TRANSITIONS OF CARE

Nursing Home Update -2014

winter OPSO

Howard Graitzer DO FACOI

Transition of Care – Doing Away With the Frequent Flyer Program Or Kicking The Can Down the Road

Transitions of Care

• 40% M’care discharges go to SNF • 8.5% Medicare admissions from NF • 5 million people >65 made 15 million

transitions in 2 yrs • 22.4% had subsequent health care use • 18 % readmissions are preventable • $25 billion save if decrease by 25%

Rehospitalizations • 19.6% of M’care pts re hospitalized w/i 30 d • 34% re hospitalized w/i 90 d • 67.1% medical 51.5% surgical • 50.2%, no bill for PCP in 30 d prior to admit • 10% re hospitalizations likely planned • Average stay 0.6 day longer • Cost to Medicare in 2004, $17.4 billion NEJM 2009

Congressional Action In Health Reform

• Public reporting of readmission rate • Penalties against hospitals with “excess”

readmissions (above expected rates) for targeted conditions, (10-31-13)

• Sole community hospitals, Medicare dependent small rural hospitals, and low volume conditions are exempt from penalties

Hospital Readmit Payment Policy

• Reduce M’care inpt payments with higher than expected risk-adjusted readmission rates for certain conditions

• Medicare payment reductions capped at 1% in FFY 2013 2% in FFY 2014 3% in FFY 2015

Paying for Coordinated Care

• Readmit Reduction Program of ACA • AMI, pneumonia, CHF 12-15% of readmits • Possible future additions – COPD, asthma,

elective surgery, vascular procedures • 2/3 of US hospitals at risk for penalty • $15 billion to recoup in 2013

What Makes 30 Day So Special?

• Oncology- 4 weeks of complete response before remission

• Society of Thoracic Surgeons – 30 d M/M • CHF – 30 day readmission benchmark • No clear biological, clinical or therapeutic

evidence base

Early Hospital Readmissions • 4 community hospitals, 300 readmissions • 36% discharged to SNF, ALF, AFH • 58% readmit w/i 7 d • 29% readmit w/i 2 wks • 75% readmit for same or related Dx • 69% PCP f/u recommended, not done • 57% readmit before seen by PCP • 15% deemed preventable Journal of Hospital Medicine 2011

Most Frequent Causes of Rehospitalization

• CHF 27% • Pneumonia 21% • COPD 23% • Psychosis 25% • GI 19% NEJM 2009 GU 30% Journal of AMDA

Potentially Avoidable Diagnoses • Cardiovascular (CHF, chest pain) • Respiratory (pneumonia, bronchitis) • Mental status change/neurological symptom • UTI • Sepsis or fever • Skin (cellulitis, infected wound, pressure ulcer) • Dehydration • Gastrointestinal (bleeding, diarrhea) • Musculoskeletal (pain, fall) • Psychiatric • Other (adverse drug effect) JAGS 2010

ED Treat and Release

• >25% NH residents transfer to ED each yr • 10% arrive with no documentation • ED visits within 30 days – 39.8% • Highest volume medical conditions - GI,

psychoses, CHF, COPD, GU • Highest volume surgical conditions –

laparoscopic cholecystectomy, C-sections, PTCA, complicated hip/femur procedures

Demographic Risk Factors • Black race • Male sex • Older age • Single • Disability (cognitive and functional) • Receipt of SSI • Level of family caregiver support • Reliable transportation

HOSPITAL Score

• Hgb at discharge • Discharge from an oncology service • Na level at discharge • Procedure during index admission • Index type of admission • Number of admissions in last 12 months’ • LOS • Low risk – 5.2% estimated risk of readmission • High risk – 18.3% estimated risk of readmission JAMA Int Med, March 2013

Interventions to Prevent Readmits • Earlier PCP follow up • Primary care case management • EOL discussion, palliative care consult, hospice • Medication reconciliation • Disposition to higher level of care • Better education on home management • Home health/ Home physical therapy • NH on site physician visit Journal of Hospital Medicine 2011

Barriers to Effective Care Transition • Delivery system level – information silo, non

existent information system, no financial incentive, formulary issues, insurance coverage, lack of transitional care

• Clinician – continuity of provider, multiple specialists, multiple care managers

• Patient – lack of advocacy, no education, conflicting information, communication barriers

JAGS 2003, Ann Int Med 2004

Points of Breakdown • Preparation of pt and CG • Communication of vital elements of care plan • Medication reconciliation – initial vs current • Transportation of pt • Completion of f/u care with practitioner • Diagnostic imaging or lab testing • Advance directives across settings • Unfamiliarity of practitioners with diff settings

Medication Barriers • Regularly used Rx discontinued in 46.4% • 38.6% of omits lead to deterioration • Adverse event related to medication

during transition – 20-66% • 19% have 1+ ADEs w/i 3 wks of d/c,

– 66% are drug events • Average 3 med changes in transfer from

NH to hospital

Discharge Summary –Components

• Main diagnosis/reason for hospitalization • Pertinent physical findings • Results of procedures and tests • Discharge medication with reason for changes • F/U arrangements • Information given to pt and family • Pending test results • Specific follow up needs JAMA 2007

Discharge Summary • 41% patients had results pending at disch • 10% requiring urgent attention • 75% pts had lab report return post discharge • 15% contained abnormal result • 60% hospitalists and PCPs unaware Ann Int Med 2005 J Am Med Rec Assoc 1982

Care Coordination

• “Good” geriatric care across care settings • IDT – interdisciplinary team • IOM - care coordination instrumental for

optimizing care especially if high risk • PCMH – patient centered medical home

Care Coordination • Synonymous w care/case management • “care” - . A function that helps ensure that

the patient’s needs and preferences for health services and information sharing across people, functions and sites are met over time

• “case” – individualized approach to coordinating pt care w complex healthcare needs or chronic medical issues

Care Coordination

• Care management – Healthcare Services and programs designed to help individuals with certain long-term conditions better manage their overall care and treatment

• Care coordination - more inclusive for patient/family centered approach

• Care/case management-more structured

Why is care coordination needed

• Lack of it can be unsafe or fatal – lab, x-rays or biopsies not followed up on – multiple providers are unaware of Rx – PCPs not receiving discharge plans – More costly for all – duplicate services – Preventable hospital admissions/readmits

Does Care Coordination Work

• Several studies show improved QOL • Especially in stroke survivors

– Decreased depression. – Improved QOL – Increased self-care practices – Decreased readmits

Who oversees care coordination

• IDT – nursing – Center stage – Pharmacy +/- – Social services. – PT/OT/ST – PCP/NP/PA – Payors

• foundation of ACO under ACA • CMS now pays to coordinate care – 30d

Coordinated Care Coding

• F2F w/i 1 wk of d/c SNF or hospital ($230) – 99495

• F2F w/i 2 wk of d/c SNF or hospital ($160) – 99496

• Requirements also include – Direct telephone or electronic contact – moderate/high MDM during 30 day f/u – Submit charge on the 30th day after stay – And after hospital/SNF submit their charges

Coordinated Care Coding

• 99487: use for first hr of clinical staff time spent coordinating care over a 30-day period where there is no F2F visit.

• 99488: use to report the first hr of care coordination time over a 30-day period and a F2F visit.

• 99489: use for 30-min increments of clinical staff time directed by a provider over the initial hr of care coordination.

Where care coordination occurs

• Healthcare plans – esp special needs pop • provider based organizations. • ACOs • home health, hospice, hospital, SNF • PCP office , esp with case manager

How can CC be optimized

• Medications self-management system • Dynamic Pt-centered record • PCP/specialist follow-up • Patient awareness of red flags

Conclusion

• The best care coordination model includes a PCP, pt and family and delivered by an integrated, multidisciplinary team that explicitly includes at least one staff care coordinator

• Can obtain coordinator independently or through an ACO or other appropriate entity