Strategies for Success Under the New Medicare Waiver – Part 2

Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies

May 21, 2014

Agenda

• Expanding your portfolio of strategies

1. ED based strategies

2. Enhanced services for high risk

3. Portfolio strategy in action

• Discussion

Expanding your portfolio of efforts The 2014 “Playbook”

2014 Playbook

• Section 1: Overview • Section 2: The Transitions: Handle with Care Driver Diagram • Section 3: Critically Review Your Readmission Efforts to Date • Section 4: Designing for Success: The Portfolio Strategy • Section 5: Essential Action

– Model Impact of Your Strategy – Improve Standard Care for All – Improve Transitions Across the Continuum

• Section 6: High Leverage Impact – Hospital to SNF – Hospital to HH – Hospital to Home with Services – Emergency Department Based Interventions

• Section 7: Special Topics – Medicaid Readmissions – Behavioral Health – Palliative Care and End of Life

• Glossary and Links to Resources • Online Resources • Transitions: Handle with Care Initiative Presentations and Webinars • Template Press Release • Readmission Data Analysis • Readmission Interview Protocol • Cross-continuum Team Sample Letter and Agenda • Hospital to SNF Action Planning Worksheet • Hospital to Home Health Action Planning Worksheet • Hospital to Home Action Planning Worksheet • Excel Tool: Readmission Strategy Impact Estimator

2014 Playbook - Appendices

The best way to avoid a readmission is to not admit in the first place

ED-based Interventions

MGH High Cost Beneficiary Demonstration Project (CMS) • Target population: most expensive Medicare FFS pts at MGH • Opportunity: Identify in ED, intervene to avoid hospitalization • Intervention: Flag in record to identify patient by registration in ED

– Patients’ full care team (SW, PCP, specialists) paged – Expectation clinicians will go to ED and avert admission

• Impact: only program in the demo that saved $$ • Lessons learned:

– May not stop patients from behavior of going to ED – These patients always “look bad” (physically, or labs) – Clinicians who know the patient know what baseline is – Partner with ED doc to reassure no substantial change is presents and

to assure that close follow up will occur

ED-based Interventions

ED to SNF Transitions • Hallmark Health System, metro Boston

– 2 hospital system, 70% admits via ED, hospitalists – 20 ED docs, 17 PAs

• ED Chief and Champion of this work explored myths of SNFs/EDs – Patients only seen once a month; can’t do IVs, etc – “ED admits everyone”

• Actions: – Discussion “why” – Education: our capacity/their capacity – Simplicity : establish contacts, standard transfer information – Feedback

• Results: increase in number of patients transferred from ED to SNF

ED-based Interventions

Adapted from presentation by Dr Steven Sbardella, System Director of Quality, Hallmark Health System, April 29 2014

Frequent ED visits for Behavioral Health patients • Non-teaching regional hospital in central/rural MA • Difficulty transferring patients to psych beds = lengthy boarding • Concept: reduce ED boarding by preventing ED visits • Opportunity: identify frequent ED BH patients in ED • Staff: PM and ED BH nurse navigator, 2 FTEs • Team: ED director, ED BH team, CNO, CIO, ED CM, cross-continuum

partners • Intervention: collaboration between community mental health provider, crisis

team, community health center, ED, documented identification, referral workflows between all 3 entities, standing orders for frequent BH ED users to facilitate med clearance; establishment of individualized care plans

• Impact: successful linkage; social work / harm reduction orientation • Time to implement: 10 weeks.

ED-based Interventions

1. Train ED staff on how to use INTERACT NH Capabilities List

2. Train ED staff on how to use INTERACT SNF-ED information

3. Meet with SNFs to discuss SNF-ED transfers & opportunities to treat and return from ED

4. Staff a dedicated admission avoidance clinician in ED to coordinate with community providers/services to facilitate d/c

5. Create a flag in ED record to identify recently d/c pts <30days

6. Create individual care plans for frequent ED users with recurrent but otherwise stable complaints

ED-based Interventions - Actions

Provide enhanced services The best “transition out” and “reception in” will not suffice for high risk

“High Risk Care Teams”

• Sometimes a “coach;” increasingly multi-disciplinary team

– Navigator – Behavioral health – Social Work – Pharmacist

• Address full complement of medical, social, logistical needs

– Affordable medications; waiving office visit copayments – Transportation – Stable housing – Navigating the healthcare system, asking questions, making appointments

• Identify using combination of clinical and non-clinical criteria

– History of high utilization, no PCP, numerous prescribers, numerous meds, behavioral health comorbidities, homeless….not “just” chronic disease

• BRIDGE – Social work-based transitional care model – Assess “person in context” – Make contact in hospital; reassess at 24-48h after going home,

as needs change/emerge; reassess periodically over 30d

– Observation: Don’t require / use additional “slush funds” for transitional care – they are adept at getting patient linked to existing services (medicaid waiver, AAA, ADRC, etc)

– Observation: Don’t medicalize social complexity – “work the case” and refer for services, follow up, advocate for the patient, but don’t “escalate” care medically when they encounter barriers

Enhanced Care: BRIDGE

Patient-Centered Community Health Worker Intervention to Improve Posthospital Outcomes A Randomized Clinical Trial; Kangovi et al JAMA Internal Medicine April 2014 • Target population: 683 low income, uninsured, Medicaid patients

– 237 (35%) declined to participate – 446 were randomized to standard care or intervention (CHW)

• CHW intervention – Engaged w/ patients during hospitalization – Developed personalized action plans – Worked with patients at least 2 weeks

• Results: – Reduced recurrent 30-day readmissions (2.3% v. 5.5%) – Among 63 pts, recurrent readmissions 40% v. 15% for CHW

Community Health Workers

Preventing 30-Day Hospital Readmissions A Systematic Review and Meta-analysis of Randomized Trials Leppin et al; JAMA Internal Medicine (online first) May 12 2014 • Review of 42 published studies of discharge interventions

• Found that multi-faceted interventions were 1.4 times more effective

– Many components – More people – Support patient self-care

• Interventions published more recently had fewer components are were

found to be less effective

46-study Meta-Analysis: What Works?

http://archinte.jamanetwork.com/article.aspx?articleid=1868538

The Portfolio Strategy in Action

Costlier care is often worse care. Photograph by Phillip Toledano.

What a Texas town can teach us about health care.

McAllen, Texas, the most expensive town in the most expensive country for health care in the world, seemed a good place to look for some answers.

THE COST CONUNDRUM

The New Yorker June 1 2009

by Atul Gawande

Annals of Medicine

McAllen is in Hidalgo County, which has the lowest household income in the country, but it’s a border town, and a thriving foreign-trade zone has kept the unemployment rate below ten per cent.

18

Rio Grande Valley - Map

H

B

M

Sept 2009

Jan 2010

July 2012

Sept 2012

Nov 2012

Feb 2013

Mar 2013

April 2013

July 2013 Current

Palliative Care / Hospice

Project Red – Appt. w/PCP or Clinic and FU Calls

CCTP – CTI Coach and PAC Program

Discharge Assessment within 24 hour of admission

Transitional CM

Walgreen’s Well Transition Program

Registration Identifying Possible Readmissions in the ED

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21

WellTransitions – Program Overview

Patient identified, enrolled in program

1 Generate medication

history

2 Fill, alignment and

reconciliation of discharge medications

3 Bedside delivery of medication

and patient consultation

4

Hospital Treatment

Education follow up

initiated 48-72 hours after discharge

5 Clinical therapy review approximately 10 days post

discharge

6 Community

integration at day 25 post discharge

7

Post-discharge Care

Joint outcomes reporting with health system and IT partner 8

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Readmission Decline for VBHS

• Fiscal Year 2011 = 28% Readmission Rate

• Fiscal Year 2012 = 21.1% Readmission Rate • Fiscal Year 2013 = 13.7% Readmission Rate

50% readmission reduction!

Story courtesy of Angela Blackford, Valley Baptist Health System

Valley Baptist Health System Readmission Reduction Portfolio of Efforts

• Redesign Discharge Process

• RN/SW Case Managers Start DC Plan within 24 h of Admission

• Discharge Plans for 30 days

• Transitional CM Team - Identify, Monitor, Call, Home and Nursing Home Visits, Medication Reconciliation

• Create and Foster Community Collaboration

• Increase Patient Satisfaction

• Improve Patient Safety

• Decrease Readmissions

• Eliminate Any Readmission Penalty Over Time

• Collect Data and Trend Results

1. Know your readmission data

2. Ask your patients & their families why readmissions occur

3. Inventory your current readmission reduction efforts

4. Quantify your hospital’s 1 and 5 year readmission reduction goals

5. Develop a multifaceted strategy

6. Invest resources – in staff and tools - to get the job done

6 Recommendations

Thank you

Amy E. Boutwell, MD, MPP President, Collaborative Healthcare Strategies

Advisor, Maryland Hospital Association amy@collaborativehealthcarestrategies.com