Hear Dr. Joanne Lynn Discuss Care Transitions

 Posted by on April 2, 2013  No Responses »  Tagged with: , , , , , , , , ,
Apr 022013
 
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A Thursday webinar cosponsored by Illuminage.com will feature Dr. Joanne Lynn discussing care transitions. Each year, thousands of older patients are discharged from the hospital, only to be later re-admitted. Avoiding preventable rehospitalizations has become a major cost-savings goal for our health care system. IlluminAge, in partnership with the National Council on Aging, has scheduled an online briefing to examine how older patients can play a larger role in the effort to reduce the frequency of hospital readmissions.

You are invited to join the webinar on Thursday, April 4, beginning at 1:30 p.m. Eastern time: Improving Care Transitions: Engaging Older Patients on the Issue of Preventing Rehospitalization.

Joining us as presenter will be Joanne Lynn, M.D., chair of the Center on Elder Care and Advanced Illness at the Altarum Institute. Dr. Lynn, a geriatrician, quality improvement advisor, and policy advocate, is a member of the Institute of Medicine and the National Academy of Social Insurance, a fellow of the American Geriatrics Society and The Hastings Center, and a master of the American College of Physicians.

The webinar aims to provide a fresh perspective on the increasingly important challenge of reducing hospital re-admissions, including:

  • The importance of educating and empowering older patients and caregivers;
  • The role senior care and aging service professionals can play in providing needed support services and other resources to older persons returning home following a hospital stay;
  • Resources you may find helpful in your own community, practice, or organization.

The April 4 webinar is free, with registration on a first come, first served basis.

To register, follow this link:  https://www1.gotomeeting.com/register/581843281

 

Key words:  Joanne Lynn, care transitions, quality improvement, patient activation

JAMA Report Finds Community Collaboration Key to Reducing Hospitalizations and Rehospitalizations

 Posted by on January 23, 2013  1 Response »  Tagged with: , , , , , , , , , , ,
Jan 232013
 
Portrait of Dr. Joanne Lynn

By Dr. Joanne Lynn

The latest issue of JAMA features our paper describing   an exciting and successful initiative from the Centers for Medicare and Medicaid Services (CMS) and fourteen of its quality improvement organizations (QIOs).  Grounded in quality improvement methodology—plan-do-study-act–this unusual project offers many insights for those aiming to reduce avoidable readmissions.  And its raises a number of important question about how we measure progress in reducing readmissions. (For more on that topic, see our earlier MediCaring blog, http://medicaring.org/2013/01/07/readmissions-count-should-cms-revise-its-calculations/ )

A Medicare patient’s ability to receive successful treatment during care transitions from one setting to another has a crucial effect on the overall cost and efficiency of the Medicare system. Errors in information transfer, care planning or community support can cause hospitalizations, rehospitalizations and unnecessary costs to the Medicare program.

This project involved a three-year, community-based effort to improve the care transition process for fee-for-service Medicare beneficiaries. Participating QIOs facilitated cooperation among providers, health care facilities, and social services programs, such as Area Agencies on Aging. They centered their efforts around each community’s unique needs.   QIOs worked with communities to understand their own particular causes of readmissions, and to implement appropriate, evidence-based models to address them.  Communities analyzed results of the intervention along the way, and changed course to stick with interventions most likely to work.

The results, when compared to 50 comparison communities, showed significant reductions in hospitalizations and rehospitalizations, both by an almost 6% average, saving Medicare $3 million in hospitalization costs per average community per year.

This correlation has already led to new national efforts such as Partnership for Patients and the Community-based Care Transitions Program. In addition, in the 10th Scope of Work, all 53 QIOs are leading community projects nationwide (so far, in more than 400 communities).

This paper may be the first time one of America’s leading medical journals has published a report based on QI methods. Doing so represents a profound change in the openness of American medicine to learn not only what works for a patient, but works for the delivery system, too.

To learn more about this complex project, you can visit www.altarum.org/QIOpaper , a special website developed by Altarum Institute, in cooperation with the Colorado Foundation for Medical Care (CFMC), which led the work. The site features background material, links to print and online materials from JAMA (including control charts from the 14 communities), a top-ten list, a clever infographic, and videos of the lead authors discussing major findings and lessons learned.

key words: quality improvement, care transitions, CMS, CFMC, Joanne Lynn, readmissions, community coalitions, JAMA

End of the Improvement Standard: An overview of Jimmo vs. Sebelius

 Posted by on December 18, 2012  No Responses »  Tagged with: , , ,
Dec 182012
 

For years, physicians and insurers have applied the so-called “improvement standard” for care rendered to Medicare beneficiaires, insisting that if the patient was not improving, he or she was ineligible for benefits. Taking on what she calls that “intractable myth”, Judith Stein, Executive Director of the Center for Medicare Advocacy, led a team that filed a class-action suit, whose plaintiffs included 5 individuals and 6 organizations. For years, Stein said, the Center had responded to individual requests for help appealing such decisions, but had been unsuccessful in its efforts to negotiate the issue with represenatives from the Centers for Medicare and Medicaid Services (CMS). The group concluded that the only way to achieve “systemic change” was to take the issue to court. On October 16, 2012, a settlement in principle was reached. According to the Center’s Litigation Director, Gil Deford, the government claimed that there was no such thing as the improvement standard and, had there been, it would not have been enforced.

The settlement is designed to ensure that denials based on the improvement standard will end. Beneficiaries can receive skilled, covered services, even if they have “plateaued” or if the services are for “maintenance only.”

To make this information more widely known and understood, CMS will revise its Medicare Beneficiary Policy Manual for skilled nursing, home health, and outpatient therapies. The current version is ambiguous, says Deford. Attorneys for the plaintiffs will review CMS’ proposed revisions, and a final version will be released. Deford estimates that this process will take about six months. CMS will then launch an educational campaign that will include updates on its website, national phone calls with stakeholders, open door forums, and materials and training.

In the meantime, any claims dating from 1-18-11 that have been denied because of the improvement standard can request a review of that denial. The Center for Medicare Advocacy has developed self-help packets that can be downloaded from its website at http://www.medicareadvocacy.org/. Margaret Murhphy, associate director of the Center, told participants in a webinar last week that if claims are denied because of the improvement standard, they should, “appeal, appeal, appeal!” There are strict time limits in which appeals must be made–but the appeals process is launched with just a phone call.  The Center is trying to spread the word: Jimmo can help people now. And it applies to anyone who needs skilled care.

 

key words:  Jimmo, improvement standard, Medicare beneficiaries, Center for Medicare Advocacy

New CMS Physician Payment Rule includes Codes for Post-Discharge Care Coordination

 Posted by on November 15, 2012  No Responses »  Tagged with: , , ,
Nov 152012
 

New Medicare Codes: I Want to Believe

From the Hartford Foundation’s Chris Langston comes a post about the final rule for 2013 Medicare Physician Fee Schedule–including codes for post-hospital discharge care. Originally appeared November 13 at http://www.jhartfound.org/blog/new-medicare-codes-i-want-to-believe/#more-6021

I’ve been hearing rumors that something big was coming but it sounded too incredible, too wonderful, and too good to be true, so I figured it wasn’t. Seems like I was wrong.

In the past few weeks, the Centers for Medicare and Medicaid Services (CMS) has issued its final rule for the 2013 Medicare Physician Fee Schedule. Nestled between pages 279 and 335 of this document are two new Current Procedural Terminology (CPT) codes (99495 and 99496) which are intended to pay physicians (and qualified non-physician providers like NPs and PAs) for post-hospital discharge care coordination provided to their Medicare beneficiary patients.

Sounds pretty good, as does the list of services that are supposed to be provided to Medicare beneficiaries under these codes:

  • Communication with the patient and/or caregiver within two business days of discharge (phone, e-mail, whatever
  • Non-face-to-face services provided by practice staff may include:
    • communication with home health or other community services used by patients
    • patient/family caregiver education to support self-management
    • assessment and support for treatment adherence and medication management
    • identification and facilitating access to available community and health resources
  • Non-face-to-face services provided by physician or other qualified provider may include:
    • review of discharge information
    • review and follow-up on diagnostic tests and treatments
    • interacting with other health professionals (specialists?) assuming or resuming care of “system specific problems”
    • education of patient/caregiver
    • referrals and arranging for needed community services
    • assistance in scheduling any required follow-up with providers or services
  • Medical decision making (equivalent to a usual evaluation and management visit)
  • A face-to-face visit (office or home) within 14 or 7 calendar days of discharge (while the visit may be done anywhere, people discharged to nursing facilities are not eligible for this benefit :-(  )

 

For these services, a provider stands to get paid $163.88 or $230.86, depending on the complexity of the medical decision making (E&M 3 or 4) and how quickly there is a face-to-face visit (less than 14 days or less than 7 days). That’s good money considering a regular Medicare office visit is around $45, but there is certainly a lot of work involved.

CMS is expecting 2.17 million claims under these codes for total payments of $600 million. Unfortunately, I am reminded of the Annual Wellness Visit (see new for 2011) which also looked like a great new benefit to Medicare patients (and even had no co-pay), but does not seem to be taken up by providers or patients, such that only 7 percent of those eligible had one in 2011. We shall see.

A couple of features of the fee schedule and discussion I thought were very notable: It is clear that CMS expects much of this work will be done by non-physician practice staff. The practice expense component of the work is big and meant to support 70 minutes of RN/LPN time for non-face-to-face activities (see page 324). And the beneficiary co-pay is quite substantial.

Despite some comments suggesting that CMS call these services “preventative” and therefore not subject to co-pays or deductibles, CMS balked. In fact, one reason that the face-to-face encounter with the physician provider was baked into the service package was the hope that it would make the co-pay fee less of a surprise to patients. And finally, the rumors were wrong about one thing—any physician can make use of this benefit; it is not limited to primary care providers (see page 309). The first provider to see the patient and submit a bill will “win” the payment.

So what does it mean? Will we see a reduction in readmissions? Will primary care become a more attractive career? I have to admit that I really don’t know. Despite more than 50 pages of discussion of this new benefit in the final rule and many, many comments, I haven’t seen any comparison between this benefit and the cooperative agreement for post-discharge care coordination offered under ACA section 3026, the Community-Based Care Transitions Program. That program requires community agencies in formal partnership with hospitals to propose an evidence-based model of care such as Eric Coleman’s Care Transition Intervention and negotiates fees with agencies between $250 and $500 per eligible discharge (or so I hear, these “cooperative agreements” are not as public as the physician fee schedule).

Will primary care offices know what to do to coordinate care? Will this payment provide sufficient incentive for practices to do the extra work it takes to prevent hospitalizations? Hire the extra staff? The AAFP, AMA, AGS, and others who advocated for this new benefit think so, but I have my doubts.

For one thing, the primary care stakeholders are quite vehement that they ALREADY provide these services and have just been cheated out of their rightful pay. If so, we shouldn’t expect any different outcomes for patients, just financial ones for providers—not a bad thing, but not enough in my opinion.

In accepting these new CPT codes, CMS has clarified at least three issues in the care of older Americans. First, it plants another giant flag on the issue of readmissions and throws the ball back into the provider court. Medicare beneficiaries have high rates of 30-day rehospitalization, much of which seems preventable with more vigorous efforts at discharge follow-up and coordination of care. As Eric Coleman and others have shown, some fairly simple interventions can reduce 30-day readmissions and improve outcomes for older adults. So one could say that CMS wagering this $600 million against a potential reduction in the $17 billion spent on hospital readmissions is a pretty good bet, even if the odds aren’t that good.

Second, primary care providers have long argued that conventional fee-for-service payment rates do not cover their real expenditures of time and effort to coordinate care for their complex patients. After many years of repeating that payments for evaluation and management do include substantial support for non-face to face services, CMS has reversed itself, and in a big way. These new codes and payments are a powerful precedent and will have more consequences down the line.

And last, but not least, CMS continues to find ways to bring additional revenue to primary care providers, perhaps to encourage them to provide more or better services, but for sure to increase their practice revenue and make primary care a more viable enterprise. This new payment comes on top of innovations such as medical homes with per person/per month fees, the 10 percent bonus primary care incentive payments, and “shared savings” vehicles such as Accountable Care Organizations. Assuming that a primary care physician has 3,000 patients in reasonably regular care, 20 percent (n=600) of whom are Medicare beneficiaries of whom 20 percent might have a hospitalization in a given year, the revenue from 99495 and 99496 (given the 70-30 split in usage CMS expects) would be $21,972. A lot of that income will go directly out in new staff costs (in my view), but I’m sure some will stick.

I want to believe.

 

key words: public policy, Medicare, physician fee schedule

Response to Howard Gleckman’s article in Forbes Online: Long-Term Care a Forgotten Issue in the Presidential Campaign

 Posted by on October 25, 2012  No Responses »  Tagged with: , , ,
Oct 252012
 

by Judith Peres, LCSW

Howard Gleckman in Forbes online (http://www.forbes.com/sites/howardgleckman/2012/10/24/long-term-care-a-forgotten-issue-in-the-presidential-campaign/) rightly states that long-term care and the needs of citizens with serious chronic conditions and functional limitations are not part of our current Presidential debate.

There are an estimated 10 million Americans with long-term care needs. The amount and quality of long-term care/palliative care/hospice received through their illness trajectories varies tremendously, as do their unmet needs near the end of life.  Studies consistently demonstrate that patients with advanced illness and functional decline experience untreated pain and other symptoms; lengthy hospitalizations involving unwanted, often low-yield and costly medical treatments; and low overall family satisfaction.

The current national dialogue about the need to reform the health care “system” includes recognition that the population is aging, a changing trajectory of illness for Medicare beneficiaries, advancements in high-tech life support systems, limitations in health care resources and issues surrounding patient autonomy and the right to a dignified death. However, for the most part, the development of the new chronic condition models tend to overmedicalize the services delivered and do not acknowledge the knowledge base developed over three decades of  long-term care and palliative care research on how to manage this population.

Recent studies suggest that medical care for patients with serious illness is characterized by inadequately treated physical distress; fragmented care systems; poor communication between doctors, patients, and families; and enormous strains on family caregiver and support systems.  Although most of the years after age 65 are a time of good health, independence, and integration of a life’s work and experience, eventually, most adults will develop one or more chronic illnesses with which they will live for years before death.  These years are characterized by physical and psychological symptom distress; progressive functional dependence and frailty; and high family support needs.

What, exactly, do we need? More than anything, we need programs that support family caregivers, those individuals who provide an estimated $450 billion dollars worth of care for older adults. We need hospice-like wraparound services that would help people from the time they are seriously ill or disabled, and that offer home care services, respite for our caregivers, and supports for what we can no longer manage or cope with on our own. We need social structures and public policies that support families as they live through years in which they simply cannot piece it together on their own.

As a country, we’ve done a remarkable job of creating a health care system that does well at treating acute problems and curing much of what ails us. But that system, with all its fragmentation and problems, is simply not one that is going to be able to serve our aging population. At Altarum Institute Center for Elder Care and Advanced Illness, we believe that doing so will require fundamental changes in how we see and care for these individuals–and that it will require sweeping changes in how we organize and manage that care. It will require a real blending of social supports and medical services. It will require comprehensive care plans, and an array of services ranging from transportation to home health to hospice. It will require local levels of management, with the authority to channel resources to meet locally identified needs and priorities. It will, indeed, take the whole village to solve this problem.

 

key words:  presidential election, Medicare, older adults, public policy

Getting There From Here: CMS Advises Potential CCTP Applicants on What It Takes to Win

 Posted by on July 16, 2012  No Responses »  Tagged with: , , , , , , ,
Jul 162012
 
cms_partnership_for_patients

Eager to apply for Community-Based Care Transitions Program (CCTP) funds from the Centers for Medicare and Medicaid (CMS)? CMS is equally eager to make awards. Aiming to encourage organizations to apply to the final round of the CCTP funding, CMS sponsored a 90-minute webinar that featured tips from program administrators on how to write a winning application, along with insights from communities that have recently been funded. The webinar offered just about everything applicants need to know to be successful.  It highlighted insights on what to do—and what to avoid—as you pull together a team and submit your application.

CMS Chief Medical Officer Paul McGann, MD, introduced the session by stating that, in terms of the Partnership for Patients (PFP), the 3026 program is critical to helping CMS achieve its goals to improve patient safety while reducing costs. He noted that the program is the first-time ever that communities have been invited to define and price a Medicare benefit. The program represents an opportunity for organizations coordinate and collaborate to deliver services that help residents experience better health outcomes. It is, he said, “a new way of reaching out.” The webinar represented CMS’ effort to push out as much information as it can so that organizations can successfully apply to become CCTP communities. A final round of funding decisions will be made in late September. To be considered, applications must be received no later than close of business on September 3, 2012.

Details about application requirements and parameters can be found on the CMS Innovations website at http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/index.html. In addition to providing an overview of the program, the site includes links to the RFP, the application package, and the budget worksheet. In general, to be eligible, programs must represent a partnership between an acute care hospital and a community-based organization; if it is the anchoring organization, the acute care hospital must be on CMS’ list of high readmit hospitals. Otherwise, it need not be. CBOs must provide care transitions services. They must have a governing board that includes consumer representation, they must be non-profits, they must be located in the community they aim to serve, and they must have previous experience in care transitions work. Closed systems—those in which, for example, a hospital and a home care agency are part of the same organization—are not eligible to apply. Preference is given to applications that include organizations supported by the Administration for Community Living (ACL, formerly the Administration on Aging), and that serve medically underserved and rural areas.

Successful applicants from around the country talked about various aspects of their applications and their work. These groups included P2 collaborative from Western New York, Carondolet in Arizona, Age Options in Illinois, and Delaware County, Pennsylvania. Potential applicants would do well to read the one-page summaries written by each of these sites and posted at:  http://www.innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP/partners.html . In the coming weeks, MediCaring aims to interview staff at each of these sites to learn more about what made their applications stand out, and what they plan to do in the coming years.

Ashley Ridlon of CMS described some of the lessons learned by organizations that have already successfully applied to the program. These organizations have found that a number of factors contribute to readmission, including those on the individual level, as well as those on a systems level. Individual problems include poor patient-provider interactions, medication mismanagement, and avoidable returns to the emergency department. Systems-level problems include the absence of standardized forms and processes, poor cross-setting communication, and a failure to “activate” patients—to ensure that they are engaged and informed partners in their care. The root cause analysis required by the CCTP application process is designed to help communities uncover their own problems and gaps in care transitions, and to consider and implement relevant interventions. This process is at the heart of a successful CCTP application. Ridlon emphasized that applicants must conduct “community-specific root cause analyses,” and develop an implementation plan that is in line with those findings. She also noted that those plans need to align with other care transitions activities currently available in a community. In addition, relevant, documented experience providing care transitions services is essential to writing a successful application. In describing that experience, CMS urged applicants to be explicit with details, describing not only reductions in readmissions, but methodology, evaluation, characteristics of patients enrolled (or not enrolled), and outcomes. They should also describe in detail any care transitions training their staff have received—who participated, when and where, and how others will be trained.

Ridlon urged participants to engage their CMS Regional Quality Improvement Organizations (QIOs), an invaluable resource. QIOs can help applicants to conduct their root cause analyses, collect data, identify partners, arrange meetings, and select interventions.

Juliana Tiongson, also of CMS, described issues surrounding the budget process. It is essential that applicants read and understand what the RFP calls for. To some extent, the program can be defined, budget-wise, by what it is not: It will not pay for services already required by Medicare’s conditions of participation. It is not a grant program. It will not pay for activities that are not directly related to providing services to beneficiaries. It will not support ongoing care management or disease management. Many applicants, Tiongson said, have completed the required budget worksheet, but fail to complete the equally important budget narrative, outlining at length exactly what is to be covered by the program’s blended rate. She also noted—and this is critical—that that rate is not likely to be competitive if the blended per-person rate is over $400.

The blended rate is not a set figure. It will vary by community and by intervention. Patient volume and expected reductions in savings will also affect the blended rate.

Tiongson listed a series of pitfalls about which applicants should be wary. These include:

  • Partnering with an ineligible CBO, or being unclear about the CBO’s structure. Problems include not identifying board members, not including consumers on the board, failing to complete audit forms, or being part of a closed system.
  • Failing to conduct a community-specific root cause analysis.
  • Completing the root cause analysis, but failing to describe the methodology behind it.
  • Failing to link the root cause analysis findings directly to the selected care transitions intervention.
  • Not having all required signatures on all required letters of commitment.
  • Not including the budget narrative along with the budget worksheet.
  • Providing insufficient detail on everything from the budget to staff training.
  • Being overly broad or subjective about the target population.
  • Not describing the readmission risk assessment tool.
  • Proposing hybrid intervention models that have not been tested, or using bits and pieces of various interventions to come up with something new and untested.
  • Being fuzzy about the nature of relationships, and being unclear about how fees will be shared among the partnership.
  • Not listing board members and not including consumers on those boards.
  • Being too slow to get started—at the very most, organizations should take three months to hit the ground running. More than that is too slow for CMS’ purposes.

In terms of the budget itself, Tiongson noted several errors that applicants have made, including:

  • Using a per member per month rate, rather than a per eligible discharge
  • Failing to include the budget narrative
  • Basing the rate on 100% participation of the target population
  • Making unreasonable assumptions about the number of admissions avoided, which inflates the savings estimates (CMS recommends assuming a 20% reduction over two years as a reasonable expectation)
  • Building the budget as a grant application, rather than as a per-eligible-discharge fee
  • Offering providers financial incentives to participate.

In closing, Ridlon and Tiongson suggested that applicants reflect on the following points as they develop their applications:

  • Focus on implementing an effective intervention closely tied to the findings of the community-specific root cause analysis
  • Consider collaborating with other payers, including the private sector, Medicaid, and Medicare Advantage programs
  • Build strategic partnerships in communities to bridge gaps, and encourage members to share resources and learn from one another.

For a sample partnership agreement, follow this link: https://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/Downloads/CCTP_Program_Agreement.pdf. To view the entire slide deck, visit the July 12 blog posting on MediCaring.org, which links to the PDF.

To find the QIO for your region, go to: http://www.cfmc.org/integratingcare and click on Contact Us.  For questions, email [email protected]

And be sure to follow Medicaring—like us on Facebook, follow us @medicaring, and join us on the blog.

 

Key words: CMS, CCTP, Section 3026, care transitions, applications, strategic planning, program implementation, budget, QIO, CFMC

 

CMS Offers Tips and Pitfalls for CCTP Applications

 Posted by on July 12, 2012  No Responses »  Tagged with: , , , , , ,
Jul 122012
 

In today’s CMS phone call and webinar, CMS officials offered tips and pitfalls that applicants for CCTP funding should keep in mind. You can find those by scrolling through the slides from today’s webinar. And Medicaring will post more information early next week, detailing what we heard in the call–and what we learned.

 

Note one correction to the slides: Do NOT use the $9600 average cost of readmission as the baseline for calculating your blended rate. It is only to be used to project savings.

 

everything_you_wanted_to_know_to_apply_to_the_cctpfinal_slides

 

 

Key words: CCTP, CMS, Section 3026, root cause analysis, tips, applications

CMS Introduces 7 CCTP Sites in a National Call Focused on How to Propose a Winning Application

 Posted by on November 30, 2011  No Responses »  Tagged with: , , , , , , , ,
Nov 302011
 

In a national conference call with the first 7 sites to be awarded CCTP funding, representatives from each pointed to common elements that characterized their winning applications. (For details about each of the selected sites, go to www.cms.gov and search for CCTP; that will lead you to  project summaries and a complete list of recipients.) In addition, CMS has posted a new advisory for potential applicants at: http://www.cms.gov/DemoProjectsEvalRpts/downloads/CCTP_FactSheet.pdf

During the call, each site described programs  rooted in the development of a broad-based community coalition with experience in working on improving care transitions, and in the development and implementation of interventions closely linked to results of the root cause analysis.  Each described previous experience in working to improve care transitions, often through pilot projects and demonstrations, and extensive community-based involvement in the efforts. Each group described programs that work across multiple hospitals and health care systems, reaching a broad area of diverse populations, in most cases, spanning several counties or towns.

Dr. Paul McGann noted the importance of the CCTP program in fostering relationships, linking community-based organizations to the broader health care system. He said, “The current health care system makes it hard to do the right thing for patients. These care transition projects are the start of healing the health care system, of making it easy to do the right thing for patients.”

For the call, a representative from each site briefly highlighted some aspect of its application or proposed program; their overviews are summarized below.

The Southern Maine Agency on Aging/Aging and Disability Resource Center, described its work to closely tie results of its root cause analysis to the interventions it proposed.

The Atlanta Community-Based Care Transitions Program focused on its work to establish a community coalition and develop partnerships, pointing to its work to develop a program anchored by three sets of partners: six carefully chosen hospitals, the Georgia QIO, and community-based organizations. Atlanta noted that when it began the application process, it did not immediately seek out hospital CEOs, but rather relied on existing relationships with hospital staff, who then “took it up the ladder,” until CEOs were on board and invested.

Elder Services of the Merimack Valley, which serves areas  in New Hampshire and Massachusetts focused on its work to conduct root cause analysis (RCA) linked to a targeted intervention. Its analysis, which included focus groups with people from across the continuum, pointed to seven factors that impede good transitions. It then matched its intervention to the problems the RCA uncovered.

The Southwest Ohio  Care Transitions Collaborative explained how it selected its target population of high risk patients, who they define as Medicare fee-for-service beneficiaries with one of three common diagnoses: heart failure, heart attack, or pneumonia. Using data from a pilot program, the team identified common conditions and patient factors (e.g., whether they were coming from home, hospital, or SNF).

The Area Agency on Aging, Region One, serving Maricopa County, AZ, focused on its previous work with care transitions, and lessons it had learned in the course of conducting pilot projects. Based on this work, the team found strengths and weaknesses in its approach, and therefore altered published interventions to match particular community needs.

The Council for Jewish Elderly, based in Chicago, described the structure of its organization, and how it met the application’s eligibility criteria. In particular, the team walked through specific details of its long history in the community, providing a tradition of  “community-focused and patient-centered care.” In its application, it walked through specific elements of its forty-year history in the community. It built a team that included hospitals that had demonstrated their commitment to the issue, primarily through their use of Project BOOST or Project RED.

Finally, the Akron,/Canton Area Agency on Aging  described its previous experience in improving care transitions. In a pilot program with hospitals, the team had already demonstrated success in reducing readmissions; the issue it faced was in the sustainability of that program.  The group’s intervention features an interdisciplinary team that meets to propose solutions to complex, difficult cases.

The call concluded with a quick wrap-up by Juliana Tiongson, the CMS staff member who leads the program who reminded potential applicants to focus on several elements in their applications, and noted that CMS has a strong preference for applications that indicate the involvement of multiple hospitals and their community, led by an eligible community-based organization (CBO). Applicants should focus on their previous experience in care transitions work, take care with their root cause analysis, and evidence consumer involvement on boards. Finally, applicants should know that their programs need not be limited by patient diagnosis; rather, interventions should clearly be tied to community patterns and needs. She also noted that there was preference for applications that include multi-hospitals and CBOs in the coalition, and that single hospital sites would likely be limited to those serving very rural communities.

The presentation did not deal with the many questions on setting the blended rate, except to say again that this is not a grant program and that indirect costs and training and start-up costs should not be included. The application process is ongoing, and CMS regularly convenes panels to review applicants as they come in on a rolling basis.

 

Key Words: CCTP sites, Section 3026, care transitions, CMS site awards, technical assistance

Comments needed on proposed rule: Encourage CMS to value continuity and smooth care transitions

 Posted by on August 19, 2011  1 Response »  Tagged with: ,
Aug 192011
 
Stack of White Paper

You have until August 30, 2011, to comment on a proposed change to CMS rules that will affect care transitions. The Center for Medicare and Medicaid Services recently issued proposed changes to the Medicare Physician Fee Schedule (“physicians” here includes all practitioners paid by Medicare – MDs, NPs, SWs, etc.). The proposed rule provides a unique opportunity to encourage CMS to work toward coordinated care for Medicare beneficiaries. CMS is seeking comments on whether physician activities should seek to ensure effective care coordination surrounding a hospital discharge, including whether hospital discharge care coordination services are appropriately valued. Getting comments to encourage CMS to undertake regulatory and developmental work on continuity and standards would greatly help very sick people who must move around in the health care system.

The important thing is to encourage CMS to get into this field and work on continuity and care planning, at least for high-risk beneficiaries. Please write your own comment or be in touch if you want to recycle and modify the comment developed by the Center for Elder Care and Advanced Illness at the Altarum Institute ([email protected]). The Center will post additional comments on the proposed rule next week on their blog at (http://www.medicaring.org). You may download the Center’s comments as a PDF file:

Comments are due by August 30, 2011.

To make it easier for you to find the text of the proposed rule change we have extracted it from the larger document of which it is a part and put it into the following PDF file that you can download directly:

You may make comments via the Federal eRulemaking Portal at http://www.regulations.gov (refer to file code CMS-1524-P). The public access point for the proposed rule is at: http://www.regulations.gov/#!documentDetail;D=CMS-2011-0131-0002

Section K, “Hospital Discharge Care Coordination”, begins on page 510.

You may also send comments by surface mail to CMS, Department of Health and Human Services, Attention: CMS-1524-P, P.O. Box 8013, Baltimore, MD 21244-8013. CMS will respond to all comments in a final rule scheduled to be issued by Nov. 1, 2011.

Keywords: Medicare rule, Medicare Physician Fee Schedule, CMS-1524-P

The Price is Right! Suggestions from current 3026 applicants

 Posted by on July 18, 2011  No Responses »  Tagged with: , , , , , , , , , ,
Jul 182011
 

As coalitions around the country move towards completing their application for Community-Based Care Transitions Program (CCTP; Section 3026 of the ACA), many teams will encounter difficulties in completing the proposal (see budget worksheet at: http://www.cms.gov/DemoProjectsEvalRpts/downloads/CCTP_ApplicationBudgetWorksheet.zip). Here are a few concerns and helpful suggestions raised during a recent meeting with potential 3026 applicants (from the IHI Triple Aim and ONC Beacon participants).

Regarding finance, the pricing is done on a per unit basis rather than a grant or contract basis that hospitals and community-based organizations (CBOs) might expect. Per unit pricing is just like any other Medicare service. Your program will submit a list of patients served each month and payment will go to the CBO. Some CBOs may find it helpful to confer with someone experienced in per unit pricing (i.e. experience in small business).

You will need to estimate what fixed and variable costs the intervention incurs, along with a reasonable estimation of the number of targeted beneficiaries eligible for your program. Having as precise an estimate as possible of this anticipated volume is crucial in arriving at the correct rate per eligible discharge. Keep in mind that having a lower than anticipated volume can lead to losses (because you incur fixed costs that you did not cover). The greater the volume, the more spread out your costs will be!

One way of improving your volume estimate is getting a good approximation for the acceptance rate into the program, which can be based on previous experience. Many programs initially have very high refusal rates, but usually you can decrease that over time. Although the budget worksheet does not include a place for an acceptance rate, you could modify your entry on Row B and then enter the explanation in an accompanying footnote.

“Not-to-exceed” budget is another aspect that might cause some confusion. Basically, your not-to-exceed budget is the money CMS will set aside for your entire program. Remember that the budget you are proposing is for five years. There might be changes in your program over this time period, only some of which you could predict. For example, you might be able to streamline your intervention over the first two years or you might predict an increase in patient volume. You could write in these predicted changes with a modification on Row M and then enter the explanation in an accompanying footnote. The aim of the program is to be integrated as a permanent part of Medicare, and to this end it allows and encourages learning throughout the program. However, the degree of flexibility is unknown.

Here is the link to the powerpoint presentation from the meeting on 7/12/11: http://medicaring.org/wp-content/uploads/2011/07/CCTP-Budget-Proposal.pptx

This is a collaborative effort and the above suggestions would not have been available if not for care transitions teams sharing their experience. So any comments, questions or modifications to our suggestions are encouraged. Please send your response to [email protected].

Key words: section 3026 applicants, Affordable Care Act (ACA), medicare, budget worksheet, financing, CCTP, care transitions, patient volume, rate per eligible beneficiary, IHI Triple Aim, ONC Beacon, community-based organizations

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