMeds for medication reconciliation & safety

Medications & Care Transitions

• 72% of post-discharge adverse events are related to medications—and close to 20% of discharged patients suffer an adverse event. *

• 35% of Medicare patients taking 5 or more medications experience adverse drug events

• HomeMeds program – a social work solution

*Mary Andrawis, PharmD, CMMI, presentation to Drug Safety Panel, May 10, 2011 (Forster et al. Annals of Internal Medicine. 2003; 128: 161-167./ CMAJ FEB 3, 2004;170-3)

HomeMedsSM proven solution in four important problem areas affecting seniors:

1. Unnecessary therapeutic duplication2. Falls and confusion related to possible inappropriate psychoactive

medication use3. Cardiovascular problems such as continued high/low blood

pressure or low pulse4. Inappropriate use of non-steroidal anti-inflammatory drugs (NSAIDs)

in those with high risk of peptic ulcer/gastrointestinal bleeding

Coach & software identify medication-related problems and pharmacist works with patient and prescribers to resolve them.

Value-Added Service: HomeMedsSM

The Right Meds… The Right Way!

www.homemeds.org

Evidence-based Protocols

Identified by expert panel – chosen for in-home intervention and positive response by prescribers (minimize “alert overload”)

1. Unnecessary therapeutic duplication

2. Use of psychotropic drugs in patients with a reported recent fall and/or confusion

3. Use of non-steroidal anti-inflammatory drugs (NSAID) in patients at risk of peptic ulcer

4. Cardiovascular medication problems• High BP, low pulse, orthostasis and low systolic BP

Care Transitions: Buy vs. Build Decision

Patients discharged to geographically disparate parts of the County

Lancaster

San Pedro

Considerations: Driving distances to patient home Knowledge of local services Training and experience Language / Culture Data collection / patient monitoring

Woodland Hills

Regional Model = centralized, cost- effective, efficient and

experienced!

Individual Hospital Approach: Each hospital must hire, train, manage and pay transitions

directors and health coaches

Partnering with Skilled Nursing Facilities & Home Health Agencies to Prevent Hospital

Readmissions

Kelley Hart, LVN, Katie Gurvitz, MHA, Michelle Hofhine, RN

Turning on the High Beams

October 10, 2013

The Problem

Discharged to SNF

Home with Home Health

Cedars-Sinai 20.2% 18.3%

All UHC Hospitals(Average)

17.8% 17.1%

All-Cause 30-day readmission rateJuly 2010 – June 2011

The Cedars-Sinai 30-day all-cause readmissions rate for SNF & Home Health patients was higher than the average for all UHC

hospitals.

Project Charge

Focus SNF Patients and Home Health Patients

Metric 30-day all-cause readmissions to CSMC

Target 50% reduction

Our Results

Discharged to SNF

Home with Home Health

Baseline30-day readmission

rate25% 14%

Pilot Period30-day readmission

rate11% 7%

By engaging in robust performance improvement, Cedars-Sinai Health System identified interventions that reduced 30-

day readmissions for SNF & Home Health patients by more than 50%.

Root Causes for SNF Readmissions

• Infrequent visits by a physician or advanced practice nurse

• Patient not seen by physician within first week of discharge

• SNF nursing staff unable to communicate with physician when needed

• Patient/Family not communicating Red Flags to SNF staff

• Lack of clinical oversight on weekends• Medication Management/Reconciliation between hospital

and SNF• Patients at end of life without an Advance

Directive/POLST completed

A chart review of 150 SNF patients revealed recurring factors that likely contributed to preventable readmission within 30 days.

SNF Intervention: Enhanced Care Program

Pilot 1: October/November 2011Pilot 2: January/February 2012

A Nurse Practitioner followed 115 CSMC patients in the SNF.• They saw the patient in the hospital

• They saw the patient in the SNF 24 hours after discharge

• They saw the patient 1-2 times per week in the SNF

• When they saw something, they said something… (to the patient’s MD, the SNF staff & to

the family)

Root Causes for Home Health Readmissions

• Patients & families often turn away Home Health agencies after hospital discharge

• Inconsistency in frequency of home visits post-discharge

• 45% of readmissions occurred on a Saturday or Sunday

• Patient/Family not communicating Red Flags to Home Health agency

• Medication Management/Reconciliation

• Physicians not responsive when Home Health Agencies have questions/concerns

A chart review of 45 Home Health patients revealed recurring factors that likely contributed to preventable readmission within 30 days.

ResultsThis intervention, tested twice, has demonstrated a statistically significant reduction in 30-day all-cause

readmissions.

n

30-day All-Cause Readmission Rate

Baseline Data:(Jan- Mar 2011) 150 25%

Test of Change I(Oct-Nov 2011) 48 10%

Test of Change II(Jan-Feb 2012) 67 12%

Cycle I: Enhanced Home Health

WHOAll CSMC Discharges to a high volume Home Health agency

WHAT

In-hospital visit by nurse + 6 touch-points after discharge

• Home visit within 48 hours of discharge• Friday “Tuck-in” Phone call• Weekend Visits• Medication Reconciliation• 24-hour call number staffed by a nurse

WHEN November 1 – 30, 2011

WHYTo determine if more rigorous home health services can prevent readmissions. (Baseline = 19% readmit rate)

75

Enhanced Home HealthOnly 6.8% of the 59 TOC patients were readmitted within 30 days of discharge.

This rate is less than 50% of the baseline rate observed during FY 2011.

Patient Population Time Frame% Readmitted

(All-Cause)

CSMC discharges home with Home Health (any agency)

Jul 2010 -Jun 2011 19%

CSMC discharges home with TOC Home Health Agency*

Jul 2010 -Jun 2011 14%

Test of Change (n=59 patients) November 2011 6.8%

* The agency selected for the Test of Change had the highest proportion of Home Health referrals from Cedars-Sinai Medical Center .

Conclusions

• Readmissions can be prevented when hospitals take the lead to collaborate with partner agencies in the community.

• Intervening during the 14 days following hospital discharge is crucial for preventing avoidable readmissions.

• Clinical resources in the community (SNF, Home Health, CBO Coaching) need to be bolstered on weekends.

• Involvement & leadership from Primary MD are key in executing improvements related to readmissions.

Avoidable Hospitalizations for Duals

77

Sources: Centers for Medicare and Medicaid Services; Kaiser Family Foundation,

Medicare Payment Advisory Commission

Over $4 billion potentially avoidable…not to mention the patient suffering this

represents

Medicaid spending – pressure points

The elderly & disabled account for majority of Medicaid spending; a subset – the duals eligibles make up 15% of enrollees and account for 40% of program spending 70% of all Medicaid duals spending is on Long-Term Care (LTC) (mental disabilities, spinal chord injuries, severe chronic illnesses, nursing home care, home health care, etc.) States may have a Medicaid problem, but Medicaid has a long-term care problem

Enrollees Expenditures on benefits

Children 20%

Elderly 25%

Disabled 43%

Adults 13%Children 49%

Elderly 10%

Disabled 15%

Adults 25%

Total = 59.5 million Total = $318 billionSOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on 2007 MSIS and CMS64 data.

$2,135 $2,541

$14,481

$12,499

Long-Term Care

Acute Care

Dual Eligibles – The Ultimate Case Study: Age + Poverty = Worse Health, Higher Cost

79

Sources: Centers for Medicare and Medicaid Services; Kaiser Family Foundation,

Medicare Payment Advisory Commission

Why the Costs Are So High

• For Medicare the reason for high costs among duals is the elevated need for acute care resulting from increased prevalence of chronic disease associated with age, disability, poverty and need for innovations in care and self-care

• Medical interventions alone are not enough• With targeted evidence-based interventions at home,

much better results can be achieved

80

Healthcare & Fiscal Pressures on Government Budgets

Federal funding on Medicaid & CHIP projected to double to 4% of GDP by 2035 States worried that balancing the federal budget would mean shifting costs to the states through block grants, or blended/reduced federal matching rates

0% 10% 20%

1960

1970

1980

1990

2000

2005

2008

2009

2019P

US Healthcare Spending as % of GDP

ACA Medicaid Expansion in 2014

ACA streamlines Medicaid eligibility rules Expands potential enrollment Federal government provides extra fiscal support for expansion till 2020

Medicaid today & tomorrow Potential enrollment growth

8 M

14 M

23 M

The Base Case (CBO estimate) built on a 55% take up rate Actual enrollment could range from 8M – 23M Medicaid eligibility & enrollment simplification could boost take up rates

Source: Health Affairs N0. 30 (11), (2011)Source: Kaiser Family Foundation

How Home and Community Services Address and Improve Health Outcomes

Multiple, complex chronic conditions Evidence-based enhanced self-care programs (e.g,

Chronic Disease Self Management (CDSMP), Diabetes Self Management (DSMP)

Complex medications/adherence (HomeMeds )℠ Multiple ER visits – gaps in care/communication Post-hospital support to avoid readmissions Nursing home diversion/return to community In-home palliative care in last year of life

83

The Need for Social Work Leadership

• Dramatic changes in the shift from hospital to home and community-based care/patient-centered care

• Requires understanding community culture• understanding regulatory requirements

• multicultural approach• understanding of different practice settings

84

Hot Spotting

• High costs come from specific target  groups, where the investment of a new intervention yields better health and quality of life outcomes while driving down costs

• Target Medi-Cal, keeping people out of nursing homes and……  

• Impact Medicare more directly by reducing ER, hospital admissions and readmissions  

Dramatic change is required

• Medicine seeks medical solutions• We must bring and sustain community-based solutions• Prevention, self management and support for functional

losses and mental health issues key• Ethnic and economic health disparities key• We must bridge into a new world with different culture,

language and requirements

Duals Demonstration Project – How the Risk Will Shift

• Total financial responsibility for the full continuum of Medicare and Medi-Cal services will now include:

• medical care• behavioral health services, and• long-term services and supports (LTSS):

• In-Home Supportive Services (IHSS)• Community-Based Adult Services (CBAS)• Multipurpose Senior Services Program (MSSP)• Nursing facilities when needed

• Social supports help dual eligible beneficiaries maintain their health and live at home as long as possible

87

America’s Dual Eligibles

88

Sources: Centers for Medicare and Medicaid Services; Kaiser Family Foundation,

Medicare Payment Advisory Commission

Challenge of the Dual eligibles

or 2.1% of GDP

America’s Dual Eligibles

90

Sources: Centers for Medicare and Medicaid Services; Kaiser Family Foundation,

Medicare Payment Advisory Commission

How to Best Care for the Duals to Achieve Optimal

Health Outcomes

Targeting Criteria for a Home Visit

1.Age 65+ and2.ED/hospital use in past year, plus:

a) Five or more prescribed meds; or

b) Warfarin/antiplatelet or insulin/diabetes meds; or

c) Dx CHF, COPD, depression, anxiety, bipolar, psychosis; or

d) Mild cognitive impairment; or

e) Recent treatment for fall or confusion; or

f) Age 80+; or

g) Any patient there is a concern about

The Problem

•Medication Errors are:• Serious: Over 700,000 people go to ED each year for adverse drug

events• Costly: Drug-related morbidity/mortality > $170 billion (ER,

hospital/readmissions, SNF use, etc.)• Common: Up to 48% of community-dwelling elders have medication-

related problems• Preventable: At least 25% of all harmful adverse drug events are

preventable

The Solution: HomeMeds℠

• HomeMeds ℠ is designed to enable community agencies to keep people at home, out of hospital & nursing home, by addressing medication safety

• Practice change with workforces that already go to the home – more cost effective use of existing effort

• Target problems for significance, accessibility to in-home staff, and likelihood of positive prescriber response.

• Focus on adverse effects (falls, vitals, confusion) … then determine if medications may be part of the cause.

Why should non-healthcare agencies work on medication safety?

• To thrive, CBOs need to play a new role connecting the home with the healthcare system• Meds are major factor in readmissions

• Home provides unique perspective otherwise unavailable to healthcare providers.

• Quality measures for health plans and providers relate to issues such as medication use and fall prevention – HEDIS, Medicare Advantage Star Ratings

• New focus on population health – identifying and proactively addressing health for high-risk patients

Core Components

• Collect comprehensive medication list• Note how each drug is being taken

• Record BP/pulse, falls, uncharacteristic confusion, symptoms, and indicators of adverse effects

• Use evidence-based protocols to screen for risks • Computerized risk assessment and alert process• Consultant pharmacist addresses problems with

prescribers, seniors, families & staff.

Evidence-based Recognition

• AoA recognition as an evidence-based prevention program – Highest Level of Evidence

• ACL Aging & Disability Evidence-based Programs and Practices(http://acl.gov/Programs/CDAP/OPE/docs/HomeMeds_InterventionSummary.pdf)

• Quality of research: 3.2/4

• Readiness for dissemination: 4/4

• US Agency for Healthcare Research and Quality (AHRQ) Innovation Exchange

• Strong evidence rating

(http://www.innovations.ahrq.gov/content.aspx?id=2841)

Expected Results

Home visit uncovers many “secrets” prescribers may not know about

• OTCs – Over-the-counter medications • Prescriptions from other providers• Adverse effects such as falls, dizziness, confusion• Adherence issues• Out-of-system meds: Drugs from other countries, borrowed,

Wal-Mart $4

Roles of the pharmacist

• Screen alerts to confirm problems

• Communicate with prescribers

• Consult with staff

• Identify problems beyond protocols

• Assist with complex cases

• Educate staff about medications/risks

• Avg. 20 min./client

Consumer Feedback…

Mr. Johnson went from 20 meds to just 8.

“You have saved us money on monthly refills and my life!

We cannot thank you enough!”

Who’s Implementing HomeMeds?

• Medicaid programs for Dual Eligibles• Care Transition programs• CBOs under contract with medical groups• Area Agencies on Aging & Senior Centers• Meals on Wheels• Home Health/Homecare Agencies• Assisted Living & Affordable Housing• Native American Tribal Community

Innovative Applications

• Contract with at-risk medical group • Targeted one-time home visit by social worker• HomeMeds screening and general safety assessment (ADLs,

environment, cognitive status, caregiver/family support, PHQ-2/9)

• HomeMeds pharmacist intervention• Reports to Case Manager, PCP, EHR system• Care plan and referrals

Pioneers in Palliative Care

• Developed with Kaiser / Dr. Brumley • In-Home Palliative Care

• Hospice – a big decision• Communication in need of major training

Key elements of our model• Trust in home care team• Call Center 24/7• Decision support

What is Long Term Care?

• Encompasses a wide array of medicine, social, personal and supportive and specialized housing services

• Social, self management and environmental factors are crucial to determining full positive impact of medicine

• Needed by people who have lost some capacity for self-care

• Care at home or in a nursing home• Most who need LTC are over age 76 (63%)

Activities of Daily Living (ADLs)

• Personal care activities people engage in every day • Fundamental to caring for oneself to maintain personal

independence• Assessment determines level of care/ assistance

needed• Certifies LTC level of care/payment level

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ADL Functions

• ADL Functions • Bathing• Dressing• Grooming• Mouth care• Toileting• Transferring bed/chair• Climbing stairs• Eating

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Each function is ratedto determine level of support required:

-INDEPENDENT

-NEEDS SOME HELP

-VERY DEPENDENT

-CANNOT DO

Instrumental Activities of Daily Living (IADLs)

• Related to independent living• Valuable for evaluating level of disease• Determinant of person’s ability to care for themselves

and their environment

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IADL Functions

• IADL Functions • Shopping• Cooking• Managing medications• Using the phone and

looking up phone numbers

• Doing housework• Doing laundry• Driving or using public

transportation• Managing finances

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Each function is ratedto determine level of support required:

-INDEPENDENT

-NEEDS SOME HELP

-VERY DEPENDENT

-CANNOT DO

AAAs and Sponsors of MSSP Offer Core Resources

• Area Agencies on Aging – crucial safety net• MSSP sponsors can evolve expanded home care

expertise • Scaling up from solid base and clinical infrastructure safer

than “reinventing”• Scaling best led by neutral community player, not health

care entity

Current MSSP Services Model: (can be adapted for Duals as CMS rules change)

Community Care

Coordination

Referred Services• IHSS• Adult day health• Regional Center• Independent Living

Centers• Home Health• Palliative/Hospice Care• DME• Caregiver Support• Senior Center Programs• Evidence-based Health

Impacting Self-Care programs

• Long-term home-delivered meals

• Housing Options• Communication Services• Legal Services• Benefits Enrollment • Money management• Utilities

Purchased Services(Credentialed Vendors)

• Safety devices, e.g., grab bars, w/c ramps, alarms

• Home handyman• Emergency response

systems• In-home psychotherapy• Emergency support

(housing, meals, care)• Assisted transportation• Homemaker, personal

care and respite services• Replace

furniture/appliances for safety/sanitary reasons

• Heavy cleaning & chores• Home-delivered meals –

short term• Medication management

(HomeMeds)

Social Worke

rRN

Client &

Family

How We Could Work Together

• Home and Community Services Network• A proposed model for experienced in-home care coordination

through a central portal

• Key Elements:• Contracted, credentialed network of trusted vendors and linked

partnerships• Community Care Management including in-home• Administrative simplicity with full access to both arrange and

purchase community care resources

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Overlapping Networks & Service LinesEvidence-Based Self-Management Network

• National Network - EBLC

• Statewide TA Collaborative

• L.A. AAA/Senior Center Providers

Care Transitions/SNF

Diversion Network

LTSS Network•Nonprofit Waiver Contract Holders for Care Coordination•Vendor Network•Respite care•Meals•Assisted Transportation•Home Modifications•Home alert & monitoring•DME

Home and Community Services Network - Key Elements

• Full geographic coverage of L.A. County - one portal for all

• Credentialed contractors for purchase of home and community-based services and personal care

• Common data system• Strong business case • MSSP model is prototype

• Build on base of 3,400 clients/170 care coordination staff – RNs and Social Workers in 7 locations

• Cost effective, proven, and uniform model of care

• Ability to scale up and differentiate• Tiered care management models possible

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Call to Action – The Time is Now

• So many opportunities to touch lives for the better• Time to innovate• Always partner with others• The Society is a great resource

Visit our Website

• This presentation and others are posted• June Simmons, MSW• WWW.PICF.ORG• jsimmons@picf.org