12/10/2012

1

Innovations in Elder Care

Jennie Chin Hansen, CEO, RN, MS, FAAN

American Geriatrics Society

Warren Wong, MD, FACP

National Medicare Strategy, Kaiser

Permanente

Session C2

The presenters have nothing to disclose

12/11/2012

1:30 PM

Session Objectives

Be able to describe initiatives that emphasize alternatives to traditional patient and disease focused care delivery.

Provide perspective on a shared and actionable vision for Older Adults with Complex Needs.

Plan activities within their own work environments

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2

Evolving Directions in Framing Health and Care of Older Adults

A directional shift from reimbursement of volume towards outcome.

Focus on improving quality, safety and value.

Recognize the importance of addressing cost outliers.

There are more concrete population health initiatives that go beyond the hospital and facility settings

Health care payors and providers are learning to expand their consideration of “patient” to “older adult”

Examples of Innovative Practices

Long Term Quality Alliance

Coalition with example of best practices

CMS-Center for Innovations and Other ACA Enabled Efforts

Partnership for Patients

Independence at Home

ACA Section 3024

Hospital at Home

Stanford Coordinated Care

Chronic Care, Employer Based Systems

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Long Term Quality Alliance (LTQA)

Begun late 2010

Influenced by December 2010 article published in the Stanford Social Innovation Review (Winter 2011) explored a new “Collective Impact”(Kania and Kramer) approach to community change

Cross sector membership committed to quality of care transitions and stewarding resources

LTQA Initial Best Practices

Cathedral Square Corporation (Housing Corporation)

• Evolved from landlord role to advocate monitoring health and

coordinating services help resident stability-

• 1 year outcome-22% falls reduction, 19% reduced risk reduction of

those of moderate risk; physically inactive residents reduced by

10%

• July 2011-112 housing projects added

• Estimated $40million w health care

Savings to Medicare

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LTQA Initial Best Practices

Community Resource Identification and Coordination to ease

transitions form home to hospital-

Created NC Alliance for effective Care Transitions-30 org

stakeholders to coordinate aging and long term care services and

supports

1. 6 counties assisted for CC Transitions Program

2. Coordination of Aging and Disability Resource Centers (ADRCs)

3. Support for 14 films-”Caring Matters” for caregivers

Carol Woods Retirement Community

The Triple Aimfor the Older Adult

Better Care

Better

Health Lower Costs

Maintain best function and

engagement in home and

community: prevention, self

care, coordination

Hospital-Quality and Safety

•ACE-Acute Care for Elders

•Transitions Programs-Naylor,

Coleman, Boost, Project Red

•NICHE

•Value Based Purchasing

•Partnership for Patients

Save $$$ for

consumer/family, payors,

society-Medicare,

Medicaid

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Community Based Care Transitions Program (CCTP)-Section 3026

Provide Payment for Care Transitions Services to Improve Health and Reduce Readmissions

An Engine & Asset to Connect Hospitals and Communities to Help Patients

47 Sites in Place with Many More on the Way

Buttressed by HENs, QIOs, AAAs, ADRCs and Many Other Resources to Reduce Readmissions

The Community-Based Care Transitions Program (CCTP, ACA Section 3026)

Now 47 Sites: CBOs with 200+ hospitals

serving 185,500 beneficiaries in 21 states

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There has never been a time like this in U.S. Health Care: unique confluence of forces for change

1. There is unprecedented Federal action and coordination, including CMS payment reform and innovation.

2. Physicians and other health professionals need to be front and center in these efforts: We need your more active involvement to get this right.

Council of Medical Specialty Societies: McGann and Wagner Nov 2012 CMS

Partnership for PatientsTen Priority Areas of Focus

1. Adverse Drug Events

2. Catheter-Associated Urinary Tract Infections

3. Central Line Associated Blood Stream Infections

4. Injuries from Falls and Immobility

5. Obstetrical Adverse Events *

6. Pressure Ulcers

7. Surgical Site Infections

8. Venous Thromboembolism

9. Ventilator-Associated Pneumonia

10. Reducing ReadmissionsSource: CMMS 2012

* Only area that would not relate to older adults

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Innovation Center PortfolioLong-Term Care Involvement in Many Areas

Primary Care Transformation●●●● Comprehensive Primary Care Initiative (CPC)●●●● Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration●●●● Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration●●●● Independence at Home Demonstration●●●● Graduate Nursing Education Demonstration

ACOs●●●● Medicare Shared Savings Program●●●● Pioneer ACO Model●●●● Advance Payment ACO Model●●●● PGP Transition Demonstration

Bundled Payment for Care Improvement●●●● Model1: Retrospective Acute Care ●●●● Model 2: Retrospective Acute Care Episode & Post Acute●●●● Model 3: Retrospective Post Acute Care●●●● Model 4: Prospective Acute Care

c ●●●● Partnership for Patients

●●●● Community-Based Care Transitions●●●● Million Hearts ●●●● Innovation Advisors Program● Health Care Innovation Challenge

Initiatives Focused on the Medicaid Population●●●● Medicaid Emergency Psychiatric Demonstration●●●● Medicaid Incentives for Prevention of Chronic Diseases●●●● Strong Start Initiative

Dual Eligible Beneficiaries●●●● State Demonstration to Integrate Care for Dual Eligible Individuals●●●● Financial Models to Support State Efforts to Integrate Care●●●● Demonstration to Reduce Avoidable Hospitalizations of Nursing Facility Residents

Source: CMMS 2012

There has never been a time like this in U.S. Health Care: unique confluence of forces for change

1. There is unprecedented Federal action and coordination, including CMS payment reform and innovation.

2. Physicians and other health professionals need to be front and center in these efforts: We need your more active involvement to get this right.

Council of Medical Specialty Societies: McGann and Wagner Nov 2012 CMS

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Header

Hospital at Home®: Disseminating an Innovative Health

Service Delivery Model into Practice

Bruce Leff, MDProfessor of MedicineJohns Hopkins University Schools of Medicine & Public Health

Hospital at Home slides source: Bruce Leff, MD 2012

Hospital Safety Pre IOM

Hospitalat Home®

16

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Hospitalat Home®

Hospital Safety Over Time – Post IOM

� 10 NC hospitals, annual review of charts ‘02 to ‘07, n=2341� 588 harms = Rate: 25.1 / 100 admits

� Harms:

� 2.9% permanent

� 8.5% life threatening

� 2.4% caused or contributed to death

� Harms from procedures, medications, nosocomial infections, other therapies, diagnostic evaluations, falls

� No change over time in rate of harms

NEJM 2010;363:2124

• 61% chose HAH care• HaH is feasible and efficacious• High-quality care• Fewer complications• Higher satisfaction • Lower costs of care

Ann Intern Med. 143:798-808, 2005. J Am Geriatr Soc. 54:1355-1363, 2006. J Am

Geriatr Soc. 2008;56(1):117-23. Am J Manag Care. 15:49-56, 2009. J Am Geriatr

Soc. 2009;57(2):273-8. Medical Care, 47(9):979-85, 2009.

Less CG stress

Better function

High provider satisfaction

Hospitalat Home®

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HaH at Presbyterian Health SystemHaH for PHS health plan pts1st year of HaH

4 diagnoses, 125 patients10/08 – 4/12: 582 patients1/1/09 – 12/31/10

323 patients93% acceptance rate

Care ProvisionMean MD visits 3.5 (SD 2.8)Mean RN visits 6.4 (SD 3.2)2.5% return to hospital to complete admissionAfter-hours, unplanned visits

15 RN, 3 MD

� LOS

� HaH 3.3, median 3, 1-31

� Hospital 4.5, median 4, 1-50� 2.5% transfer to hospital to complete

admission� Mortality during admission

� 0.93% HaH v 3.4% hospital � Satisfaction – Press Ganey CAHPS

adapted to HaH� 90.7 HaH v 83.9 hospital

� Readmission 30d� 10.8 HaH v 10.5% hospital

Scaling HaH into a Nationwide Model is the New Frontier

Goal: to transform the site of acute health care from the hospital to the home with a nationally scaled health services delivery organization

Australian example

Key decision 1994: reimburse HaH as inpatient service. Led to units being based in hospitals

2009: 32K admissions = 2.3% all inpatient admissions & 5% all bed days

Hospitalat Home®

20

MJA 2010;193:598

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Independence at Home (IAH)

� 2009 HB 2560 (Markey) + S 1131 (Wyden)� 2010 ACA section 3024� Medically-led interdisciplinary team (MD or NP)

� House calls, with technology�Portable diagnostics, telemedicine

� 24-7-365 availability� Electronic health record� Expertise and experience with model

� Keep + use existing Medicare benefits (A,B)� Savings (gain-sharing)

� First 5% � Medicare; then 80% � IAH� 10,000 beneficiary cap in current demo

Why Independence At Home (IAH)

Immobile, complex population is better served at home

Patient and family centered

Better insight into illness and needs, better care plan

More timely response when getting sick

Real opportunity for near term cost savings

Targets highest cost subset with a viable solution that people prefer

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Cost Savings Evidence

VA HBPC (large cohort before and after) ~ 24%

Savings relative to HCC-modeled costs

Naylor post-hospital transitional care (RCT) ~ 50%

GRACE (RCT) ~ 30% in high cost subset, year 2

ElderPAC (AAA + house calls; case control) ~ 50%

VCUHS Transitional Care (pre-post) ~ 50%

Many examples with reported positive impacts

Mount Sinai, Inspiris (acquired by United HC), Clinic Without Walls, etc

IAH Patient Selection

� Multiple chronic diseases (at least 2)�Ones that directly cause disability (not HTN)

� Functional deficit (2 or more ADLs)�Requiring human help

� One or more non-elective inpatient hospital stays within 12 months

� Post-acute care�HHA, SNF, IP Rehab (all report ADLs)

� High cost – higher is better ($50,000 +)

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IAH Demontration Project

Under Office of Research and Demonstration, now in CMMI

RFA released 12-20-11; August 2012-18 sites

Minimal IAH site size = 200 patients

Maximum number for demo (currently) is 10,000 nationally, all sites

3 options: single site, part of national pool, regional consortium of programs

3 years

IAH Attributes

� Voluntary

� Advanced mobile medical team = access

� Medical leader = adjusts to condition changes

� Longitudinal, continuous, comprehensive

� Where you want it, when you need it

� Less ER, hospital time = better, safer

� Incents medical providers to engage in model

� Funded from savings = accountable� Minimal initial investment

� Immediate savings (1 to 2 years) - $billions

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Stanford Coordinated Care

“Tools, Training and Teams to Achieve the Triple Aim”

Alan Glaseroff, MD

Sept 2012

Adapting a Trend-Bending Care Model:

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A Costly Health System Failure

• Avoidable Hospital Admissions 2x more likely for asthma and diabetes in US

vs. average of 30 developed countries in Organization for Economic

Cooperation and Development

“The United States does not do well in preventing costly hospital admissions

for chronic conditions, such as asthma or complications from diabetes,

which should normally be managed through proper primary care.”

(Organization for Economic Cooperation and Development. Expensive

healthcare is not always the best healthcare, says OECD’s Health at a Glance

[Internet]. Paris: OECD; 2009 Aug [cited 2010 Jan 3)]).

vs.

1.Panel Management 2. Care Management for 3. Complex Case Management

Chronic Disease

•Registries

•Gaps in Care

•Planned Visits

•Self Management

Support

•Patient Education

•Patient Activation

•Care Coordination

•Problem Solving

•Linking with

Community Resources

•Empowerment and

Education

Modest Potential Value Gain from

std Medical Home

Large Potential Value Gain from

Intensified Medical Home

Where’s the Leverage on Trend?

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Take away themes

Treating segments of population with the most appropriate health and health care in settings that are most conducive to effectiveness

Consider the whole environment of the person as an asset to health and chronicity maintenance

Engagement and capacity of the person/patient toward health and well being

Enlargement of the caring provider roles-i.e. not just the professionally licensed

Current Practice Model

DM & CRF

DM & HTN

COPD

CVA & HTN

DM & CAD

DM & Alz & AF

BPH

Physician

HTN

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Segmentation-Based Practice Model

33

Segment 1

Healthy, Robust

Segment 2

Chronic Conditions

Segment 3

Advanced Illness

Segment 4

Severe Frailty

End-of-life

Segment Specific Interventions

• benefit from palliative care, hospice care and high touch programs• use health care services erratically partly due to poor access to care

• have chronic illness and benefit most from disease management approaches • use health care services, mostly outpatient, regularly

• have multiple complex issues• frequent ER visits and hospital admissions

• largest benefit is from disease prevention, screening and health promotion• use health care services periodically

Features

of each

segmentSegment 1

Robust

Segment 2

Chronic

Conditions

Segment 3

Advanced

Illness

Segment 4

Severe Frailty/

End of life

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What is the Optimal Process to Segment Older Adults??

•Self report yields important domains

of information but is logistically

intensive and prone to inaccuracy

over time.

•Provider report is arduous and prone

to inconsistency.

The Senior Segmentation Algorithm was initially developed

with a group of physicians based on empirical derivation,

clinical reasoning, & workflow choices. It incorporates a

combination of diagnosis, a utilization prediction tool, and

specific data points available from administrative data and

the EMR.

15-20% 10-15%

Per Member per month Cost Ratio:

1X 2-3X 5-8X

5-7%

Estimated %

Medicare

Members:

60-65%

Healthy

15-20X

Chronic Conditions

Advanced Illness

Frailty

End of life

Overall cost of

care per segment

based on

membership and

cost ratio:

PMPM Cost x

percentage

/total costs

5% 45% 30% 20%

What is the Cost of Care in Each Segment??

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Segmentation Findings

Most members remain in the same segment over a year’s period of time

Those that change segments generally move to a “higher” segment

1/1/2010 As of 12/1/2010

As of 1/1/2010

Starting Pop Seg 1 Seg 2 Seg 3 Seg 4

Seg 1 14.0% 68.4% 29.4% 1.5% 0.7%

Seg 2 63.1% 2.6% 88.2% 7.0% 2.1%

Seg 3 15.0% 0.2% 9.5% 80.1% 10.3%

Seg 4 7.9% 0.2% 5.5% 13.7% 80.6%

Mortality Risk Increases from Segment to Segment

Segment @ 1/1/10

Members % Deceased 6/30/10

% Deceased 12/31/10

Segment 1 8563 0.4% 0.6%

Segment 2 38629 0.5% 1.2%

Segment 3 9175 2.6% 5.5%

Segment 4 4822 15.2% 28.0%

• Determining and implementing optimal system

design features for each segment.

• Is there VARIATION in segment sizes in various health

systems?

• Is there variation in health system practices for

specific segments?

• Is there variation in migration from segment to

segment and can the rate of migration be impacted?

•Segmentation is a TOOL, not an outcome

•Segmentation and PERSON CENTERED care go hand in

hand

How Can Segmentation be Used?

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A nation's greatness is

measured by how it treats

its weakest members."

Mahatma Ghandi

Achieving the Triple Aim

for Older Adults with

Complex Conditions

Patients age 85 and over account for 10.2

% of all hospital days in the United states

while accounting for 1.7% of the

population

Only 41% of these patients are discharged

home, while 33% are sent to institutional

care

http://www.cdc.gov/nchs/data/series/sr_

13/sr13_165.pdf

Achieving the Triple Aim for

Older Adults with Complex Conditions

I. Core Conceptual Framework

II. System Design

III. Critical Factors for Success

A goal beyond the capability of the

system will not be reached. You will

get whatever the system will deliver.

W E Demming

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Core Concept A: Older Adults benefit from a comprehensive whole person evaluation and personalized health and well-being plan.

1. What matters to you: preferences, values, priorities, preferences, attachments, concerns and social milieu.

2. Tell us about yourself: Emotional, social, cognitive and physical well-being, functional status.

3. Common conditions in older adults/geriatric syndrome.

4. The evaluation should be done routinely akin to a well child check.

5. The evaluation should be the basis of a health and well-being plan.

NOT TYPICAL PRACTICE NOW

Core Concept B: Care must be integrated

and coordinated across settings

• Within the entire Health Care Delivery

system.

•Between the health care system and

community services.

•Coordinated with caregivers. Most care

occurs in the home.

NOT TYPICAL PRACTICE NOW

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Core Concept C: Functional Status

should be a cornerstone of care.

•Primary importance for independence.

•Key indicator of reserve capacity,

prognosis and health care utilization.

•Variable and fluctuates but overall

decline over time occurs in the older

adult.

NOT A CORE TENENT OF PRACTICE

Core Concept D: With progressive functional decline,

disease based model of care becomes of less and less

value.•SLIGHT DECLINE: “linked” to desirable services such as transportation

services and meals on wheels.

•MODERATE DECLINE: patient should remain in the primary care setting but

there is more emphasis on “well-coordinated” care in which community

based and home based services play an increasing role and are partners in

care. At this point, these services provide strong support to the patient,

unpaid caregivers as well as to the primary care team.

•SEVERE DECLINE: transitions to special programs of care such as hospice,

home visit program or nursing home care. Non physician services become

more important and physician services less.

NOT TYPICAL PRACTICE NOW

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Frailty Care SettingsHospital-based Services

Clinic-based Services

Geriatrics principles embedded in all services and programs

Connected by an integrated, informed, accurate, and available information system

System measurement and monitoring across the continuum of care

Status: Robust

Linked Services

Status: Progressive Frailty

Coordinated Services

Status: End of Life

Fully Integrated Services

Frailty Care Services (at home)

Home and Community-based Services

System Features Enabling Older Adults with

Complex Conditions to Live at Home

A Report from Primary Care

Comparison of Needed vs Available Elements of Care

For Older Adults with Complex Needs

Very or Extremely Likely to improve Care & reduce costs

Occurs most of the time or always

Occurs sometimesOr rarely

Element

Case Management

Assessment of psychosocial needs

Plan of Care

Home visit by MD or NP

88 %

81 %

69 %

63 %

13 %

27 %

27 %

20 %

80 %

73 %

73 %

80 %

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CRITICAL FACTORS FOR SUCCESS

BUNDLED FEATURES: Features must all be present in a system

design. Studies of various individual interventions have not

shown desired results.

CORRECT TIMING: Transitions pathways must be optimally

designed such that transitions in care occur neither too soon,

at high cost for an unnecessary intervention, or too late, at

high cost for an intervention occurring too late.

SYSTEM DESIGN IS RELIABLE AND TRUSTWORTHY, such that it

is easy to do the right thing and hard to do the wrong thing

Older Adults with Complex Conditions

Metrics

I have dignity in my life

Agree strongly, Agree, Neutral, Disagree, Disagree Strongly

All the time, Most of the time, Sometimes, Rarely, Never

Hospital/Institutional Days/1000

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Will providing care that meets the needs of the

majority of older adults with complex needs control

the cost of care for these patients??

% of People

Will providing care that meets the needs

of the majority of older adults with complex needs

control the cost of care for these patients??

20%

40%

60%

80%

20% 40% 60% 80%

% ofcost

�

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% of People

Will providing care that meets the needs of the

majority of older adults with complex needs control

the cost of care for these patients??

20%

40%

60%

80%

20% 40% 60% 80%

% ofcost

� 80 % of people

20% ofcost

80 % ofcost

20 % of people

Current Health Care Reality

Perfectly Designed for Current OutcomesHighly Developed

TestingPhase

Conceptual

Disease Model

Hospital

Clinic

Skilled careAt Home

& institutional

SocialServices

Dept

CaseMgt

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Population Health, One of the Triple Aims,

is largely at the conceptual stage

Highly Developed

TestingPhase

Conceptual

Disease Model Population Health Model

patient

person

Dz““““Family””””Existing community

infrastructure

Community health workers

Self help Villages

Community ActivationSocial Movements

Social Policy

Hospital

Clinic

Skilled careAt Home

& institutional

SocialServices

Dept

CaseMgt

““““Public Health””””

patient

person

Dz““““Family””””Existing community

infrastructure

Community health workers

Self help Villages

““““Public Health””””Community ActivationSocial MovementsSocial Policy

Hospital

Clinic

Skilled careAt Home

& institutional

SocialServices

Dept

CaseMgt

Highly Developed

TestingPhase

Conceptual

Creating Change in Health Care Reality

PUSH PULL

TOOLS

Disease management tools

Care Plans

Segmentationmodels

Personal Navigators

Information Tech

Social Networks

Big Data

Community Integration

Disease Model Population Health Model

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Jennie Chin Hansen, RN, MS, FAANCEO, American Geriatrics Societyjhansen@americangeriatrics.org

Warren Wong, MD, FACP, Physician Lead, Medicare Transformation, Kaiser PermanenteWarren.f.wong@kp.org

Thank You