Please join us in this week’s Integrating Care for Populations & Communities
Learning Session Webinar on Thursday, May 23, 2013 at 3:00 pm ET.

This webinar is the tenth presentation in the Learning Session series: Shining
Stars Across the Nation

During our series entitled, “Shining Stars Across the Nation”—we will hear from
local communities that have been successful in improving healthcare through
reducing hospital readmissions. We will feature communities from different
initiatives— those communities that are lead by the QIOs, those that are part
of Aligning Forces For Quality, those that have received state funding, Robert
Woods Johnson awardees, CCTP awardees, Beacon communities, ACOs and more.

These sessions will be held on the 2nd and 4th Thursdays of the month.  We have
a schedule of these presentations posted at: http://www.cfmc.org/integratingcare/learning_sessions.htm

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Call Information

Shining Stars: Rio Arriba County Community – New Mexico- A Quality Improvement
Organization Community

Presented by:

Lauren Reichelt, MA, Director of Health and Human Services, Rio Arriba County

Event:
Care Transitions Learning Session webinar

Date:  May 23, 2013

Time:  3:00 PM – 4:00 PM ET

Teleconference:
866-639-0744  (No pass code needed)

https://qualitynet.webex.com

Meeting
Password: community

Please join us 15 minutes prior to the presentation to ensure the automatic
system set-up has been properly established.

Attendee Instructions:

1) Click or Copy and Paste this to your web browser:  https://qualitynet.webex.com

2) Locate the event you wish to join

3) Click on Join Now (located to the right of the event title)

4) Enter your name and email address as prompted

5) Enter the password: community

6) Dial in to the teleconference. The number is 866-639-0744 or 678-302-3564.
The access code is none.

If you have any questions or problems accessing the meeting, please call the
Buccaneer WebEx Helpline at 540-347-7400 x390

Presentation slides will be posted prior to the call at http://www.cfmc.org/integratingcare/learning_sessions.htm

These calls are open to all, please invite anyone who wants to learn along with
us.  As a reminder, these sessions are recorded and all previous Learning
Sessions are available at:

http://www.cfmc.org/integratingcare/learning_sessions.htm

Read more: http://medcitynews.com/2013/05/onc-backs-30k-app-challenge-for-improving-cancer-care-transitions/#ixzz2TxPeFe00

This article is used with permission from www.medcitynews.com, where it originally ran on May 15, 2013.

This is story about the jacket painting of TomEvans, MD. If you read Tom’s biography you’ll see many accomplishments in his long career. He has succeeded at so many things. He is President and CEO of Iowa Healthcare Collaborative. He has a BA, MA and MD to his name. He was the Chief Medical Officer at Iowa Health System. He was on the board of the National Patient Safety Foundation and is currently working with HEN’s in the Partnership for Patients Initiative.

But today we are going hear about Tom’s failure.

This is Tom’s jacket: “Stair Steps.”

Tom is the eldest of nine children.

So like many large families they were arrayed as stair step order in family portraits. In this painting you can see Tom, his father and all of his siblings in descending order.

Here is Tom telling the story that inspired this painting:

“This story is about my mother. As a family physician, and she a nurse, we always had a fairly frank and open discussion about medical issues. These took on an entirely new and unexpected dimension when her health began to fail.

I am the oldest of 9 children born over an eleven year span. I think we were more of a herd than a family sometimes! My mom was an RN and worked nights at the hospital. Dad was an insurance agent. My parents were always there and worked hard to make sure everyone had what they needed.

Mom became diabetic late in her 50s. Always too heavy and non-compliant with diet, she never took real good care of her diabetic management even though she was a nurse. I think she was in denial. She was happy, loving mother and the perfect grandmother to our kids. Complications began to catch up in her 70’s and by age 77, she had accumulated several medical conditions that made her a prime candidate for the medical system. Her diabetes was a constant challenge in balancing diet and insulin (she refused to exercise!). She also developed heart disease. She had a “silent” heart attack (no symptoms) and almost died. After a valve replacement and bypass surgery, she was recovering nicely when the wheels began to come off.

As the oldest son and a physician, my role evolved to make sure Mom’s medical needs were met. I found myself mentally moving from “visiting my parents” to a “making house calls” mentality. I also became quite vigilant for patient safety issues in her care. I saved her life three times from medication safety issues. Twice when in the hospital, she was over-medicated with narcotics. Neither situation required Narcan, but both required significant observation and dosage adjustments. The most dramatic intervention what when my father called me over to their home to evaluate Mom as she just wasn’t right. I watched her become unresponsive before my eyes and called 911. Before the ambulance arrived I put together that she might have double dosed her insulin. While a normal blood sugar is between 60 and 110, hers was 7. She was having a hypoglycemic reaction and needed hospitalization.

In the last year of her life, I spent a lot of time with my Dad just trying to keep Mom stable and in the home. Dad was managing her diet, housework, medical regimen (now after the insulin episode), the farm…and burning out. Mom was occasionally a little confused, and had also begun falling. While she had never been graceful, but she just seemed to be “sliding down” through weakness now about twice a month. When Dad was out one time, I came over and found Mom on the floor. She was fully conscious and content, but unable to get up. When I asked how long she’d been there, she replied about an hour. She was just waiting for Dad to help. I expressed to Dad my concern about his ability to care for her at home, and he basically said he would die before putting her in a nursing home. So we went on. Interestingly, her diabetic control was the best it had ever been, so I thought I was doing a good job.

On New Year’s Eve I got a call at 2 a.m. from Dad asking me to come over and check Mom. After watching “Guy Lombado reruns”, they were heading to bed and Mom fell in the kitchen. She hit her face on the floor, but more importantly, couldn’t move her right arm. She had broken her humerus and was admitted to the hospital. On the way home with my dad that morning, I noted that her care at home now exceeded his capability and he should consider a nursing home.

The physician taking care of Mom in the hospital requested a “palliative medicine” consult. Because this is usually reserved for patients at the end of their life, I didn’t really think this would do much good. The next day my dad and I were called in for the results. We were strongly encouraged to consider hospice placement. Though my mom didn’t have cancer, or some fatal debilitating disease, she had developed “failure to thrive” over the past 6 months…her body just wore out. Her falling, increased weakness, confusion and decreased appetite were all signs of this…and I missed it. The reason her diabetes was under such good control wasn’t that her medication regimen was finally good…it was that she had basically quit eating. When we discussed this situation with Mom in the hospital, and she whole-heartedly agreed.

Mom was admitted to a hospice unit the next day and we had a wonderful two months. As her arm healed though, her mind got weaker and she became increasingly disoriented. She was happy, comfortable, all of her wishes were met, and her all of her children were near. Most important, she and my Dad had a wonderful period to review their life together and to say good-bye.”

So within this image I painted Tom racing up a fire escape, as metaphor, to once again rescue his mother. The windows have become the pills she is supposed to take. We live within a world focused on rescue and in the case of fire that can be a great thing. But within our lives it leads us believe there is always one more treatment, one more path of care, when eventually each of us must end. We must appreciate ends as much as we do beginnings.

And I would like to close with Tom’s words:

For me, there are really two points to this story:

2) As a society, we don’t do “end of life” transitions well. Often the medical community considers dying a failure, and providers may vacillate from over delivery of care and total disengagement. The patient’s true wishes may not really be considered, and the family is left starved for information and confused. I found myself stuck between the roles of provider and family in this situation, and am embarrassed to note that hospice placement didn’t even occur to me…I was fixing her problems and missed her problem. I wish someone had thought about end of life strategies sooner. I wish I could rewrite the last 8 months of her story for the sake of both my mom and my dad.

This article originally ran on Regina Holliday’s blog (www.reginaholliday.blogspot.com) on May 15, 2013.. Regina is an artist, advocate for patient voice and power, speaker, and author. We reprint this today with her permission.

key words: Regina Holliday, Walking Gallery, end of life, frail elders, patient voice, caregivers

By Carol Castillon

The County of San Diego’s Health and Human Services Agency, Aging & Independence Services (AIS), in partnership with Palomar Health, Scripps Health, Sharp HealthCare and the University of California San Diego Health System has received CCTP funding from the Centers for Medicare and Medicaid Services (CMS). The project, which launched in January, will use those funds to provide innovative care transitions services countywide to up to 21,000 high-risk Medicare patients in 13 hospitals.

All partners will test an intervention called Care Enhancement. To appreciate the scope of this endeavor, keep in mind that each Care Enhancement worker is assigned to a specific hospital but must also provide coverage to various other hospitals across the different systems.  As the project’s common intervention ,we’ve learned to adapt our approach to each hospital culture to ensure consistency across the services provided.

The Care Enhancement intervention offers  patients and their caregivers critical social support services, either by referral or direct provision of support services, that can reduce the risk of an avoidable readmission.  A Care Transitions coach—a nurse—completes a risk assessment, which can trigger the referral to the Care Enhancement team. The Care Enhancement worker is then required to make a hospital visit prior to discharge as well as a home visit within 72 hours of discharge.

The Care Enhancement position is brand-new.  Even so, all of the Care Enhancement workers had had years of experience in various programs throughout AIS prior to this role.  The manner in which they had provided services was engrained in handbooks—and shifting to new roles and procedures required a huge shift in what they were doing.

Yes, shift does happen! But never did we realize that it would take so much work to shift. As we further engulfed ourselves in developing the CCTP, we realized that this was going to be a process, not something that would happen overnight.

The new world of CCTP totally changed our work. A world that was once filled with 23 -page assessments, and all the makings of what is typically long term case management by community-based organizations (CBOs) was brought to a sudden halt. That model shifted into an intense short –term patient centered care coordination.  Clients became patients, partners became nurses and our assignments became tasks.

Shift is difficult and, for many of us, it has been laborious.  Along the way, we  have created a CCTP training module for Care Enhancement to assist staff in adjusting to their new roles.  We lovingly called the module CCTP 101, and even included a section about this “shift”.  We have found it essential to foster an environment in which over communication and input is maintained as a vital piece to our developing system. However, our old ways sneak up on us like those catchy songs that play in your head over and over again.  Nevertheless we are confident that we will adapt to this shift and soon enough we will be asking what was that song we kept singing?

key words: San Diego County, CCTP, care transitions, readmissions, frail elders

Klein describes CMS’ plan to end funding for a home health visit program developed by Pennsylvania’s Health Quality Partners. First developed as part of a demonstration created in the wake of the 1997 Balanced Budget Act, this little program has achieved great successes. An independent evaluation found that Partners, one of 15 in that demonstration project, reduced hospitalizations by one-third, and cut Medicare costs by one-fifth.

Despite that track record, CMS has notified Health Quality Partners that CMS funding will end in June. Over the years, it seems, CMS has learned something from the ongoing demonstration—but its attention has now turned to other projects, ones that it hopes will prove to be scalable, and in which it will invest tens of millions of dollars via the Center for Medicare and Medicaid Innovation (CMMI).

This seems—to Klein, to me, and to many people who commented on the article—a little counter-intuitive: If a new treatment or procedure had led to this kind of result, investors and patients would line up to support it and demand it.  But CMS appears to be stymied by good reports from one particular community about its own particular situation. To be sure, learning from the one gem in a demonstration program with more than a dozen that did not make the grade is difficult, perhaps more difficult to pull off than interpreting a clinical trial or testing an investigational new drug.

There are risks, to be sure, in assuming that what works in Doylestown, PA,  will be equally effective in St. Louis, Missouri, or in thinking that the concerns and solutions experienced in one community can be addressed by solutions devised by another. Communities are so varied in how they operate, and no one solution is likely to work for each.

Even so, many communities find that their frailest residents benefit from the kind of one-on-one attention to care that house calls can provide.  Each clinical service program must address real risks to effectiveness and efficiency—here, an obvious issue is how to target people for whom such a service is a necessity, one that helps them to remain independent and out of the hospital, rather than those for whom it would mostly be a convenience?  Also, how can incentives be structured so that profits are not a chief motivating factor—and so that costs are contained while care and outcomes improve? These issues require ongoing attention—from communities, from the health care industry, and from CMS, as they work to reshape  the health care industry to a framework that includes better care and services for the oldest among us.

As the country’s leaders and policymakers increasingly turn attention to the looming challenges created by aging Boomers, many look to individual communities and their successes.  In fact, it is likely that the solutions we need—and find—will hinge on what different communities are allowed to assemble: What each identifies as priorities, how each allocates resources, and where each turns its energies. Learning how other communities succeed at this hard work will be critical for others testing for inspiration and ideas. Dismantling a successful program—without even testing whether its principles can be adopted elsewhere or it can grow to scale–hardly seems to make sense.  Continuing to learn from it, and deliberately adapting it in ways that work elsewhere, seems to be a more responsible response. Throughout our history, we’ve turned to outliers to point the way—and inspire—others along the journey.

key words: home health care, house calls, CMS, coordinated care, frail elders

Dementia is a chronic disease of aging that robs people of cognitive function, leaving them unable to tend to even the most basic activities of living. But demented persons can live for many years, incurring long-term care bills that can leave surviving spouses impoverished and estates depleted.

In a study published recently in the New England Journal of Medicine, my colleagues and I reported that the total costs of paying for care for seniors with dementia in the United States are expected to more than double by 2040. Medicaid pays these costs for the poor, and some people have private insurance. But for large numbers of elderly Americans, dementia brings not only human suffering but financial ruin as well.

Designing and building a program to protect Americans from the cost of dementia care is a daunting and expensive task, one that probably cannot be accomplished without the help of the federal government. The federal government has broad experience in creating health safety nets and has been expressing concern over the state of the nation’s long-term care systems for some time now. If Congress and the administration need a reason to act, our numbers on costs can provide it.

Currently, some 15 percent of Americans 71 or older have dementia. That is about 3.8 million people; a large number to be sure, but one that will pale by comparison to the 9.1 million expected to be suffering from the disease by 2040.

Our report, The Monetary Costs of Dementia in the United States, estimated that in 2010 Americans spent $109 billion for dementia care purchased in the market place, like nursing home stays. Factoring in the costs of informal care—provided by family members or others outside of institutional settings—the total cost of caring for dementia patients grew to between $159 billion and $215 billion.

As the U.S. population ages in the coming decades, we can expect these costs to continue to escalate. Even if we assume that dementia’s prevalence stays at the current rate and the cost of care per person does not go up, our research showed that by 2040 total costs will have soared to between $379 billion and $511 billion as measured in today’s prices.

We estimated that the average cost per case in 2010 was between $41,000 and $56,000, but this average conceals a great deal of variation from family to family.  A large majority of Americans will not face large costs for dementia care. Many patients will have their care covered by Medicaid or private long-term care insurance, or their stays will be short and relatively affordable, or for some other reason they will avoid serious hardship.

Yet, a minority of families will face financially devastating costs because of very long nursing home stays.   This calls for an insurance-style solution, one in which the costs of long-term care could be spread across the entire population rather than being concentrated on the unlucky few.

Insurance companies are probably not going to step into the void because the costs associated with these extreme cases are quite uncertain.  But the federal government could take it on and, in fact, has crafted similar solutions in the past.

For example, in 2006, Medicare Part D was partly enacted to protect seniors from the high out-of-pocket costs of expensive medicines such as exotic perscription drugs for cancer and other diseases. The program was designed to help all seniors, but especially those with prescription drug bills large enough to impoverish them.

As recently as 2010, the federal government sought to create a long-term care safety net for the aging population.  The Community Living Assistance Services and Support Act, the CLASS Act, was enacted as part of President Obama’s health care reform package.  The CLASS Act was supposed to do something for seniors by setting up a self-funded and voluntary long-term care insurance program. But, last year, the administration determined that implementing the law would be too expensive and it was abandoned.

It is time for the government in partnership with industry to return to the drawing board to craft a plan that will provide protection for the more than 9 million people who will need care for dementia by 2040. Until it does, too many Americans will be forced to spend themselves into poverty.

Michael D. Hurd is a senior principal researcher at the RAND Corporation, where he directs the RAND Center for the Study of Aging.

This post originally appeared on April 30 on The Health Care Blog (http://thehealthcareblog.com/) and is posted here with permission.

key words:  health care costs, dementia, Alzheimer’s disease, frail elders

To be sure, disruptions in air travel disrupt people’s lives and, in some ways, impinge on their safety. But as the sequestration begins to take its toll on social services programs around the country, we all will start seeing its devastating effects on the lives, safety, and well-being of other groups: People less likely or able to speak up, speak out, and demand congressional responses.

As Huffington Post reports today, sequestration means that millions of Meals on Wheels meals will not be prepared or delivered—anywhere from 4 to 19 million, depending on who is making the estimate—nationwide. The article describes how one Meals on Wheels recipient, William McCormick, a resident of Roanoke, Virginia, is responding to news of cuts to the program on which he has relied since 2005: He has decided he can, somehow, get by on his own. Despite the fact that he lives with multiple chronic conditions, has no car, and lives on his own, he is convinced that he can somehow make do—which is more, he thinks, than others in his situation can manage. McCormick harkens to his own boyhood, when neighbors looked out for and helped neighbors who were down on their luck.

In years to come, we are likely to face this kind of dilemma more and more often. Our failure or inability to confront problems created by an aging society and a fragmented health care system mean that millions of us face a future in which we will rely on the kindness of our communities to keep us housed, clothed, and fed—and we have to be worried that neighborliness and charity will simply be insufficient.

We face so many problems—as individuals, and as a society. For the short-term (or short-sighted), it can sometimes just seem easier to focus on things that affect us directly: Don’t make ME late by delaying MY plane!  We really need to find ways to take a longer view—and one that is based on conscience and compassion. We cannot be a decent society and let frail older people go without food (or young children go without school, or any of the other social programs that are falling by the wayside).  Where are our priorities—and when will Congress hear them?

key words: sequestration, Meals on Wheels, Huffington Post, frail elders

Participants have an opportunity to hear from local communities that have been successful in improving healthcare through reducing hospital readmissions. The webinars feature communities from different initiatives— those that are led by Quality Improvement Organizations (QIOs), as well as those that are part of Aligning Forces For Quality, that have received state funding, Robert Woods Johnson awardees, CCTP awardees, Beacon communities, ACOs and more.

The sessions are held on the 2nd and 4th Thursdays of the month.  A full schedule is  posted at: http://www.cfmc.org/integratingcare/learning_sessions.htm

If you are interested in participating, follow the steps below.
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Call Information

Shining Stars: Healthy Columbia Campaign – South Carolina – ReThink Health Community funded by the Fannie E. Ripple Foundation  
Presented by:
Kate Hilton, JD, MTS, Director, ReThink Health
Richard Foster, MD, Senior Vice President for Quality & Patient Safety, South Carolina Hospital Association

Event: Care Transitions Learning Session webinar
Date:  April 25, 2013
Time:  3:00 PM – 4:00 PM ET

Teleconference: 866-639-0744  (No pass code needed)
https://qualitynet.webex.com
Meeting Password: community

Please join us 15 minutes prior to the presentation to ensure the automatic system set-up has been properly established.

Attendee Instructions:

1) Click or Copy and Paste this to your web browser:  https://qualitynet.webex.com
2) Locate the event you wish to join
3) Click on Join Now (located to the right of the event title)
4) Enter your name and email address as prompted
5) Enter the password: community
6) Dial in to the teleconference. The number is 866-639-0744 or 678-302-3564. The access code is none.

If you have any questions or problems accessing the meeting, please call the Buccaneer WebEx Helpline at 540-347-7400 x390

Presentation slides will be posted prior to the call at http://www.cfmc.org/integratingcare/learning_sessions.htm .

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These calls are open to all, please invite anyone who wants to learn along with us.  As a reminder, these sessions are recorded and all previous Learning Sessions are available at:

http://www.cfmc.org/integratingcare/learning_sessions.htm

key words: QIOs, CFMC, care transitions, community coalition, CCTP, CMS

Every Community-based Care Transitions Program (CCTP) in the country (of which there are now 102, funded by the U.S. Centers for Medicare and Medicaid [CMS]) aims to balance targeted, evidence-based interventions to patient needs. CCTP teams know that every avoidable readmission has a story behind it. The Area Agency on Aging 1-B (AAA 1-B), seeks to meet care transitions needs for elders in two of their counties, Oakland and Macomb, with an innovative multilayer strategy.

CMS directed communities applying to participate in the CCTP to conduct a root-cause analysis, so that they could build a CCTP that meets community needs. The AAA 1-B found that it could deliver the highest priority services by dividing the population based on five clinical needs:

1.Care Transitions Intervention (CTI) Coaching: Following the self-activation model developed by Dr. Eric Coleman, this strategy empowers participants with coaching that helps them find the strategies that enable the patient to take charge of recovery and achieve personal goals. Through increased health literacy and greater confidence, individuals with chronic conditions are better able to make decisions about their care and recovery, and insist that clinicians provide appropriate help.

2.CTI Coaching with Behavioral Intervention: Many patients experience mental health issues such as depression, anxiety, and serious mental illnesses, which contribute to frequent readmissions. In this strategy, a behavioral health coach works with patients to provide support and mitigate some of the problems that can hinder recovery.

3.CTI Coaching with In-Home Services: This strategy provides coaching and referrals to in-home services, such as meal delivery or transportation to the doctor, which help reduce risk of readmission.

4.Coaching with Multiple Interventions & Hospice: Coaches connect with patients who have little family support and who do not want home care or hospice, and try to reconnect them with supportive services and initiate longer-term care planning.

5.Skilled Nursing Facility (SNF) Transitions Coaching: Skilled nursing facilities in the area had especially high readmission rates, so this strategy provides coaching for better transitions from the hospital to the SNF and from SNF to home. Coaches meet with participants and their caregivers before hospital discharge, again shortly after nursing home admission, and then shortly before discharge from the SNF. In addition, the coach also discusses differences between the nursing home and hospital, how to pursue personal goals, and how to find help to achieve these goals at the nursing home. The coach also works with the participant and caregiver to complete the personal health record modified for the SNF and encourages them to participate in the care plan meeting. The coach also engages hospital and nursing facility partners to increase communication and improve shared processes.

Tailoring these strategies to the five distinctive categories of patients allows AAA 1-B to provide high-value transitions coaching to virtually everyone. “Many of the coaches say people have been dealing with chronic conditions so long and no one has asked them their opinion on their plan of care,” says Barbra Link, director of care transitions for AAA 1-B, “Coaches help them to get tools to self-activate. That’s the most powerful thing. That’s the foundation of the program.”

Participants in the program must be referred from AAA 1-B’s partner hospitals, have traditional Medicare, and either have one of the targeted conditions (chronic obstructive pulmonary disease, heart attack, pneumonia, or congestive heart failure) or, any condition with a readmission within the last 90 days.

The AAA 1-B Care Transitions Coach assigns each beneficiary to a category using a risk assessment completed by the hospital’s care management team. The program also allows Strategy #1 Coaches to refer the participant to a Specialty Coach (Strategy 2, Strategy 4, and Strategy 5) when appropriate. All coaches provide Strategy 1 and Strategy 3 Coaching but may consult with Specialty Coaches whenever needed.

The AAA 1-B project is about 10 months into its initial two years, with the possibility of renewal for the following three years. All five strategies are operating, and 650 beneficiaries have enrolled. Although the first strategy has the highest volume of people (67 percent), the other strategies are proving to be just as important for elders who need more support.

The CCTP team quickly recognized that project leaders and staff must watch for problems that call for different remedies. For example, when AAA 1-B leaders observed that many of the program’s vulnerable elders did not understand their nutrition needs, they reached out to a nutritionist at a partner hospital to develop simple, accessible, one-page flyers for patients regarding nutrition. One flyer explained how to cut back on dietary sodium and how to calculate sodium intake from a nutrition facts label. Through close interactions with the patients, coaches were able to identify and respond to specific nutritional problems that would not have otherwise been apparent.

In its CCTP, AAA 1-B has a coalition with three local hospitals that had some of the highest readmissions rates in the state. Creating these coalitions, while ultimately quite beneficial, did present some initial challenges. Before implementing the program, AAA 1-B leaders had to help all stakeholders understand the benefits of the program. Once this had been done, referrals from the hospitals took a major upswing.

According to Barbra Link, “We found that each hospital is unique, and lots of relationship-building was required. Once we established greater trust and better understood the system, things seemed to go well.” The future of this program involves moving toward a larger community-based coalition with more community organizations. Link explains, “We are trying to move into becoming a learning network. Our focus will be information exchange and growing as a coalition. Now that the program is up and running, we can work on this over the next year.”

AAA 1-B also collaborates with other CCTP organizations nationwide. Through regional and national phone calls and virtual learning sessions, they share best practices and solve problems together. In this way, AAA 1-B is spreading its innovative multilayer approach to reducing hospital readmissions and empowering patients.

This article originally ran on the Altarum Institute Health Policy Forum on April 18, 2013.

key words: care transitions, CCTP, community-based, Area Agency on Aging

Call Ezekiel (“Zeke”) Emanuel an optimist. Currently serving as Vice Provost and professor of bioethics and health policy at the University of Pennsylvania, much of his career has been about bucking mainstream medical thinking.  These days, Emanuel is using his background in medicine and ethics to lead conversations among health care policymakers and stakeholders in directions they must take: the impact of multiple, simultaneous delivery system reforms on costs.

“Keep an eye on 2020,” Emanuel told a crowd gathered by  Disruptive Women in Health Care (http://www.disruptivewomen.net)  at a March  briefing in Washington, D.C.  It will take that long, Emanuel suggests, to determine whether costs will begin to drop on a sustained basis.

Although critics continue to pound against the Affordable Care Act ceaselessly, Emanuel said, health care reform law is only now starting to unfurl its sails. To assign the law a grade at this point is “far too early. We’re not even close to the midterm yet.” But by 2016, state exchanges will be up and running, and other game-changing developments are likely to be on the horizon, including the possibility of “interoperable health records” created by “two young kids in a garage somewhere.”

By the end of the decade, “we’ll have better quality measures,” Emanuel continued, and “lower rates of infection in hospitals.” Such developments can help the U.S. health care system “get off fee-for-service” medicine, and chart a course toward other delivery system reforms and payment reforms. Whether these are Accountable Care Organizations, bundled payments, or global capitation — “whatever mix is fine,” he said. At the same time, Emanuel acknowledged that success “won’t happen overnight,” and “a lot of different payment models” will need to be tried.

“The problem is that fee-for-service and delivery system changes do not line up,” Emanuel said.  For example, marketing and advertising for costly procedures and treatments influence patient decision making.  More important, he observed, health care providers, many of whom are not primarily focused on delivering the best possible care for the most efficient price, follow entrenched patterns of practice. The result is that “rising [health care] costs are threatening wage growth and all of the other things we human beings care about.”

Despite the large challenges inherent in bending the health care cost growth curve, Emanuel does not advocate abandoning U.S. social insurance programs. Instead, he advocates serial systemic reforms.  For example, he notes that although “we don’t have a good alternative to peer review” (which some critics call a bottleneck to rapid reform) he believes it is feasible and imperative to develop new protocols for more rapid testing and dissemination of pilots, demonstrations, and other types of initiatives. “We need a frame shift to look at multiple factors at the same time,” he said. “We need to evaluate differently – with different standards and perhaps larger numbers.”

It is within this broader measurement context that Zeke Emanuel believes transparency will be an essential driver of change. “Doctors are highly competitive,” Emanuel told the crowd of Disruptive Women. “They are trained to want to be number one.” The current dilemma, he says, is that “the driven nature [inherent in] training physicians goes out the window when they start practicing.” But as quality measures increasingly become public, spotlighting how good processes of care and delivery are, along with patient outcomes and patient experience, “the big push for change” will come from providers, he predicted.

Emanuel also acknowledged that the quest to coordinate services and drive down costs must involve and engage individual patients. “Right now [patients] are not focused on costs,” he said. “They are not going through websites” to compare the costs of various procedures and treatments.  But if metrics of cost and quality can be “arrayed in a simple way” and if a “selection among them” can be developed to include price, this could help to drive costs “to a more reasonable level,” he said.  To that end, Emanuel is currently writing a concept paper on shared savings that discusses the possibility of sharing savings not only between health care providers, but also with patients.  If there is a choice between treatments that are clinically equivalent,” he reasoned, “why shouldn’t patients get part of the savings?”

Why not indeed?

Anne Montgomery is a Senior Policy Analyst for the Center for Elder Care and Advanced Illness at Altarum Institute.