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Role of Private Duty in Healthcare Reform :

Integrated Chronic Care Management

©2010 Beth Hennessey, All rights reserved

Management

6th Annual Private Duty Leadership Summit & ExpositionJanuary 24, 2011

ObjectivesHighlight the business case for integrated chronic care management as a strategic focus of private duty homecare and healthcare reformhealthcare reform.

Describe the foundation & tenets of a patient focused evidenced based care delivery model. Identifythe “retooling” necessary for replication & success


replication & success.

Discuss the importance of private duty homecare demonstrating value and partnerships for transitions of care, community based teams, and ACOs.

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Journey to Excellence


Our Patients’ Healthcare Experience


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IOM Quality Chasm ReportConclusions

C t h lth t • Current healthcare systems cannot do the job

• Trying harder will not work• Changing care systems

will work


will work• Make the right thing to do

the easy thing to do

Innovative Leadership:

Looking at your business through a different lens


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A New Way of Seeing:Reversing the Flow of Healthcare

Current Flow Reversed Flow

Policy & Regulation Policy & Regulation

Payment Methodology Payment Methodology


Provider Practices Provider Practices

Patient’s Health Needs

Chronic Disease• “Non communicable illnesses that are

prolonged in duration, do not resolve t l d l d spontaneously, and are rarely cured

completely. “ (CDC) • Most costly are heart conditions, cancer,

COPD, asthma, mental disorders, & trauma related disorders.


• Bulk of expenditures are on hospitalizations and physician services

IOM “ the Role of Human Factors in Home Care : Workshop Summary” © 2010

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The Number of People With Chronic Conditions is Rapidly Increasing


Source: Anderson, G.; Chronic Conditions: Making the Case for Ongoing Care; Johns Hopkins University; November 2007

Across The Board

Uninsured

Private Insurance

Medicaid

Medicare & Supplement


Medicare/Medicaid

Medicare Only

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All ages are affected

Percent of U.S. population with chronic conditions

2640

68

90

42

72

40%

60%

80%

100%

1 or morechronicconditions2 or morechronic


615

0%

20%

0-19 20-44 45-64 65+

conditions

AgesSource: Anderson, G. Chronic Conditions: Making the case for ongoing care. Johns Hopkins University. November 2007.

The Bottom Line


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So what about coordination?


Uncoordinated Care


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Medication Mismanagement


Source: Anderson, G.; Chronic Conditions: Making the Case for Ongoing Care; Johns Hopkins University; November 2007

Facilitating Behavior Changeis the KEY to Chronic Care Management

99%

1% Medical

Management


Self-Management

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“Patients can

Complexity :Behavior Change Required

undo a month’s worth of

expensive and intensive care just

going home


g gand going about

their normal routines.”

John Charde, MDVP Strategic Development, Enhanced Care

Initiatives, Inc (April 2006)

Non-adherence: significant for those with chronic conditions

Non-adherence contributes to:– Increase in number and length of acute care visits

(25% of hospitalizations due to medication errors)– Increase in ED visits– Unnecessary changes in treatment


– Overuse of scarce and expensive medical resources– Loss of productivity and decreased quality of life

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• Multiple medications • Multiple physicians

B i t

On the Front Lines

• Barriers to care coordination

• Gaps in transitions of care• Poorly controlled disease• Inconsistent evidence-based


care• “Non-compliant” patients• “We will see this pt again”

Bottom Line : Home Care

• Our business success is linked to our success i idi hi h lit i th hin providing high quality care in the home

• Our success in providing high quality care in the home is linked to our success in the management of chronic disease

• Our success in providing high quality CCM in


• Our success in providing high quality CCM in the home has resulted from the change in our care delivery prompted by HBCCM

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Bottom line:Across the Healthcare Continuum

• Healthcare systems are designed for short-term acute rather than long-term chronic care


rather than long term chronic care• Chronic care management models must support the

individual in the environment where they face their daily challenges

Source: “Improving Primary Care for Patients with Chronic Illness” Bodenheimer, Wagner, Grumbach, JAMA , October 9, 2002 Vol. 288, No. 14

Our Iceberg is Meltingby John Kotter and Holger Rathgeber


The “acute care iceberg” is melting, and from our perspective there is urgency for change .

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Patient Centered + Evidenced Based

Desperately Seeking a Solution

• Literature search: nothing for homecareD t ti j t l l d• Demonstration projects: lessons learned

• Extracted best practices from other fields (adult education, behavior change theory, etc.)

• Dr. Wagner’s Chronic Care Model


• Combined experience from across the healthcare continuum

• “We’ll have to build our own model.”

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We CAN do this!

©2010 Beth Hennessey, All rights reserved© 2010 Beth Hennessey and Paula Suter (ALL RIGHTS RESERVED)

Leaders are visionaries with a poorly developed sense of fear

and no concept of the odds against them.Robert Jarvik

Medicine: Some Viable Solutions

• Traditional DM & M di l H lth Medical Health Support Programs

• Models focusing on care transitions

• Wagner’s Chronic


• Wagner s Chronic Care Model

• Guided Care Model

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Lessons Learned From Traditional DM & The Medical Health Support Programs

Face to Facevisits by

experiencedRN’s

Use of behavior change theory

Ability to acton data


Better Outcomes

Wagner’s Chronic Care Model:The Foundation of Our Model


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Key Derivatives: Wagner’s Model

In order to achieve outcomes:– Division of labor: non-physicians – Redesign care delivery model– Proactive / prepared practice team– Innovative leadership and financing to sustain


Informed,Activated

Patient

ProductiveProductiveInteractionsInteractionsProductiveProductiveInteractionsInteractions

PreparedPractice

Team

Leadership Support

Evidence-Based Guidelines (EBG)

Home Health Care

SWOT Analysis : Opportunities

Delivery SystemDesign

Decision

Support

Clinical Information

Systems

Self-ManagementSupport

Health System Organization

Support ( )Health Care Delivery Model


pp SystemsLinks to Community Resources

Embed EBG &Dashboard

Clinician Training

Caregivers / Volunteers

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Areas for Focused ImprovementSelf – Management Support:

• Emphasizes pt’s central role in managing health• Use effective SMS goal setting (SMART goals), action

planning & problem solvingDecision Support:

• Embed evidence-based guidelines into practice• Share guidelines with patients


Delivery System Redesign:• Prepared proactive practice team

• Care coordination across healthcare system• Long term partnership with patient

Behavior Change is HARD

Are you “non ycompliant?”


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The Home Based Chronic Care Model

Building Relationships Changing Behavior


Accessing Expertise Maximizing Technology

HBCCM PillarsHigh Touch:•Holistic assessments including barriers to self managementT t b ildi•Trust building

•Patient engagement•Front load visits

Self-management support (SMS):•Pt specific SMART goals


•Motivational Interviewing•Facilitation of behavior change

•Build skills & confidence•Provide reinforcement

•Problem Solving

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HBCCM Pillars (cont.)Accessing Expertise:• Specialist consultation & oversight• EBP chronic disease care plans • Support interdisciplinary team &Support interdisciplinary team & “ learning environment “• Promote “expert” communication among all providers: eg SBAR

Use of Technology:•Early identification of exacerbation•Interventions based on trended data


Interventions based on trended data•Positive reinforcement & SMS•Consistency of care•Meaningful data exchange•Make “right thing to do the easy thing to do”

Integrating the Model into Daily Operations

• Administrative leadershipleadership

• Chronic Care Certification Course

• Report for monitoring practice

• Job descriptions


Job descriptions• Case conferences• Embedded in EMR• Learning organization

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Outcomes Experienced With Model

CLINICAL

Decrease in hospitalizations

FINANCIAL

Volume Increase

Increase in net

SATISFACTION

Pt Satisfaction


REGULATORY/ SAFETY

TJC : transitions

Employee engagement

INFORMATION SYSTEMS

Meaningful data exchange

IT : Meaningful Data Exchange


SMART Goal: I will meter once a day forthe next week

MD Follow-up Appts: 7/20/10 10am Dr T (PCP)

7/23/10 2pm Dr. G (Endo)

6/1/10- 6/6/10 BMC LR: UTI & Sepsis

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Customer Satisfaction• Patients• Staff• Staff• Leadership• Physicians• Stakeholders

– Providers


Providers– Payers– Policymakers

Value to StakeholdersAcross the Healthcare Continuum

Valued Hospital Partner

Valued PhysicianPartner

Valued SystemPartner


•Reduce LOS/ Rehospitalizations/ ED•Reduce avoidable EOL

care expense •Improve Care

Transitions

• Physician Access • Transitions across providers•Physician extenders as a pro-active practice team• PQRI data • Pt-Centered Medical Home

• Payment reform models : bundled

payments to ACOS•Delivery reform: State

& Fed demos : Community Based

Transitions

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Potentially preventable 30-day readmission rates

Type of Number of potentiallyPercent

readmittedAverage Medicare Total spending on

Initial condition

Type of hospital

admission

Number of potentially preventable 30-day

readmissions(in thousands)

readmitted within 30

days*

Medicare payment for

readmissions

Total spending on potentially preventable

readmissions(in millions) Heart failure Medical 139.2 19.1% $6,490 $903 COPD Medical 85.1 16.5 6,491 552 Pneumonia Medical 86.4 13.3 6,681 577 AMI Medical 30.5 18.7 6,540 199 CABG Surgical 26.6 18.1 8,085 215 PTCA Surgical 68.2 14.7 8,342 569 Other vascular Surgical 30.0 18.6 10,061 302 Total for seven 465 9 $3 318


conditions 465.9 $3,318

Total for all DRGs 1,715.5 $12,008 Percent of total 27.2% 27.6%

*30-day readmission rates are calculated based on the set of cases that are potentially eligible for an initial readmission, thus they exclude readmissions and people that died in the hospital from the denominator.

Source: 3M analysis of 2005 Medicare discharge claims data.

Targeted for Improvement Nationwide: Care Transitions

• Quality Improvement Organizations (QIO)Quality Improvement Organizations (QIO)• Special Interest Groups : H2H• Pilots / Demonstrations / Grants• Hospitals : Hospital Compare


• TJC: patient safety / culture of safety• Payors : federal / state / and private insurers

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Two Effective Models for Transitions

Coleman Care Transitions Intervention

By Eric Coleman MD,MPH

Naylor Transitional Care Model

By Mary Naylor, PhD, RNUniversity of PA

Tools & support for pt to take active role

in care


University of COUniversity of PA in care

Common to Both Models

Naylor ColemanNaylor Coleman

Medication education and management

Medication education and management

Patient education with h i d fl

Patient education with h i d fl


emphasis on red flags emphasis on red flags

Follow up with MD Follow up with MD

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Pt familiar & competent

MedicationManagement have access

di i

Three Question Focus “AND”

Appt scheduled within a week

competent

Early Follow-up AND

to medications

ability to get there


Comprehend S&S that require

attention

Symptom Management

whom to contact

Source: American College of Cardiology and the Institute for Healthcare Improvement, Hospital to Home Campaign

Pt familiar & competent

MedicationManagement have access

di i

Three Question Focus + AND + Homecare’s Unique AND

adherence & perseverance

Appt scheduled within a week

competent

Early Follow-up AND

to medications

ability to get there AND

access as needed in between

scheduled appts

perseverance


Comprehend S&S that require

attentionSymptom

Managementwhom to contact

Problem solve & behavior change

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The Call for Innovative Leadership in Healthcare

• Great crises produce great leaders• Three-quarters of innovative

solutions come from “outsiders” • Vision sustains progress in the

midst of difficulties• Tenets of HBCCM offers a model

for transformational change


for transformational change

Building Upon A Strong Foundation“ Dombi, with the National Association forNational Association for Home Care and Hospice, said Baptist’s model is a ‘modernization’ of what homehealth agencies have done for more


have done for more than a century.”

Home-health program seen as national model

BY CAROLYNE PARK ARKANSAS DEMOCRAT-GAZETTE

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NEW STRENGTHSHomecare retooled to deliver CCM is a perfect fit as both

• Pt centered goals• Pt engagement

pthe “health coach” AND the “prepared proactive practice team.”


• Pt engagement• Self mgt support• Uniform best practices• Health data exchange

Financing to Sustain:Redesigned care delivery supported by new

payment models (PPACA)M f l b d • Move from a volume-based reimbursement system to a value-based reimbursement system

• Achieve greater accountability for both


accountability for both efficiency, quality, and slow spending

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Center for Medicare & Medicaid Innovation (CMI) Planned Opportunities for Chronic Care Mgt

Financing Opportunities within PPACA

Planned Opportunities for Chronic Care Mgt

• Geriatric assessment and care plans for beneficiaries with multiple chronic conditions and 2 ADLs

• Care coordination enabled by health information networks including telehealth


• Home health providers offering chronic care management via interdisciplinary teams

• Community-based teams to assist PCP with chronic care management

ACO’s will require delivery reformSupport for Clinical Transformation:

Cli i l t f ti i th li h i f ACO’ • Clinical transformation is the linchpin of ACO’s success, and it does not happen automatically by simply changing payment arrangements and measuring performance.

• Requires effective investment in infrastructure, process and organizational redesign to achieve delivery reform


and organizational redesign to achieve delivery reform.• Examples: Chronic disease management & care

transitions“A National Strategy To Put Accountable Care Into Practice” McClellan, A., Lewis, J., Roski, J, & Fisher, E, Health affairs, May 2010, 29:5

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Private Duty’s Unique Role inMeaningful Healthcare Reform

• Fill the gaps of community based care needed g p y• Cost effective care• Located where patients want their care• “Army at the ready” for:

– Transitions of care– Patient Centered


– Patient Centered Medical Home

– Long term CCM– Value based partnerships– ACOs

Value to StakeholdersAcross the Healthcare Continuum

Valued Hospital Partner

Valued PhysicianPartner

Valued SystemPartner


•Reduce LOS/ Rehospitalizations/ ED•Reduce avoidable EOL

care expense •Improve Care Transitions

• Physician Access • Provider transitions• Physician extenders as a pro-active practice team• PQRI data • Pt-Centered Medical Home

• Payment reform models : bundled

payments to ACOS•Delivery reform: demos on State &

Federal Level

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A Golden Opportunity Knocks

• To spark meaningful healthcare reform

• Make pts’ needs & providers’ expertise the drivers of reform

• Lead our organizations in a new way of delivering careT d t t fi ll


• To demonstrate a fiscally sensible & sustainable solution for CCM , transitions of care, PCMH & ACOs

Change has a considerable psychological impact on the human mind. To the fearful it is threatening because it means that things may get

worse.To the hopeful it is encouraging because things may get better.

To the confident it is inspiring because the challenge exists to make things better.

King Whitney, Jr.

©2010 Beth Hennessey, All rights reserved© 2010 Beth Hennessey and Paula Suter (ALL RIGHTS RESERVED)

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Answering the Call

• If we can envision...A patient-centered h lth t th t i ibl ff d bl healthcare system that is accessible, affordable, sustainable and provides the best care in the world, and…

• If we can embrace...A blueprint for genuine reform that has immediate real world


reform that has immediate, real-world applicability with specific action steps for today, as well as clearly defined long-term objectives for the future, and…

Answering the Call• If we can embark…On a journey with colleagues

in the pursuit of excellence for those we are pprivileged to serve, and…

• If we can propose...That homecare providers are in a unique position to reform healthcare delivery by starting with integrated chronic care management


management…When we succeed, we will have delivered

meaningful healthcare reform and restored hope for those we are committed to serve.

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The Journey BeckonsThe Journey Beckons


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