Southeast Michigan CCTP Tests New Approaches to Reduce Readmissions

 Posted by on April 23, 2013  No Responses »  Tagged with: , , , , , , , , ,
Apr 232013
 
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by Benjamin Kuder

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

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

Reaching Rural Residents: Improving Care Transitions in Western New York State

 Posted by on August 23, 2012  No Responses »  Tagged with: , , , , , , ,
Aug 232012
 
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The P2 Collaborative of Western New York represents a different spin on the Community-based Care Transitions Program (CCTP) model. It is unique in its focus on a very rural area of Western New York, and is unusual in that it is one of a few  community-based organizations in CCTP that is NOT an Area Agency on Aging. P2 is a non-profit regional health improvement collaborative, with origins as a Robert Wood Johnson-funded Aligning Forces for Quality community project. Through that work, it has engaged in various activities within eight counties in Western New York.

As Megan Havey, Manager of Care Transitions, explains, “P2 doesn’t provide direct services, but acts as a facilitator to members of the collaborative.” The scope of the project really called for coordination by a regionally based group, one that could work with and understand the diversity of partners, and that could offer the sort of infrastructure support that such a collaborative would require.

The collaborative is one of the largest in the CMS CCTP portfolio. It includes eight local community-based organizations (CBOs) and ten hospitals, and works with other community agencies, organizations, and foundations including the Health Foundation for Western & Central New York, IPRO (the QIO), the Alzheimer’s Association, local  hospice organizations, and county health departments.  The work sprawls across seven counties, with programs that aim to serve more than 2,600 patients annually. The diversity of participating organizations is remarkable, ranging from a 5-bed to a 150-plus-bed hospital.

Over the last six years, many of the participating organizations had participated in pilot programs to improve care transitions. Other groups had little experience, but, Havey says, “…were in a great position to be mentored by groups that had experience.” In building the application, IPRO helped with many tasks, such as creating templates to conduct the required root-cause analysis, analyzing admissions data, and convening partner organizations. Havey says that although IPRO has now “stepped back” from the project, P2 continues to solicit IPRO for technical assistance and support.

The application process was instructive, Havey says, in helping the partners to appreciate just how flexible the project would need to be. “Each county had a very different target population and model,” she says. “It was important  to be able to engage partners and obtain their buy in, but also to be realistic about what we could achieve in each county. We could not create a cookie cutter model.” All of the local CBOs and hospitals are using the Coleman model, the Care Transitions Intervention™, and are targeting Medicare Fee-For-Service patients.

Havey says that developing a web-based data platform that all partners could use has been an essential step. The platform had to accommodate the range of reporting capacity partners bring to the project. To that end, P2 worked with a software company to invest in and develop a platform all hospitals could use to enter data about eligible patients. The system operates within the context of the Care Transitions Intervention, and allows care managers to document data about home and hospital visits, as well as follow-up calls and evaluation information.

Havey notes special challenges in serving a rural population, particularly in terms of accessing care. There are not enough providers, she says, and transportation to get to them can be difficult. “Rural counties have very poor health outcomes, with many medically underserved areas and populations. Our goal is to reduce readmission rates with an intervention that leads to better health outcomes and improves quality of life.”

For more information about the work underway at the P2 Collaborative, contact Havey at [email protected], or read more about the group’s work at http://www.p2wny.org/

Key words: care transitions, CCTP, Section 3026, rural residents, readmissions

SAGE: Bridging the Divide between Acute Medical Care and Social Services in Northeast Ohio

 Posted by on July 23, 2012  No Responses »  Tagged with: , , , , , , , , ,
Jul 232012
 
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By Dr. Kyle Allen  and Susan Hazelett

The Summa Health System/Area Agency on Aging, 10B/Geriatric Evaluation Project(SAGE) is a collaboration between an integrated health system and the local Area Agency on Aging which was begun in 1995. SAGE  provided the organizational structure to develop the resources and processes needed to effectively integrate geriatric medical services and community-based long-term care services. Such integration is essential to bridging gaps between acute medical care and community-based care, enabling medical and social services providers to reach frail older adults living in the community with multiple chronic conditions, and to improve their quality of life. The SAGE project, which operates in the Akron, Ohio, metropolitan area, has managed to do just that. Results of the 17-year collaborative indicate that consumers, health care systems, health care providers, and payers have all benefited from the focus on integrating service delivery.

In the early 1990s, Summa Health System (SHS), an integrated not-for-profit health delivery system, had launched several projects aimed at improving care for frail elders. Summa comprises six community teaching hospitals with more than 2000 beds, as well as its own health plan, skilled home care, hospice, and a foundation. Summa’s insurance plan has 150,000 covered lives, including a Medicare Advantage Plan of 23,000.One of the projects being tested at Summa was the ACE (Acute Care for Elders) model, a model of hospital care delivery aimed at improving the functional status and clinical outcomes for hospitalized older adults. Recognizing that this model did not have the necessary patient connection in the outpatient setting, Summa realized it would need to expand its reach to elderly patients across the continuum of care. To this end, it created the Center for Senior Health (CSH), an outpatient consultative service that supports primary care providers by offering an interdisciplinary, comprehensive geriatric assessment; high-risk assessment; a geriatrics resource center; a clinical teaching center; inpatient geriatric consultation and outpatient consultation followup. The CSH attempts to treat and reach the whole patient by addressing acute and chronic medical needs, psychosocial needs, and family concerns. Despite the range of services provided, the CSH continued to be limited in its scope because it did not have access to patients in their homes, nor could it provide long-term case management. As a result, it began to rely increasingly on community-based long-term care agencies for this kind of information and management.

At about the same time, the Area Agency on Aging 10B, Inc. (AAA) found itself managing a growing number of consumers with functional decline, geriatric syndromes, and multiple chronic illnesses. The AAA, which serves more than 20,000 elders in Northeast Ohio, recognized that it needed to be better integrated with the acute medical sector if it were to achieve its goal of delaying and preventing nursing home admissions.

Leaders from Summa Health and the AAA recognized the challenges and deficits each one faced in providing continuity of care to patients/consumers, and began meeting to discuss how they could build a new, integrated model of care. They realized that they shared a common goal and vision to improve care for frail elders, and launched SAGE, which provided the organizational structure needed to effectively integrate their services. SAGE had no grants or funding, just a spirit of collaboration and cooperation, and a common desire to do more than just business as usual.

A SAGE task force was created comprised of staff from both organizations, including physicians, nurses, and social workers, as well as senior leaders, to promote communication, provide feedback, and create initiatives that linked the two. The group met monthly for two years, and now meets quarterly. Among its early objectives were the development of protocols to screen and identify at-risk older adults, to establish mechanisms for information sharing and resources, to identify gaps and duplication in service delivery, to locate a AAA case manager at the CSH, to educate staff from both organizations, to collect data and information, and to identify and address barriers to implementation.

Eventually SAGE created an RN care manager assessor program, in which placed an AAA assessor in the acute care hospital. The assessor works closely with the ACE team to identify hospitalized patients who can benefit from community-based programs, as well as patients who are eligible for PASSPORT, the state’s Medicaid waiver program. This was a new initiative for the AAA, which had traditionally conducted these assessments post-discharge, in the patient’s home. That assessment now occurs before the patient is even discharged from the hospital, thus helping to determine needs for  community based services and facilitating the process for eligibility  and approval for Medicaid long term care benefits.  This is beneficial because patients will typically receive Medicare covered services for skilled needs but long term care needs are not addressed as well and the Medicare skilled benefits are provided for only a limited time usually < 30 days.   Without the other supports this vulnerable population is at risk for poor health care access, emergency department visits and  hospital readmission. The AAA then assumes case management for the consumer, and offers periodic geriatric follow-up.

This program has facilitated improved capacity management for complex patients in the acute care hospital. It improved AAA communication with primary care and hospital staff, reducing repeat hospitalizations, ED visits, and nursing home placements. It improved outcomes for complex patients, and decreased discharges from PASSPORT to nursing homes. During the pilot period,  referrals to and enrollments in the PASSPORT program doubled.   The AAA was also successful in replicating this model at other hospital systems in the Northeastern Ohio AAA service area.  A more recent positive outcome  related to this collaboration work was the awarding for AAA 10b Inc. one of the first seven  Community Based Care Transitions projects from CMS/CMMI as part of the The Community-based Care Transitions Program (CCTP), created by Section 3026 of the Patient Protection and  Affordable Care Act

In developing SAGE, several barriers had to be overcome, primarily those affecting leadership of the program, development of an effective multidisciplinary workgroup, and resources (in terms of staff time). The program can be adapted by other communities around the country, offering their acute medical system and community-based programs a way to align their services and collaborate in ways that better address the needs of frail older adults.

 

 

Key words: community collaboration, SAGE Project, ACE Units, CCTP, 3026, pilot programs

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
 
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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

 

Reducing Rehospitalizations… The Right Way

 Posted by on March 7, 2012  No Responses »  Tagged with: , , ,
Mar 072012
 
The following post by Toby Edelman, Ed.M, JD, Senior Policy Attorney for the Center for Medicare Advocacy, first ran on that site on March 1, and is reprinted here with permission.
For several years, reducing rehospitalizations of Medicare beneficiaries has been a key public policy goal, the intent of which is to improve quality of care for beneficiaries and reduce costs for the Medicare program.[1]  Studies have shown that rehospitalizations are common and expensive.  In 2006, for example, nearly one-quarter of nursing home residents (23.5%) were rehospitalized within 30 days, at a cost to the Medicare program of $4.34 billion.[2]  Yet, in many instances, nursing home residents’ rehospitalizations are avoidable.[3]

However, reducing hospitalizations and rehospitalizations must be accomplished appropriately and with attention to the needs of residents.  This is especially true in the current national environment where much of the emphasis in health care is on cost-containment, with increased penalties for unnecessary hospitalizations and rehospitalizations.

  • Not all hospitalizations and rehospitalizations should be prevented. Some, given a patient’s particular circumstances, may well be medically necessary and appropriate.[4]  Moreover, denying Medicare beneficiaries the hospital care they actually need can be dangerous.
  • It is important to avoid cost-shifting gimmicks.  Labeling patients in the hospital as outpatients receiving observation care[5], for example, so that their initial time in the hospital is not counted as inpatient hospitalization and any return to the hospital is therefore not technically a rehospitalization (or, vice-versa, so that the initial time in the hospital is inpatient, the return, outpatient) is simply a semantic trick.  It does not reduce patients’ actual stays in acute care hospitals.  Rather, for many Medicare beneficiaries, this gimmick only serves to increase their potential liability for the costs of outpatient Part B services and put Medicare-covered skilled nursing facility coverage out of reach.

Unnecessary rehospitalizations are correctly reduced by assuring, first, that patients are not prematurely discharged from acute care hospitals and second, that settings where patients receive post-acute care (such as skilled nursing facilities, SNFs) properly provide necessary post-hospital care services.

The Wrong Way to Reduce Rehospitalizations

Imposing artificial numbers of reductions in hospitalizations and rehospitalizations is, by itself, the wrong approach.  There are already too many instances in which nursing home residents who need to be hospitalized are not. As Drs. Joseph G. Ouslander and Robert A. Berenson wrote in The New England Journal of Medicine in September 2011, “not all hospitalizations for conditions that can theoretically be managed outside an acute care hospital are preventable” and “not all nursing homes have the capacity to safely evaluate and manage changes in the condition of the clinically complex nursing home population.”[6]  They conclude, “Setting unrealistic expectations and providing incentives to poorly prepared nursing homes to manage such care rather than transferring residents to a hospital could have unintended negative effects on the quality of care and health outcomes.”[7]

Unfortunately, legislation being promoted in Congress to save Medicare dollars would require the Secretary of the Department of Health and Human Services to establish a hospital readmission reduction target rate for skilled nursing facilities, using a baseline hospital readmission rate (as of October 1, 2011) and the goal of achieving aggregate Medicare savings of $2 billion for 2014 through 2021.  Simply requiring nursing facilities to reduce their rates of hospitalization and rehospitalization, but not requiring them simultaneously to take steps to assure that residents who remain in the facility receive the care they need, could harm patients.

The Right Way to Reduce Rehospitalizations

Rehospitalizations can be reduced if nursing facilities are appropriately staffed to meet the complex health care needs of their residents.  Many studies have demonstrated that improved staffing in nursing facilities (particularly, registered nurses, nurse practitioners, and physicians) can lead to the appropriate reduction of hospitalizations.[8]

The Centers for Medicare & Medicaid Services’s (CMS’s) Medicare-Medicaid Coordination Office, in collaboration with the Center for Medicare and Medicaid Innovation, is now establishing “a new initiative to help States improve the quality of care for people in nursing facilities by reducing preventable hospitalizations.”[9]

CMS will competitively select independent organizations to partner with and implement evidence-based interventions at interested nursing facilities.  These interventions could include using nurse practitioners in nursing facilities, supporting transitions between hospitals and nursing facilities, and implementing best practices to prevent falls, pressure ulcers, urinary tract infections, or other events that lead to poor health outcomes and expensive hospitalizations.[10]

This initiative builds on studies demonstrating the importance of staffing at nursing facilities as a key way to reduce hospitalization.

CMS funded a pilot quality improvement project in three nursing facilities in Georgia from May 1 to October 31, 2007.  The pilot facilities reported an average reduction of hospitalizations of 50% over the six-month period.  The project’s Expert Panel identified as key factors for “preventing avoidable hospitalizations…greater on-site availability of physician or nurse practitioner or physician assistants, more registered nurses providing care, availability of lab results within 3 hours, and the capability of the NH to administer intravenous fluids.”[11]

The nursing home chain, Life Care Centers of America, reports that it reduced rehospitalizations from 40% to 15% in one year in its facilities that employed a full-time physician.[12]  Additional benefits of the employment of physicians in nursing facilities reported by the corporation were reduced use of antipsychotic drugs, “reduced staff turnover, greater resident and family satisfaction, and improved clinical outcomes.”

As the Center for Medicare Advocacy wrote in anAlert from March 2011, earlier studies of hospitalization of nursing home residents found that hospitalization could be reduced if facilities employed geriatric nurse practitioners,[13] physicians, nurse practitioners, and physician assistants.[14]  The nursing home corporation Genesis HealthCare reported that it employed more registered nurses, nurse practitioners, and physicians in its nursing facilities, resulting in an 11% decline in unplanned hospitalizations since 2004.  Sixty percent of Genesis facilities have a “‘transitional care unit,’ in which an RN-intensive staff team cares for residents who have been in the hospital within the past 25 days.”[15]  The RNs “are intravenous (IV)-certified.”  The transitional care units also have a nurse practitioner or physician on staff every day.

Reducing rehospitalization by increasing staffing in nursing homes is not a new idea.  In an article published 23 years ago, reporting research conducted between 1985 and 1988, Professor Jeanne Kayser-Jones of the University of California, San Francisco, identified various factors that contributed to the hospitalization of nursing home residents.  Professor Kayser-Jones found that almost half the hospitalizations were unnecessary and that the residents could have been cared for in their nursing homes.  The predominant factor causing hospitalization was “the insufficient number of adequately trained nursing staff.”[16]

Conclusion

Reducing hospitalizations and rehospitalizations is a worthy goal so long as policymakers first recognize that:

  • Many hospitalizations and rehospitalizations are medically necessary and appropriate,
  • Hospitalized patients should not be misclassified as observation status outpatients, and
  • Nursing homes must be appropriately staffed so that Medicare beneficiaries receive the care they need.

[1] Misha Segal, “Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations,” (CMS, Center for Strategic Planning, Policy Insight Brief) (Sep. 2011), https://www.cms.gov/Insight-Briefs/downloads/PAHInsightBrief.pdf [hereafter "Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations"].  A recent White Paper for the Long-Term Quality Alliance discusses three separate themes of research literature on this broad topic: hospitalization from the community, hospitalization from nursing homes, and hospital readmissions.  Katie Maslow, Joseph G. Ouslander, “Measurement of Potentially Preventable Hospitalizations” (White Paper prepared for the Long-Term Quality Alliance) (Feb. 2012), http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//PreventableHospitalizations_021512_2.pdf [hereafter "Measurement of Potentially Preventable Hospitalizations"].
[2] Vincent Mor, Orna Intrator, Zhanlian Feng, David C. Grabowski, “The Revolving Door Of Rehospitalization From Skilled Nursing Facilities,” Health Affairs 29, No. 1 (2010): 57-64.
[3] Stephen F. Jencks, Mark V Williams, Eric A. Coleman, “Rehospitalizations among Patients in the Medicare Fee-for-Service Program,” New EnglandJournal of Medicine 360;14 (April 2, 2009),
[4] Joseph G. Ouslander, Robert Berenson, “Reducing Unnecessary Hospitalizations of Nursing Home Residents,” New England Journal of Medicine 2011; 365: 1165-1167 (Sep. 29, 2011), http://www.nejm.org/doi/full/10.1056/NEJMp1105449 [hereafter "Reducing Unnecessary Hospitalizations of Nursing Home Residents"]; “Measurement of Potentially Preventable Hospitalizations,” supra note 1.
[5] Patients in observation status are placed in hospital beds and receive medical and nursing care, diagnostic tests, treatments, prescription drugs, and food.  But because they are in observation status, they are labeled outpatients.  For more information about observation status, see Center for Medicare Advocacy, “Observation Status,” http://www.medicareadvocacy.org/medicare-info/observation-status/.  See also Kenneth R. Dardick, MD, Judith Stein, JD, “Hospital Readmission and Measures of Quality” Journal of American Medical Association, Vol. 301, No. 4 (January 25, 2012)
[6] “Reducing Unnecessary Hospitalizations of Nursing Home Residents,” supra note 4.  See also “Measurement of Potentially Preventable Hospitalizations,” supra note 1.
[7]  Id.
[8]  See Center for Medicare Advocacy, “More Nurses in Nursing Homes Would Mean Fewer Patients Headed to Hospitals” (Weekly Alert, March 10, 2011), http://www.medicareadvocacy.org/2011/03/10/more-nurses-in-nursing-homes-will-mean-fewer-patients-headed-to-hospitals/.
[9]  “Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations,” supra note 1.

[10] CMS, “Obama Administration Offers States New Ways to Improve Care, Lower Costs for Medicaid; Initiatives Focus on People Receiving Medicare and Medicaid Benefits” (Press Release, July 8, 2011), http://www.cms.gov/apps/media/press/release.asp?Counter=4024&intNumPerPage=1000&checkDate=&checkKey=&srchType=1&numDays=0&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=1&pYear=1&year=2011&desc=false&cboOrder=date.
[11] Joseph G. Ouslander, Mary Perloe, JoVonn H. Givens, Linda Kluge, Tracy Rutland, and Gerri Lamb, “Reducing Potentially Avoidable Hospitalizations of Nursing Home Residents: Results of a Pilot Quality Improvement Project,” Journal of the American Medical Directors Association, DOI:10.1016/j.jamda.2009.07.001 (2009).  Abstract available at http://www.jamda.com/article/S1525-8610(09)00248-5/abstract.
[12] Kathleen Lourde, “Physicians Moving In; Life Care Centers of America hires full-time, facility-based physicians to reduce rehospitalizations,” Provider (Feb. 2012), http://www.providermagazine.com/archives/archives-2012/Pages/0212/Physicians-Moving-In.aspx.
[13] William H. Barker, James G. Zimmer, W. Jackson Hall, Brian C. Ruff, Charlene B. Freundlich, and Gerald M. Eggert, “Rates, Patterns, Causes, and Costs of Hospitalization of Nursing Home Residents: A Population-Based Study,” American Journal of Public Health, 1994; 84:1615-1620.
[14] Joseph G. Ouslander, Gerri Lamb, Mary Perloe, JoVonn H. Givens, Linda Kluge, Tracy Rutland, Adam Atherly, and Debra Saliba, “Potentially Avoidable Hospitalizations of Nursing Home Residents: Frequency, Causes, and Costs,” Journal of the American Geriatrics Society 58:627-635, 2010.
[15] Kathleen Lourde, “Providers Tackle Preventable Hospitalizations: Nursing facilities ramp up efforts to care for higher acuity residents,” Provider (Jan. 2011), http://www.providermagazine.com/archives/archives-2011/Pages/0111/Ramping-Up-For-Higher-Acuity.aspx.
[16] J.S. Kayser-Jones, Carolyn L. Wiener, Joseph C. Barbaccia, “Factors Contributing to the Hospitalization of Nursing Home Residents,” The Gerontologist 502 (1989).

 

 Key words: care transitions, readmissions, avoidable rehospitalizations

Early Days: Chicago-Based CCTP Program Describes The Work To Date

 Posted by on February 23, 2012  No Responses »  Tagged with: , , , , , ,
Feb 232012
 

CJE SeniorLife, a community-based organization that serves some 18,000 older adults annually, is among the first cohort of recipients for  Section 3026 or  Community-Based Care Transition Program (CCTP) funding from the Centers for Medicare and Medicaid. One of seven early awardees, CJE will anchor a project that includes three large hospitals in Northern Chicago, as well as long-term services and supports organizations that serve frail older adults.

Medicaring talked to Heather O’Donnell, JD, LLM, CPA, who is CJE’s Director of Planning for Healthcare Reform. She said that the process that led to funding has been underway for more than a year, and began when the group first began to consider opportunities that were arising as a result of health care reform, and how it might further its effort to bridge gaps between social services and medical care.

CJE, which had already been involved in care transitions improvement efforts, began to reach out to hospitals in its community, approaching them to find out whether they would be interested in partnering for the CCTP opportunity. Ultimately, three hospitals were selected:  Northwestern Memorial Hospital (a major academic medical center), Provena-Resurrection Saint Joseph Hospital, and Provena-Resurrection Saint Francis Hospital. The team also includes Telligen, the Illinois Quality Improvement Organization and local Care Coordination Units. These state-run units, housed in communities throughout Illinois, address the needs of older adults who have complex, ongoing health care needs. Patients who have  diagnoses of pneumonia, congestive heart failure, or AMI are targeted, as well as those who have complex conditions or take multiple medications.

The intervention is based on Eric Coleman’s model, which focuses on coaching patients and families to improve self-management skills for chronic conditions and medication management. The 30-day intervention aims to help people access home and community-based services and features a follow-up home visit by a transitional care nurse within 72 hours of discharge. These nurses, who have participated in the Care Transitions Intervention training program, help patients and families to set 30-day post-discharge goals, and to make and keep followup appointments. In addition, CJE received foundation funding which is enabling it to include a social work intervention; very high risk patients are identified and receive followup with a social worker for six months post-discharge.

“We had to adapt the Coleman protocols,” says O’Donnell. “We felt that for some patients, those with chronic conditions and psychosocial problems, thirty-days of followup were insufficient. We found that about 10 percent of the patients in our program would need more support services. That part of our program is not covered by CMS but is funded with private foundation funds.”

O’Donnell says that pulling the project together has taken a great deal of collaboration with the participating hospitals—from the on-the-ground work of finding the right contact people to developing specific strategies for the intervention. “But we felt that this was a good fit with what the hospitals were already doing,” she said. “It is very exciting work, getting every provider in the community to think about the quality of care from the standpoint of preventing an unnecessary readmission.”

Asked whether there had been any problems in bridging the divide between social services agencies and hospitals, O’Donnell said there had not. “This isn’t about us versus them. This is about everybody pulling together and undertaking a new initiative that’s good for everybody—good for the hospital, the nursing home, the patient. It’s a new approach.”

CJE meets regularly with its partners at each participating hospital, although the three are some miles apart and there is no reason to try to pull them all into one meeting. Orchestrating such a meeting, O’Donnell said, would be quite difficult, given how busy people are, and how hard it is to accomplish specific tasks when so many people are involved. “We’ve found it’s more effective to address each hospital and their concerns and our strategies individually.” CJE is, however, convening quarterly meetings of participating nursing homes, at which it hopes participants will talk about their successes, challenges, and processes. CJE is also mindful of the role to be played through partnerships with its local AAA (Area Agency on Aging), which is in the midst of applying for separate CCTP funding. It is also keeping the Department of Health Care and Family Services apprised of its work.

The process of actually launching the program took several months of work with CMS to address questions and concerns and finalize a contract. The application, submitted in August, received final approval in November. The first wave of projects will begin in one hospital on March 1, with other hospitals launching in April and May; ultimately, the project anticipates serving some 2,700 people each year.  As O’Donnell notes, “It is a significant undertaking, and there are lots of details to be sorted out.”

She also noted that the relatively quick launch can be attributed in part to ongoing planning for implementation, addressing in advance issues that were likely to come up as the project rolled out. “We had these conversations internally and with hospitals before the application was even approved.” 

 

Key words: care transitions, Section 3026, CCTP, CMS, Coleman model, CJE

 

Dr. Joanne Lynn on the Need for Rapid Follow-up Post Discharge

 Posted by on December 5, 2011  No Responses »  Tagged with: , , , , , ,
Dec 052011
 

Patients just discharged from the hospital urgently need rapid follow-up in the community. Dr. Joanne Lynn describes the care coordination needed among patients, community providers, hospitals, and other settings, and what’s needed to make it work.

 

 

Key words: rapid follow-up, care transitions, discharge planning, quality improvement, rehospitalization

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

Southwest Ohio Care Transitions Collaborative Talks to Medicaring about CCTP Award

 Posted by on November 28, 2011  1 Response »  Tagged with: , , , , , , ,
Nov 282011
 

The Southwest Ohio Care Transitions Collaborative, one of 7 sites chosen by the Centers for Medicare and Medicaid for the first cohort of 3026 funding, had lots going for it as it pulled together a broad-based community health coalition and implemented strategies to reduce avoidable readmissions for older adults. The program brought to its application a coalition that included major community-based organizations, the local hospital association, and five hospitals serving the Greater Cincinnati area. It had demonstrated success with a care transitions pilot program based on the Coleman model, and it submitted an application to CMS that clearly explained the strategy behind its blended rate calculations. The Collaborative estimates that it will serve some 5,400 seniors each year, with a cost savings to Medicare of more than $1 million. The specific intervention is built directly on the Coleman model, with some modifications to account for local needs and experiences (For the Council’s full press release on the project, see http://www.help4seniors.org/newspage.asp?ref=1192.)

The application built on the success of a pilot project implemented at UC Health University Hospital, which showed that participants had a lower-than-average readmission rate, and that most patients were discharged to their home or other community setting, rather than to a skilled nursing facility. Sharon Fusco, Director of Business Results and Innovation for the Council on Aging of Southwestern Ohio, is optimistic that the care transitions intervention will significantly reduce readmissions among hospitalized Medicare beneficiaries with diagnoses that include pneumonia, heart failure, heart attack, or multiple chronic conditions.

In building the coalition, Fusco says the group aimed to be certain to include all of the organizations that could influence and affect patients’ lives; where the root cause analysis identified gaps in care, the coalition took care to find organizations that could fill them. As a result, the coalition now includes the Greater Cincinnati Health Council, which is the local hospital association; a health information and technology exchange organization; a program that helps to coordinate patient access to physicians; and a local mental health and recovery services board.

The Collaborative used its root cause analysis to identify gaps in care, and to consider strategies that would mitigate problems. So, for instance, as Fusco explained, the root cause analysis identified mental health issues as a significant barrier to patient involvement in discharge planning and follow-up. “We had to find a way to help these individuals, and to connect them to a mental health medical home,” Fusco explained. To that end, the mental health board was enlisted, and will play a critical role in assisting patients whose mental health problems present barriers to good care.

The analysis also found tremendous problems in medication reconciliation, a problem that affected more than 90% of patients in a pilot at University Hospital. In exploring this issue more deeply, the Collaborative found that many patients did not have relationships with or access to primary care physicians, a real barrier in trying to help hospitalized patients make and keep important follow-up appointments. To this end, the Collaborative involved a group that focuses on coordinating patient access to physicians.

In general, the Collaborative found that the Coleman Model matched most of its needs in responding to problems identified by the root cause analysis. The Council on Aging added a fifth pillar to the four pillars of the Coleman model home and community-based programs for which some patients might be eligible. Meals, home care assistance, and transportation are among the services these programs offer.

Fusco and  her colleague, Communications Director Laurie Petrie ,anticipate that the Collaborative will encounter some challenges in with regard to operations and technology  differences among participating hospitals (e.g., rural versus urban settings), and to the ramp-up of health information technology  systems. Fusco noted that one challenge will be “getting the right staff and the right tools to each hospital.” But she is confident in the Collaborative’s ability to overcome  these  barriers and deliver successful interventions.

Fusco offered some advice for other potential applicants. In particular, she advises that groups take time to explain in detail how they calculate their blended rate, “really spend time explaining the rate and what goes into it.” According to Fusco, the process of calculating the blended rate was difficult but critical. She said,  “The process of [pulling together this application] turned out to be a healthy exercise for us. Costing out all the inputs that go into providing this service was challenging and time consuming, but completely necessary. We built a cost model that allowed us to account for both fixed and variable costs. In the end, the process increased our learning, and we found it very beneficial.”

She advises other potential applicants to be thoughtful and meticulous as they develop their calculations. “You need to understand what your costs are, what’s fixed and what’s variable. Then you can plug in the numbers. But you have to think about everything that goes into serving a client—what does it cost you to actually run the intervention? Not just the face-to-face time with the client, but all of the rest of the costs.”

She also feels that the Collaborative’s application was stronger for having been reviewed and critiqued by external partners, individuals with no connection to the program being proposed. To that end, she said, consultations on aspects ranging from policy to cost were helpful.

 

Key words: care transitions, CCTP, Section 3026, award sites, community coalition, quality improvement

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