Mar 282020
 

Joanne Lynn, MD, MA, MS

March 28, 2020

Note: this post is aimed to help people leading or working in nursing homes, and regional planners. If you are someone who is worried about your relative in a nursing home, you may find this a bit overwhelming, and you’d certainly need to do some translation. Also, this is the informed opinion of one geriatric and palliative care physician. Undoubtedly, this can be improved. If you see an improvement, please let us know at [email protected] As with all of our materials, this is published with a Creative Commons Attribution-NonCommercial 4.0 license. In short, feel free to re-use this in any way you like, just give us an attribution and say whether you modified it. We would appreciate your letting us know how you use it.

Nursing homes are being held to an impossible standard – as if they could prevent outbreaks in these settings. CMS cited the nursing home in Kirkland for three “immediate jeopardy” deficiencies and threatened them with closure, and one of the deficiencies was failure to have a back-up physician! How many nursing homes are going to have a reliable back-up physician in a pandemic?!

Below is the outline I’ve put together to help guide the thinking of staff and leadership in nursing homes. The fundamental claim, beyond all the details below, is that the country desperately needs nursing homes to step up and provide care for a LOT of people who will die in this pandemic.

Nursing homes have no way to avoid outbreaks – they can reduce the risk and increase the likelihood of delay, but it still is a roulette. Unless we get an effective vaccine or treatment, eventually almost every facility will have their crisis. More than 20% of their residents will die and another 20% or more will be much less functional for having been so sick. During the peak of the pandemic, many will be unable to be transferred to hospitals. This is not the result of inattention in the nursing homes – it’s the combination of the behavior of this virus and congregate living of very disabled elders.

Hospitals and planners need to value these facilities and include them in the decision-making. The solution is not generally to send out surveyors to enforce infection control; it is to get masks and other PPE – and morphine – to nursing homes. It’s to encourage calls for help, rather than issuing penalties for situations that are built into the way we’ve structured nursing home care. Similar issues affect assisted living, home care, and hospice.

I know this is tough stuff. I know it is hard to say, and harder to implement. But it is the nursing homes, home care, hospices, and assisted living that shortly will become the sites of a great deal of serious illness and death, as the hospitals fill up and overflow. Others in the health care system and the government would do well to help nursing homes to do their generally quite unfamiliar job, since they won’t have the option to opt out.

1. There will be serious outbreaks in (many, perhaps most) nursing homes

  1. The virus has a 5-day average incubation period and is infectious during that time – before any symptoms
  2. Many people (especially younger people) have no symptoms at all – and still are infectious
  3. Nursing homes cannot always completely isolate residents, at least not for months
  4. Nursing home staff must each provide care for multiple residents
  5. Nursing home staff are not being given protective equipment for each contact with a resident (or for any!) – and some residents can’t tolerate protective equipment on themselves or their caregivers
  6. The swab test has a substantial false negative rate – 37% in the one reported study – so a negative test might be misleading
  7. The case fatality rate in nursing homes is upwards of 20%, and those who survive a serious case will often be more impaired afterwards

2. Since all nursing home residents are at substantial risk, we should know what they would want to happen if they got a bad case

  1. A bad case gets very bad over a few hours or a couple of days – not much time to make decisions
  2. Many of our residents (or their surrogate decision-makers, usually family) would look at their odds of surviving hospitalization and ventilator support and realize that this would be an undesirable way to come to the end of life and would prefer to stay on-site, where things are familiar – and to have hospice-type care. Some might even be aware of the limitations of hospital beds and ventilators and altruistically want to leave those resources to younger people.
  3. But nursing home staff can’t count on being able to lay this out when the person is becoming very sick, and staff might not be able to find their surrogate decision-makers quickly – so nursing homes need to get decisions made in advance and know which residents would not want a transfer.
  4. This requires that we carry out a substantial number of sensitive discussions quickly – this week, or as soon as possible. Initial experience shows that capable residents and the surrogates of cognitively disabled residents are remarkably open to this discussion at this time – they have usually been thinking about it.
  5. And our hospitals may well become so overwhelmed that they cannot accept transfers, in which case the nursing home is going to have to do the best it can to support the person’s life and to ease their suffering.

3. How to discuss resident-centered preferences in advance of illness, in the context of Covid-19

  1. Emphasize that you (the person seeking to clarify preferences) are trying to be sure that everything is done in the way that the resident wants (or would want, if talking to a surrogate)
  2. Check on what the resident (or surrogate) already knows about the situation and how it applies to them
  3. Offer to fill in gaps in knowledge
  4. Ask if the person already has a decision in mind – and if so, assess whether it is reasonably well-informed and get that documented
  5. If the person is conflicted, ask them to tell you more about what considerations are in their mind and document those, and come back a day or two later and ask if they have given it more thought and offer to hear what they are considering.
  6. This conversation may be done with a religious counselor or a social worker – and it can be done over the telephone or over an audio-video connection like Skype or Zoom (now that using these platforms does not violate HIPAA requirements)
  7. There are some good suggestions on how to phrase your conversation at:

4. Treatment of a very seriously ill person with respiratory failure

  1. Obviously, a very sick person with respiratory failure will need oxygen, so each nursing home needs to have enough ways to get oxygen to our residents. Nursing homes may need to try to stock up on oxygen concentrators, tanks, tubing, and masks.
  2. Air hunger is the most severe symptom these residents are likely to have, and the treatment for that is morphine (or equivalent of another opioid medication).
  3. For most people, there is a dose of morphine that allows the patient to relax and still to have enough oxygenation to survive and maybe to recover. Sometimes the pneumonia is so severe that the only way to stop overwhelming suffering is to be deeply sedated, and nearly all patients in that situation will die. The severe suffering of the feeling of suffocation justifies relieving the air hunger with morphine even in these situations.
  4. Morphine can be given in a number of ways – under the tongue, in a suppository, under the skin, as a pill, or as an intravenous drip. The method used will depend upon supplies and the clinical situation.
  5. In most situations, the dose needed will be found by titrating repeated small doses until the patient is reasonably comfortable and then continuing that dose until the patient is better, symptoms worsen, or the patient dies. Testing for improvement may require backing off on the dose for an appropriate interval.
  6. Handling opioid drugs will require the usual cross-checks to prevent diversion.
  7. If it is permitted, it might be wise to be sure that the nursing home has some supplies on hand, or that the pharmacy is keeping a substantial supply on hand.
  8. Many nursing homes will benefit from having the backing of the local hospice or hospices, whose physicians and nurses will usually have more experience. Some might set up a consulting line to check on next steps. Some might set up rapid enrollment into a formal hospice program. In general, nursing homes would do well to consult with their hospice(s) in advance of any outbreak and settle on a plan.
  9. Under the law, opioids left at the time of a patient’s death must be wasted and documented as wasted. In the context of this pandemic, the nursing home may want to delay any wasting of such a valuable resource and instead provide for locking up any remaining supplies or asking their physician or hospice to manage this off-site. There are efforts being made to regularize this practice during the pandemic.

5. Removal of the bodies of residents who have died

  1. The nursing home would do well to talk with the major funeral homes and crematoria in the area to be sure that they are staffing up and stocking up, and that they understand the urgency of removing the body promptly
  2. The usual requirements for notifying the coroner, getting death certificates signed, and managing the grieving family may need to be reconsidered during this epidemic. The nursing home will need to stay abreast of any changes and to reconsider their own practices

6. Serologic tests for immunity

  1. Within a few weeks, tests for immunity to Covid-19 virus should begin to become available.
  2. IF a person is immune and if the person is not still shedding the virus (takes about 2 weeks after onset of the disease, but can go longer, up to a month) as documented by a diagnostic test – that person is no longer a target of the virus nor a person who can spread the disease (with ordinary good hygiene)
  3. If a nursing home can get those tests for its staff, you can tell which of the staff are already immune, and those staff can probably work with Covid-19 patients without risk to themselves.
  4. Likewise, the nursing home could tell what family members can visit and what current and future residents are safe from this virus.
  5. Guidance on this testing is likely to appear within a few weeks.

7. Engagement in the regional planning process

  1. Nursing homes must be “at the table” when disaster planning is underway. A region may need to designate some facilities for all Covid-19 residents, perhaps because they had an outbreak and now have mostly immune staff and residents. Some regions may call on nursing homes to take in sick and disabled elders from the community, beyond their typical bed capacity, in order to help elders who are sick and live alone or who have lost their caregiver.
  2. In order to be “at the table,” nursing home organizations or ad hoc coalitions might support one or two representatives who are knowledgeable and able to communicate to all affected facilities.
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Aug 212019
 
Picture of Anne Montgomery
Anne Montgomery

by Anne Montgomery

Now that the health care sector is focusing on social determinants of health (SDOH) in older adults and actively pursuing partnerships with community-based organizations (CBOs) to meet a surging demand for supportive services, it’s an excellent time to ask: What do we already know from key demonstration programs in this space?

Some of the best evidence—both from the standpoint of challenges encountered and also of achievements realized—comes from a five-year demonstration enacted as part of the Affordable Care Act (ACA): The Community-based Care Transitions Program (CCTP).

Administered by the Centers for Medicare & Medicaid Services (CMS), the CCTP was bold and ambitious and was among the six original initiatives funded under the authority of the Center for Medicare & Medicaid Innovation (CMMI). Starting in 2012, 101 CBOs—mainly Area Agencies on Aging (AAAs)—began to receive funding to partner with hospitals to offer transitional care services. CBOs were reimbursed for each beneficiary receiving transition services; amounts were based on an agreed-upon, all-inclusive rate per eligible discharge.

The survey was developed by N3C members and was completed by a convenience sample of CCTP participants. The survey was disseminated to the National CCTP Coalition, which included successful CCTP sites that received continued funding from CMS and was convened by Aging & In-Home Services of Northeast Indiana, Inc. The survey was also disseminated broadly via the National Association of Area Agencies on Aging and the Aging and Disability Business Institute to capture input from other CCTP participants. The authors reviewed all responses, edited examples for clarity and grammar, and conferred on themes. All respondents have had the opportunity to review this report.

A first-of-its-kind program for CMS, the CCTP asked CBOs to target high-risk Medicare beneficiaries who were transitioning from the hospital back to their homes. Once they identified willing participants, CBOs worked to provide individually tailored supports in the community. For CBOs, the goals were twofold: 1) to improve the quality of care for Medicare beneficiaries at a highly vulnerable time; and 2) to reduce their risk of returning to the hospital. For hospitals, the primary goal was to reduce all-cause readmission rates, and thereby lower their risk of paying financial penalties that were also enacted as part of the ACA. For CMS, the measurement metrics for what counted as success for CCTP sites focused on whether they achieved a target of lowering 30-day all-cause readmission rates in participating hospitals by 20%, regardless of whether baseline admission rates were high or low and regardless of how many individuals the CCTP program touched.

This 20% reduction goal exceeded the ability of many community-based organizations that did not already have close working relationships with participating hospitals (many did not); that lacked compatible information technology (which greatly hampered data sharing); and that did not have staff already trained in transitions protocols (primarily the Coleman care transitions intervention), which for some proved more costly to implement than anticipated. These and other start-up structural difficulties caused many CBOs to lose momentum, and many were not continued after the initial period.

Nevertheless, 44 CBOs continued to be funded and to operate through 2015. Those that did devised strategies for delivering comprehensive services post-discharge in beneficiaries’ homes, including helping them obtain assistance with personal care and household tasks they could not manage. The official CMS evaluation conducted by Econometrica focused mainly on readmissions, rather than close analysis of the actual interventions and lessons learned by both participating CBOs and hospitals in collaborating to manage complex, high-risk beneficiaries. Information from beneficiaries on their experience with the program was not collected.

To gain additional insights from CBOs, the National Coalition on Care Coordination and the Center for Health and Social Care Integration surveyed the more successful CCTP sites in late 2018 and 2019. The focus of this survey was to elicit additional information from CBOs about the basic structure of their programs, the nature of the adaptations they made to partner with hospitals, and the challenges they struggled with most, along with observations about what they have been able to take forward. Many of these responses suggest that CCTP opened the door for CBOs to make key improvements to the way that health care and care transition services are coordinated and delivered. As a result, hospitals and CBOs gradually became more efficient at communicating critical information about patients; relationships between medical and CBO staff improved; and referral processes solidified over time.

These adaptations and quiet successes can be seen in the continuing work that CBOs are now pursuing. For example, several CBOs that participated in the CCTP are now involved in CMMI’s Accountable Health Communities demonstration. More broadly, there is a clear push to organize AAAs into larger networks, both within states and more recently across states, to better leverage contracts with large health care organizations. This work is one of the legacies of collaborative work that was launched by the CCTP program.

Within the confines of the five year CCTP demonstration, CCTP sites made solid gains in driving down readmission rates and in lowering Medicare spending. For example, CMS’ final evaluation found that the average Medicare Part A and Part B expenditures over all sites was $634 or 8.23 percent lower in the 30 days after discharge for participants relative to matched comparisons. In the process of learning how to collaborate closely with hospitals on care transitions, CBOs developed better clinical protocols and increased their field capacity, thereby gaining experience in taking on contracts and acquiring valuable insights about how to market their services. The growing sophistication of the Aging Network is evident in the ongoing work of the National Association of Area Agencies on Aging’s Aging and Disability Business Institute. As more and more health care organizations look for ways to better control the costs of complex, aging Medicare and Medicaid beneficiaries, prospects for CBOs that can position themselves as nimble, flexible, business-savvy partners are excellent. As the Medicare population steadily increases in size and as the “longevity wave” takes hold, CBOs are in a prime position to expand their services footprint exponentially.

For a detailed overview of CBO experience with the CCTP as reported by participating sites, please click here to access the survey responses. Two of the interesting summaries from the overview are presented here:

The Four Overarching Themes from the Participant Surveys

CCTP Survey Responses Table

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Sep 252018
 
portraits of Anne Montgomery and Sarah Slocum
Authors Anne and Sarah

By Anne Montgomery and Sarah Slocum

On May 4, 2018, the Michigan State Legislature voted to “just do it:” to assemble a group of experts to craft a blueprint for taking the Wolverine State deep into the future of Michigan’s age wave – all the way through the mid-21st century.

Specifically, the language requires the Michigan Department of Health and Human Services (MDHHS) to contract for: “an independent feasibility study and actuarial model of public, private, and public-private hybrid options to help individuals prepare for, access, and afford long-term services and supports.” The study will take 9 months. It is meant to squarely address the fact that current options for individuals to fund their long term supports and services (LTSS) needs have been unworkable and have often resulted in impoverishment and bankruptcy for Michigan families.

Since Medicare doesn’t pay for LTSS and less than 10% of Americans have purchased private long term care insurance, most people have to pay out-of-pocket when they need in-home care, assisted living, or nursing home care. This continues until the disabled person qualifies for Medicaid, which picks up the cost of nursing home care. Or, if there is an available program for home and community-based services (HCBS) that doesn’t have a waiting list, families may be able to tap into Medicaid for in-home services and other types of assistance.

Along the way, thousands of formerly middle-class families in Michigan are forced to impoverish themselves every year in order to qualify for Medicaid LTSS coverage. This “spend down” process is anguishing for many, who would prefer to have more control over their lives and perhaps to leave some of their accumulated resources to children and grandchildren. Recognizing this, the Michigan legislature, led by Rep. John Hoadley (D-Kalamazoo) and Sen. Margaret O’Brien (R-Portage), went to work last year — along with a coalition of concerned organizations led by Michigan United and including Altarum’s Program to Improve Eldercare – to ensure that the study bill would become law.

The Michigan budget for fiscal year 2019, which begins in October, includes language directing the Department of Health and Human Services (MDHHS) to draw up a workable, practical plan that will make LTSS available to middle-class Michigan families. MDHHS has $100,000 in state funds that will be matched with at least that much in private philanthropic funds – and possibly far more — to take a hard look at LTSS financing possibilities, workforce development capacity and future needs. The study will assess the current landscape of long-term care needs including:

  • What private and public services exist;
  • What the costs for current services are;
  • Who is accessing them and who is not;
  • What are the challenges to accessing care, including the gaps in services;
  • The impact that care has on the care workforce and family caregivers.
  • The primary goal of this study is to assess the cost and impact of three main financing proposals:
  • o A long-term care benefit for all Michiganders;
    o A public-private risk-sharing insurance program that reimburses insurers;
    o A long-term care benefit for those who do not qualify for Medicaid.

Today, Michigan Medicaid spends almost $3 billion per year on LTSS — and the cost goes up each year. But Michigan families spend more. AARP Michigan reports that Michigan families provide $15 billion worth of uncompensated care each year. New options are needed to keep both the state budget and Michigan families healthy during the state’s “age wave” era.

On the workforce side, Michigan is already facing shortages of people able and willing to fill direct caregiving jobs. MDHHS will engage experts to examine what supports current workers need to remain in the LTSS workforce: e.g., career ladders, benefits and wages to make LTSS jobs more attractive, and workplace conditions to make LTSS jobs safer and valued to attract candidates and keep them. Overtime and turnover due to stressed staff are major cost centers and major causes of staff shortages. The LTSS study will examine all of these factors and create new solutions to make LTSS jobs a career option for many more people.

Similar studies in the states of Washington and Hawaii have resulted in major changes to how LTSS is delivered and paid for in those states. The AARP Long Term Supports and Services Scorecard ranks these states respectively first and seventh in the nation on an array of measures. Washington and Hawaii have used results of LTSS studies to develop much better options for individuals and workers. Michigan is overdue for a serious examination of issues in financing and staffing LTSS, and this opportunity will jump-start major innovations. In the absence of a national strategy or plan for affordable high quality LTSS, several additional states are pursuing state level action. The chart below provides some current examples:

The current environment of long term care in Michigan includes over 40,000 nursing home beds in about 430 facilities, another 40,000 beds in about 4,500 Adult Foster Care Homes, and 10,000 beds in about 190 Homes for the Aged. An unknown number of unlicensed Assisted Living facilities operate in Michigan, serving an unknown number of people. In addition, another unknown number of people are getting care through visiting nursing services, private duty home care, and other unlicensed businesses offering various services. Medicaid also funds 11,000 Medicaid HCBS beneficiaries through the “MI Choice” program, and over 3,000 beneficiaries (the vast majority are dually eligible) through 10 PACE organizations (Program for All Inclusive Care for the Elderly). Michigan is home to nearly 1.9 million Medicare beneficiaries, of whom almost 300,000 are also eligible for Medicaid.

Experts estimate that 50% of the Medicare population will need long term care at some point in their lives. In Michigan and around the country, elders are the fastest growing segment of our population – so the need for LTSS, which seems high today, is set to increase steeply over the coming years.

To put some financial parameters around this discussion, nursing home care costs Michigan’s Medicaid budget $1.7 billion dollars per year; private pay rates in nursing homes range from $9,000 to $11,000 per month. Adult Foster Care and Home for the Aged monthly rates range from $800 to $5,000 for those able to pay privately. Michigan spends another $350 million on MI Choice and PACE, both of which have lower monthly costs than nursing home care. Area Agencies on Aging and other community organizations provide supportive community services, but their budgets are quite limited and have not seen the significant budget increases needed to keep pace with the growing aging population.

The costs to individuals and families of unplanned, poorly coordinated LTSS are also very high: First there are substantial “out-of-pocket” costs associated with in-home services, equipment, medications and more medical procedures and visits; second are the high costs to family caregivers, who may face the loss of their jobs and their own livelihoods as care needs increase. Some families may also find it necessary to move to different housing that can accommodate an ill or disabled family member’s needs for disability access, thus incurring the costs of moving. Many families struggle and figure out how to cope for a while, and later give up – leading to costly nursing home admissions. Others simply go bankrupt.

Like other states, Michigan must devise ways to stretch publicly financed health care dollars further to support LTSS. For families, LTSS must be made more affordable and reliable – and delivery systems must shift to services that can readily be delivered at home. The workforce that delivers this care must be well-trained, supported, and paid a living wage to assure quality and continuity of services. With advocates, researchers, policymakers and funders at the table, the Michigan LTC study is a prime opportunity to create smart adaptations to existing programs, and to create new and more efficient initiatives. Both will serve as investments in the future.

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Mar 282018
 

By Les Morgan

The following reports were produced as deliverables for our project “Aggregating Care Plans to Manage Supportive Care Services for Elders” (Joanne Lynn, M.D., Principal Investigator).This project is funded by the Gordon and Betty Moore Foundation through Grant GBMF5662 to Altarum Institute. Dr. Lynn will provide a more detailed report on the project as a whole in a following blog post.

We are releasing these reports now particularly to help some of the community groups we are working with on data projects. The first three reports cover technical details of how care plans can be structured, stored, and shared in electronic information systems. Those three reports taken together provide useful information that can be used by community groups seeking insight into eldercare through the use of data aggregation methods.

Communities that are seeking to improve eldercare need trustworthy data to use in setting priorities and in monitoring improvements. One appealing approach is to aggregate existing health-related records and analyze the data for key indicators of how their local system is functioning. However, for most of the communities we have worked with, on a practical level the aggregation of this sort of data seems to be very difficult or impossible, given important concerns over privacy and the serious penalties associated with breaches of privacy obligations. Our hope is that these reports will help overcome some of the obstacles that stand in the way of improving care for some of our most vulnerable citizens.

To read the full reports in PDF format, click on the report name you wish to view.

Report 1

Interim Report on the Variety and Merits of Care Plan Templates and Regulations in Use, Including Implications for Information Technology [PDF]

Joanne Lynn and Les Morgan. October 20, 2017

Effective multidisciplinary clinical teams know their patients but document only a skeletal summary of the case. That summary generally includes diagnoses, basics of the living situation, medications, treatments, and supportive services in use or recommended. The various biases, omissions, and lack of long-term perspectives in the clinical documentation are substantial, as summarized in the report.

Our scan of forms and data formats for care plan documentation shows a wide variety of approaches. All made heavy use of free-text narrative elements. The most complete and up-to-date set of care plan records that we have seen was done longhand on a typewritten sheet by a single care coordinator responsible for over one hundred high-need patients seen at one hospital.

The electronic record systems that we reviewed used only to carry the minimal information needed for a C-CDA transmission mostly limited to immediate and near-term needs. None of the electronic records we examined were being used to record the caregivers with their roles, the prognosis, or an advance directive. None used the existing FHIR data format standards for complete care plans.

Report 2

Interim Report Summarizing Data Aggregation Methods in Use To Date and Their Strengths and Weaknesses [PDF]

Les Morgan. October 20, 2017

This is a high-level Information Technology (IT) architectural review discussing major variations in system design approaches for care plan data aggregation, based on a content analysis of interviews with vendors and some key users. A series of architectural diagrams is included to classify approaches. Our interviews with technology vendors are ongoing, and this preliminary summary of methods will evolve as we see more examples of working systems.

Report 3

Aggregating Patient-Level Data: Regulatory, Ethical, and Privacy Issues for Communities [PDF]

Les Morgan and Joanne Lynn. March 2018

This report gives an overview and assessment of regulatory, ethical, and privacy issues specifically related to the use of aggregated care plan and related health data for analytical use across defined geographical catchment areas. The literature covering regulation and privacy of healthcare data is extensive and often contentious. Our review here highlights some major sources for authoritative guidance, then moves on to the specific situation of using aggregated and de-identified data sets for geographic analysis. Regulations that are specific to requirements for maintaining care plans were covered in our prior project report (Interim Report on the Variety and Merits of Care Plan Templates and Regulations in Use, Including Implications for Information Technology) and are not repeated in this report.

A key conclusion of our review is that using aggregated and de-identified data on a broad geographic basis is probably not restricted as much as many of our community stakeholders and leaders think. Some uses of such data are specifically exempted from key privacy laws when appropriate protections are in place. Some regional health care payer systems and Health Information Exchanges (HIEs) have mechanisms to enable such research now, using very large data sets they have already compiled. This means that it is feasible to carry out pilot projects to demonstrate practical methods for data aggregation and analysis for a community or region in many parts of the United States.

Report 4

Benchmarking the Eldercare Workforce: A Community Focus [PDF]

Meghan Hendricksen and Joanne Lynn. February 2018

The overall purpose of this report is to provide an initial, alpha-version, benchmark of the workforce within geographic communities to use for illuminating comparisons with their own workforce estimates.

This baseline benchmark will provide a tool for consideration, and then feedback for improving the tool. In essence, we are creating the start of a learning system for optimizing the workforce in a geographic community. Once the estimates and ranges become substantiated in multiple communities and improvement activities, the maturing benchmarks will provide a trustworthy source of guidance for communities, where evidence is currently lacking, on what the priority needs are for the workforce that is serving older adults living in the community and also will provide a tool for monitoring improvements. Measuring the local workforce capacity also helps engaged community leaders to envision their whole system and its products, even though that “system” is owned and operated by many different entities that are not necessarily coordinated.

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Feb 222018
 
Photographs of Joanne Lynn and Sarah Slocum
Authors Joanne & Sarah

By Joanne Lynn and Sarah Slocum

“All models are wrong, but some are useful”. – George Box

In late November, the Centers for Medicare and Medicaid Services (CMS) released an extensive evaluation of the Community-based Care Transitions Program (CCTP). (https://downloads.cms.gov/files/cmmi/cctp-final-eval-rpt.pdf)

While the report has some useful points, the primary metrics used to measure performance – re-hospitalization/discharge rates, are seriously deficient. To start with, reducing hospital readmissions – or, for that matter, reducing admissions – is not always good for patients. More importantly, the CCTP evaluation presumed that the relevant part of the patient’s journey starts in the hospital at discharge, and that the main issues revolve around having and adhering to the correct discharge instructions, especially for medications, which then lead to engaging the patient in his or her outpatient medical care. These are certainly important, but the evaluation’s narrow focus on short-term transitions of care leaves out much of what happens in the lives of seriously ill persons that reflect the capacity of their community to provide ongoing supportive services – disability-adapted housing, home-delivered nutritional food, the adequacy of the personal care workforce, employer flexibility for family caregiving, and more.

The CCTP was part of a larger innovation effort sponsored by CMS, the Partnership for Patients, which had an overall goal of a 20% reduction in Medicare fee-for-service (FFS) hospital readmission rates. The agency was given $500 million to implement CCTP in 101 sites around the country. Most project sites applied basic commonsense transitions of care protocols, for which there is substantial evidence, i.e., ensuring that newly discharged patients received the right medications and were engaged with their community-based physicians in order to prevent avoidable hospital readmissions within 30 days after discharge. Yet the focus on medical services provided at and for a short while following hospital discharge, as well as the metric that applied to hospital rates, distorted the endeavor and put a good number of participating community-based organizations at serious financial risk.

The original Quality Improvement Organization (QIO) project that preceded the CCTP measured the effect of improvement activities on entire communities (rather than specific hospitals), and aimed to reduce readmissions per 1,000 Medicare FFS beneficiaries across the entire population, https://jamanetwork.com/journals/jama/fullarticle/1558278. That model accepted the need not only to address medical errors and mobilize patient self-care, but also to focus on what it takes to successfully shift the support of very sick and disabled persons to community service providers and reduce the challenges of living with ongoing serious illness.

In the QIO project, most Medicare beneficiaries who were re-hospitalized within 30 days were known to be very sick and disabled prior to the initial hospitalization. This meant that the hospitalization episode represented a few somewhat worse days in the course of living with a serious condition, such as an organ system failure, neuromuscular degenerative disease, or frailty. That understanding broadened the focus of reforms to include examining the capacity of the person’s community to support very sick and disabled persons with reliability and competence. The interventions aimed to optimize the overall course of disease and disability and to ensure that the individual and family (and other caregivers) felt well supported. For example, they worked to ensure the adequacy of the care plan, prompt availability of supportive and personal care services, and realistic planning for decline and death.

However, in building on the QIO results, CMS shifted the focus to a hospital-centric design and evaluated performance on a hospital-specific basis. This creates the problem that we reported in a previous blog, https://medicaring.org/2014/12/08/lynn-evidence/, which is that good practices in the community reduce the number of admissions at about the same rate as the number of readmissions, is ignored. In turn, this makes the hospital-based readmissions/admissions metric misleading. Perhaps more important, structuring the CCTP to measure the impact only on the hospital leaves out the importance of how effective community-based providers were in providing supportive services over time to frail elders living at home and in other community settings.

Some community services providers nevertheless managed to help their partnering hospitals make impressive gains in reducing re-admissions. For example, the Eastern Virginia Care Transitions Program (EVCTP) brought together five Area Agencies on Aging that improved support and smoothed transitions across 20% of the state. Five health systems and 69 skilled nursing facilities joined. Re-hospitalizations for the whole area declined from 18.2% of all FFS Medicare discharges in 2013 to 8.9% in 2015, resulting in a $17 million savings to Medicare and a great deal of avoided suffering by patients, families, and caregivers. EVCTP used the Coleman Care Transitions Intervention© and offered enhanced services as part of the admissions process for certain segments of the Medicare population. It also prompted formation of a coalition of all 25 Area Agencies on Aging in Virginia to infuse best practices in subsequent partnerships across the state, http://www.chcs.org/media/EVCTP-Case-Study_101217.pdf/.

In Akron, Ohio, “Direction Home,” the Area Agency on Aging’s program, first began embedding coaches (either nurses or social workers) in local hospitals in 1998 to assist patients through connecting them to various community services, including home care and home delivered meals. That history of collaboration between health care providers and social services providers gave Akron a head start in reducing hospital use by Medicare beneficiaries with ongoing serious chronic conditions. Between 2010 and 2016, hospital readmissions fell from 19.6% of Medicare FFS hospital discharges to 11.7%. Akron leaders attribute much of this success to intentional relationship building, which extends to having health system professionals on the boards of community organizations, http://www.commonwealthfund.org/publications/case-studies/2017/aug/akron-ohio-health-care. However, CMS did not allow community-based organizations to use CCTP funds for training, overhead, data development, administration, or outreach – only for the patient-facing services. This meant that some of the community-based organizations encountered major difficulties and high costs in trying to forge initial connections and close working relationships with hospitals in their area.

Other findings in the evaluation point to well-documented challenges for some CCTP sites, including incorrect (or poorly understood) discharge instructions on medications and dietary restrictions; under-resourced community-based services; fragmentation between social services and health care systems; and a lack of data at the individual level for high-value individual care planning, and at the aggregate level for geographically-based system planning.

Every model leaves out a great deal of complexity. What matters is what we retain and take forward in subsequent work. We can accept that high re-hospitalization rates are probably evidence of shortcomings in a hospital’s discharge processes, and that mobilization of patients to take care of themselves gets us partway toward a better model of care. However, we should also include how communities and their social support organizations can improve access to adequate safe housing, nutritious food, reliable personal care, and other key services. That more complex model requires the involvement of multiple stakeholders, and measuring the performance of a complex, multi-faceted care system that serves similarly situated individuals across a geographic community — rather than just the re-hospitalization rates of certain hospitals.

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Dec 122017
 
Anne Montgomery portrait
Anne Montgomery

By Anne Montgomery [as posted on the American Society on Aging (ASA) website]

As evidence accumulates on how community-based organizations (CBO) can cost effectively meet the medical and long-term care needs of older adults through supportive services, the importance of linking multiple data streams across settings becomes clear. But until recently, policy barriers hampered effective collaboration and communication between the healthcare sector and CBOs.

Read the full post at the American Society on Aging (ASA) website:

Overcoming Barriers: The Case for Enhancing Collaboration and Communication Between Medical and Community Settings

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Jun 202016
 

MediCaring Communities: Getting What We Want and Need in Frail Old Age at an Affordable Cost
Published June, 2016
194 pages, 6″ x 9″ (15.24 x 22.86 cm)

ISBN-10: 1481266918

List Price $9.95 at Amazon.com

Americans want a long life and most of us will get to live into our 80’s and beyond, but we have not squarely faced the challenges of living well in the last years of long lives. This book lays out a thoroughly pragmatic way to organize service delivery and financing so that Americans could count on living comfortably and meaningfully through the period of disability and illness that most will experience in the last years of life – all at a cost that families and taxpayers can sustain. MediCaring Communities offers to customize care around the priorities of elders and their families and to manage the local care system so it is reliable and efficient.

MediCaring Communities book cover

MediCaring Communities book (click cover to view on Amazon.com)

Three out of four of us will need long-term care. The period of needing someone’s help every day now lasts more than two years, on average. Most of us will not have saved enough to get through this part of life without financial help from family or government – indeed, we’ll spend almost half of our total lifetime healthcare expenditures in this last part of life, mostly on personal care that is not covered by Medicare. We have not yet required housing to be modified for living with disabilities or secured a ready supply of home-delivered food, and we certainly have not required medical care to focus on the patient and family priorities in order to enable the last years to be meaningful and comfortable. Family caregiving will be a crisis as families become smaller, more dispersed, older, and facing inadequate retirement income for the younger generation.

MediCaring Communities improve care by building care plans around the health needs and living situation of the elderly person and family, and especially from respecting their choices about priorities. The improvements in service delivery arise from integrating supportive services at home with customized medical care and installing local monitoring and management. The improvements in finance arise from harvesting savings from the current overuse of medical tests and treatments in this part of life. These come together in MediCaring Communities.

Strong evidence supports each component, but the real strength is in the combination, where savings support critical community-based services, communities build the necessary environment, and elders and their families craft their course with the help of interdisciplinary teams. This book lays it out, using expansion of PACE (The Program of All-Inclusive Care of the Elderly) as the test case. The book provides a strong and complete guide to serious reform, and just in time for the aging of the Boomers which will escalate the needs dramatically during the 2030’s. Now is the time to act.

You can read extracts online.

Advance Praise for MediCaring Communities

“For decades, Joanne Lynn’s has been the clearest, strongest, most soulful voice in America for modernizing the ways in which we care for frail elders. This essential book is her masterpiece. It offers a magisterial, evidence-based vision of that new care, and an entirely plausible pathway for reaching it. Facing a tsunami of aging, our nation simply cannot afford to ignore this counsel.”
—Donald M. Berwick, MD, President Emeritus and Senior Fellow, Institute for Healthcare Improvement, and former Administrator, Centers for Medicare & Medicaid Services.

“MediCaring Communities integrates good geriatrics and long-term services and supports, and building upon an expanded PACE program can be a tangible start. We should try this!”
—Jennie Chin Hansen, Lead in Developing PACE; Past President, AARP; and Past CEO of On Lok Senior Health Services and the American Geriatrics Society.

About Joanne Lynn

Joanne Lynn, MD, MA (Philosophy and Social Policy), MS (Quantitative Clinical Sciences), is Director of Altarum Institute’s Center for Elder Care and Advanced Illness. Dr. Lynn has served thousands of persons in their last years of life in home care, office practice, hospice care, and nursing homes. She was one of the first hospice physicians in the United States. Dr. Lynn has been a tenured professor at Dartmouth and George Washington University, a quality measurement expert on the staff at the Centers for Medicare & Medicaid Services, the Bureau Chief for Cancer and Chronic Disease in the public health office for Washington (DC), a senior researcher at RAND, and on the Institute for Healthcare Improvement’s quality improvement faculty. She is a member of the National Academy of Medicine, a Master of the American College of Physicians, a Fellow of the Hastings Institute and the American Geriatrics Society, and an author of more than 280 peer-reviewed publications, 80 books and chapters, and a dozen amicus briefs and publications for public commissions.

The reader can learn more about our work and give us advice and insights at MediCaring.org.

About Altarum Institute

Altarum Institute (Altarum.org) is a nonprofit research and consulting organization based in Ann Arbor, Michigan. Altarum integrates independent research and client-centered consulting to create comprehensive, systems-based solutions that improve health. One focus has been addressing the challenges of living with advanced illnesses and disabilities in old age through the Center for Elder Care and Advanced Illness. The dozen staff at the Center aim to help the United States achieve social arrangements that ensure that, when we must live with serious chronic illnesses associated with advancing age, we can count on living meaningfully and comfortably, at a sustainable cost to our families and society.

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Jan 042016
 

By Anne Montgomery and Leslie Fried of the National Council on Aging

One of the hallmarks of the 21st century—increased longevity of the population—will increasingly drive federal, state, and local health care programs to focus on optimizing coordination of services across a range of medical care and community services providers. Discharge planning will play a central role in these efforts, particularly discharge to home.

In November, the Centers for Medicare & Medicaid Services (CMS) issued a proposed regulation for hospitals (defined as including critical access hospitals, long-term care hospitals, and inpatient rehabilitation facilities) and home health agencies. Overall, it is a solid effort and a welcome step forward in calling for Medicare and Medicaid to interface with Older Americans Act providers and disability programs under the jurisdiction of the Administration for Community Living. All of these programs and others are centrally concerned with managing beneficiaries who have complex chronic conditions. They are also well-positioned to set out criteria that can help providers establish systems of joint management of complex patients over extended periods.

However, while the rule prominently references Aging Network providers—Area Agencies on Aging, Aging Disability Resource Centers, and Centers for Independent Living—in the preamble, it does not carry substantive discussion through to actually require health care providers to coordinate with these community-based organizations.

We see this as a shortcoming, since the array of services offered by these organizations, which include home and physical environment modifications, access to assistive technologies, transportation, meals, household services, and housing support, are essential to millions of Medicare beneficiaries who cannot function day-to-day without some assistance. Absent clear requirements for health care providers to coordinate with social services organizations, risks will remain high that many fragile, complex older adults living in the community will fall through the cracks and into crisis, cycling in and out of high-cost health care settings.

If we think about discharge planning in a larger context, it is effectively only the start of a successful transition. Keeping information about patients with chronic conditions in the hands of a “sending” health care provider only, with no explicit requirements to make adequate provisions for communications and preparations with “receiving” community-based organizations, is likely to result in frustration for families and missed opportunities. By comparison, to maximize opportunities for success, CMS could bring the Aging Network into discharge planning discussions as soon as health care providers start to prepare for a patient’s transition—and could determine the actual availability of these services. If it turned out that publicly funded community services were not available (possibly due to waiting lists and/or underfunding), health care providers could be asked to explore alternatives. In all cases, figuring out what options are actually available and affordable must be done in consultation with the patient and family caregiver.

To improve the chances that community social services organizations can be better funded, we believe that CMS should direct nonprofit hospitals to assess services shortages as part of their Community Benefit Needs Assessments, and take subsequent steps to mitigate and augment critically needed services in the community. For-profit hospitals should be similarly required to work with public health offices and Aging Network providers to assess and correct any inadequacies in service supply.

On a related point—assessment of the discharge planning process—we strongly encourage CMS not to limit these reviews to assessment of the impact on readmissions (§482.43(c)(10)). Rather, in the spirit of the regulation’s frequent references to Aging Network providers, we urge that hospitals be required to establish advisory committees to conduct periodic reviews that include community social services organizations and other stakeholders in order to track the full impact of discharge planning on patient outcomes over time.

In another area—the specific elements that must be covered in discharge planning documents—the regulation proposes varying requirements for different providers. In the case of home health agencies, for example, discharge and transfer summaries must include demographic information; contact information for the physician; an advance directive, if available; the course of the illness/treatment; procedures; diagnoses; lab tests and other diagnostic testing; consultation results; a functional status assessment; a psychosocial assessment, including cognitive status; social supports; behavioral health issues; reconciliation of discharge medications; all known allergies; immunizations; smoking or nonsmoking status; vital signs; unique device identifiers for implantable devices; recommendations for ongoing care; patient goals and treatment preferences; the current plan of care, including goals, instructions, and the latest physician orders; and “any other information necessary to ensure a safe and effective transition of care that supports the post-discharge goals for the patient.”

In contrast, there is a much shorter list for critical access hospitals to consider in the context of “areas where the patient or caregiver/support person(s) would need assistance.” It includes admitting diagnosis or reason for registration, relevant co-morbidities and past medical and surgical history, anticipated ongoing care needs post-discharge, readmission risk, relevant psychosocial history, communication needs (e.g., language barriers, diminished eyesight and hearing), patients’ access to non-health care services and community-based care providers, and patients’ goals and preferences. Yet another list of criteria pertains to “discharge to home” situations, which requires instruction on post-discharge care to be used by the patient or the caregiver/support person; written information on warning signs and symptoms; prescriptions, including the name, indication, dosage, and significant risks and side effects; medication reconciliation; and written instructions for patient follow-up care, including appointments, diagnostic tests, and pertinent contact information.

Logically, there should be a list of core elements that could also be the foundation for a common care plan, and which could then be readily shared across providers working in different settings. Requiring a list of core elements would simplify care coordination and basic communication between providers, and decrease confusion and chaos for families who are often confronted suddenly with very difficult tasks when taking a seriously ill or disabled person home. Perhaps the list of required elements outlined for home health agencies could be the basis for crafting standardized core elements for all covered health care providers, along with a person’s likely future course, strengths, treatment preferences, and goals.

Concerning the critical role played by family caregivers, the rule recognizes and acknowledges the importance of families in many places – yet does not clearly establish the voluntary nature of this support: In other words, the primary consideration in discharge planning with regard to family caregivers should be to determine their willingness to provide services. To address this, we hope that CMS will consider requiring health care providers to engage in a conversation and subsequently document that a family caregiver has been asked about specific supports that he or she may need, taking into account the family’s economic resources.

The regulation features thoughtful discussion medication reconciliation and health information technology (HIT). For beneficiaries with complicated medication regimens or a track record of medication problems, we believe that CMS should encourage covered providers to use a pharmacist or physician (as compared to a software program or a nurse) whenever practicable. To make strides on HIT, there may be scope for the agency to require a standard format for recording a care plan, in order to improve interoperability and to make care plans an integral part of standards for certified electronic medical records.

Finally, the regulation should guarantee that discharge planning documents are immediately accessible to patients and family caregivers. Under current protocols governing medical records, it is often difficult for family caregivers to obtain a medical record from a hospital until after discharge, even with a patient’s signed consent (which is not always possible to get if the patient is seriously ill). This is unhelpful and counterproductive for families and should not be allowed to be extended to discharge planning documents.

CMS’ discharge planning regulation is moving in the right direction. As the agency considers these and other ideas for improvement, we hope that the agency will take the opportunity to advance a national conversation on how discharge planning can play a key role in health and social services delivery system reforms.

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Oct 282014
 

By Joanne Lynn

What matters in the lives of frail elders centers on function — and understanding an elderly person’s course, over time, requires that everyone involved learn to measure functioning in the same way. That’s the core of the new Improved Medicare Post-Acute Care Transformation (IMPACT) Act, passed by Congress in September 2014. Within a few years, we will have a uniform way of measuring what matters, including at least functional ability, across all post-hospital settings. The work that Medicare will have to do to implement IMPACT provides a remarkable opening for advocates to get Medicare measuring the things that matter.

About a decade ago, I started working at the Centers for Medicare & Medicaid Services (CMS) in the Quality Measurement and Health Assessment Group. In straightening up my cubicle on the first day, I was dumbfounded to find a small cache of notepads emblazoned with “HCFA” and even more yellowed ones saying “Social Security Administration.” But the real gem was a set of transcripts from hearings nearly 30 years ago that addressed the wisdom of having a Uniform Assessment Instrument (UNAI) for the elderly. The arguments were cogent, and many of those testifying were well-known in geriatrics and gerontology to this day. But the world did not turn their way.

CMS ended up with some assessment instruments: the Minimum Data Set (MDS) for nursing homes, the Outcome Assessment and Information Set (OASIS) for home care, and the Inpatient Rehab Facility-Patient Assessment Instrument (IRF-PAI) for rehabilitation hospitals. There was little consistency between them. One instrument might ask whether an elder could do a task, another asked if he did do the task, and the last could ask how quickly he did it. If a person were in a sequence of settings that used different instruments, there was no way to see whether the person changed or it was just that the specific questions were different. This inconsistency was crazy! It precluded doing a serious study of outcomes across settings, characterizing populations of frail elders who used multiple settings, or even training practitioners to optimize the quality of data.

CMS has done one remarkable study, the Post-Acute Care Payment Reform Demonstration (PAC-PRD), in which elderly hospitalized persons were measured with a standardized tool, called the CARE Instrument. The findings have slowly surfaced and show that most outcomes are not affected by the setting of treatment, but the costs are dramatically different. This has led the Medicare Payment Advisory Commission (MEDPAC), in its June 2014 Report to Congress, to take notice and call for more site-neutral payments. This would mean that Medicare would not pay differently for treatment in settings that are not shown to make a difference in outcomes.

But for any rationalization of the increasingly expensive period just after hospitalization, one really needs the UNAI, a uniform way of measuring what matters, including at least functional ability, across all settings and time. That is the core of IMPACT. The Act requires that CMS promulgate a standard assessment and that all post-hospital providers use it and report data in that form. This meshes with an entirely separate project by the same name, Impact, an Office of the National Coordinator for Health Information Technology project that has identified and standardized hundreds of elements that might be part of an assessment and care plan and is beginning to pilot-test the interoperability of records across sites in long-term care. The IMPACT Act makes UNAI real, with various deadlines, mostly 2018.

Having uniform data that will allow identification of functional disability and other important clinical categories creates the possibility of developing quality measures that reflect the priorities of frail elders, and the Act and the Executive Action Fact Sheet that accompany it give clear instruction to build measures of this sort.

How do the IMPACT Act and the associated executive actions give us a window of opportunity? IMPACT, in its section on quality measures, requires that care preferences of the individual and the family caregiver be part of the data to be reported at the time of a transition in setting of care. In a section on quality measure use, the Act requires that conditions of participation include procedures to address the patient’s treatment preferences and goals of care. The Act also calls for studies of the effects of socioeconomic factors and beneficiary activation on quality measures. The Act requires stakeholder input, and all of us are stakeholders. We hope to grow old, and we hope our loved ones do also.

What matters most when we are living with disabilities, chronic conditions, and frailty associated with advanced age? Most people still want to live a bit longer if possible. But most of us become more aware with age that we are working with a truncated timeline and long-term outcomes are no longer relevant. For that and other reasons, many additional considerations start crowding the stage. Some want to be sure that a disabled adult son has assets to live on; others have no dependents. Some want to honor their faith traditions; others want to solidify their departure from those beliefs. The endless variations make it impossible to have one care plan that fits all people.

So why do we now measure quality for frail elderly people as if everyone wanted mainly just to live longer with better health? Often, our metrics just comply with professional (mostly physician) guidelines on how to take care of (somewhat younger) bodies. People become more and more individualized with their particular family, finances, dreams, and fears as they age. We really must learn to measure the quality of health care by the degree to which it serves the individual’s priorities. We must learn to ask, “What matters to you, and what matters most to you?” and to judge quality by how well the services actually deliver on what matters most.

Could we do that? Sure! First, we need to document what matters most to the frail elderly person (and family) and what strategies will most likely accomplish the feat — commonly termed an “assessment and care plan.” Then we need to measure whether the elderly person (and family, as appropriate) feels that the services help to achieve what matters most. We could start with a simple scale: “Working against my interests,” “Not clear or not particularly helpful,” and “Completely or mostly aligned with what matters to me.” We would learn how to do it better, but the important thing is to start caring about what matters to the individual person.

Of course, some things are important to so many people that we might learn to measure them across the frail elder population. Metrics of “what really matters to me” could include, for example, “the rate at which the care system spends down my financial assets,” “the likelihood that I can stay in my home as long as I want to,” “my confidence in having adequate preparation for adverse events and adequate backup for challenges,” and “the stress that my family and friends feel as they try to ensure that I have what I need.” Most people care about avoiding falls and injuries and living where they want to live. While we are at it, let’s start measuring important things about family caregivers: availability, skills, stresses, and challenges. These are what most often really matter when you are living your last years with disabilities and limitations. How different this is from the usual “percentage with diabetes under control” or “percentage with colon cancer screenings”!

Let’s do what we can to help CMS commit to building the metrics that we need. Here are some suggestions:

  1. Contact the organizations to which you belong and encourage them to include advocacy on behalf of quality measures appropriate for frail elderly people in their work with Medicare and Medicaid.
  2. Write to CMS and your congressional representatives to push for metrics that really reflect the concerns of frail elderly people and their families.
  3. If you are funding or doing research in this arena, stretch the scope to include what really matters.
  4. When you look at Nursing Home Compare, Home Health Compare, or any of the quality information for the public sites, send a comment to CMS, your congressional representatives, or your Quality Improvement Network that the metrics are not yet what you hope to see. You can offer some of the ones that I listed above as examples of what we should have.
  5. Some responsive and forceful advocacy for frail elderly people is at Consumer Voice, OWL, and Gray Panthers and caregiver groups. Join them and encourage their work in these arenas.
  6. Write to us with suggestions and plans. The time is upon us! We will watch for CMS requests for information, proposed regulations or conditions of participation, and RFPs. You can also let us know if you see something potentially important going by.

This is important, and an opportunity has opened up that might move us along well.

Want to know more?

Post-Acute Care Payment Reform Demonstration: Final Report
http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports/Research-Reports-Items/PAC_Payment_Reform_Demo_Final.html

CARE Instrument
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/CARE-Item-Set-and-B-CARE.html

Medicare Payment Advisory Commission (MEDPAC) June 2014 Report to Congress
http://www.medpac.gov/docs/default-source/reports/june-2016-report-to-the-congress-medicare-and-the-health-care-delivery-system.pdf?sfvrsn=0.pdf?sfvrsn=2

Standards & Interoperability (S&I) Framework
https://www.healthit.gov/topic/interoperability/standards-interoperability-si-framework

White House Fact Sheet on Executive Actions to Improve Quality of Care
http://www.whitehouse.gov/the-press-office/2014/10/06/fact-sheet-administration-announces-new-executive-actions-improve-qualit

PDF Download of the full text of HR 4994 (the Act)
http://www.gpo.gov/fdsys/pkg/BILLS-113hr4994enr/pdf/BILLS-113hr4994enr.pdf

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Aug 262014
 

By Joanne Lynn and Steve Jencks

Work to reduce readmissions has started to yield remarkable improvements in integration of care for frail elderly people – by prompting hospital personnel to talk with community-based service providers, by teaching patients and families how to manage conditions and navigate the health care system more easily, and by paying more attention to trying to fill gaps in the community’s services. But the measure being used to track improvement is seriously misfiring in some settings, and if CMS does not mitigate the adverse impacts, they may become destructive to the momentum and the good that has been done. This is much more than an issue of imperfect risk adjustment or inadequate identification of planned readmissions: it is a punitive error that undermines program goals.

Since CMS mostly aims to assign responsibility for readmissions to the discharging hospital, the key metric has been the risk of readmission for the average person discharged, which is the number of readmissions, divided by the number of live discharges. Any time outcomes are monitored with a ratio, one has to watch out for whether interventions that affect the numerator also affect the denominator. Here, that’s happening enough to completely obliterate the usefulness of the metric – at least in some circumstances.

Here’s a quick hypothetical example: At baseline, a hospital has 1,000 Medicare fee-for-service (FFS) discharges per quarter, with 200 of them back within 30 days. Subsequently, the hospital team and various community-based providers work together and drop the readmissions to 160 per quarter. Does the readmission rate go down to 16% under the metric? No. First, they no longer have the 40 readmissions that are also admissions and in the denominator. But more important – the very things that are reducing the readmission rate also affect the likelihood of coming back in 45 days, or 6 months, or ever! Patients are supported in learning to take care of themselves and to advocate for themselves in the care system, they make good care plans (including advance care plans), and they encounter a more supportive care system in the community. These things are still affecting the patient many months after the hospitalization. Indeed, as the care system learns how to support fragile people in the community better, fewer patients will need to come to the hospital in the first place. The result for our hypothetical hospital is that it ends up with 800 discharges per quarter, and it has not budged its readmission rate! Officially, it has not improved, even though the work done by the hospital, by patients and families, and by community-based providers has improved care substantially, and has saved millions of dollars for Medicare. Yet, using the current flawed metric, the hospital is still likely to be penalized for having a high rate of readmissions!

This is not a new observation. The first sizable pilot project that CMS sponsored involved 14 communities, and the readmissions/discharges metric functioned so poorly that the outcome measure was changed during the project to a population-based measure: readmissions per 1,000 Medicare FFS beneficiaries in the geographic community [See: http://jama.jamanetwork.com/article.aspx?articleid=1558278]. That measure works to track changes in the experience of those living in a community, but it does not help in assigning credit or blame to particular providers (unless there is only one provider in the area). It is intrinsically community-anchored. The rub is that while good care of frail, chronically ill persons is at heart a community endeavor, Medicare has few tools to incentivize or penalize communities.

Furthermore, it is not clear what the “right rate” of readmissions should be. Very little work has been published on how well the various metrics perform in various circumstances, though NQF has a score of new ones under consideration [See: http://www.qualityforum.org/ProjectDescription.aspx?projectID=73619]. The hospital penalty measure has a very complicated risk adjustment, but should the population-based measure also be risk-adjusted (perhaps at least for the population age structure and whether the person is in Medicare due to disability or age)?

The problem here is more urgent than other controversies regarding the Medicare readmission measure such as higher readmission rates in disadvantaged populations and whether communities with low total hospital utilization should be expected to have higher readmission rates. In the case of measuring change, the measurement flaw directly punishes hospitals and communities for doing what the Affordable Care Act and the Medicare Readmissions Reduction Program otherwise encourage them to do: reduce preventable hospitalizations.

What should a responsible system manager like Medicare do? Below are some suggestions.

In the short-term:

  1. Quickly sort out how to exclude certain contexts, perhaps as part of risk adjustment – e.g., whether CMS is authorized to limit application of the readmissions/discharges metric through regulation, or whether the issue has to go back to Congress.
    1. For safety net hospitals – don’t penalize hospitals primarily serving poor beneficiaries.
    2. For reducing admissions – see which of these approaches works best (or combine them)
      1. Hospitals with declining admissions (and the same bed size), when the decline is at roughly the same rate (or more) than declining readmissions
      2. Hospitals with >50% of their Medicare FFS utilization in counties with admission rates in the lowest quartile in the nation
  2. Allow hospitals in a particular geographic area to propose accountability for a population – jointly or singly – so long as they together supply more than, for example, 70% of the hospital use for that population. Then measure their success on a population basis (readmissions/1,000 relevant people living in the area/quarter, and admissions/1,000/quarter)

In the longer-term:

  1. Develop useful metrics for continuity and quality of care, especially for:
    1. Reliability, patient/family sense of trustworthiness/preparation; and
    2. Patient/family driven care plans, evaluated for quality with feedback
  2. Develop useful metrics for the global costs of care, including private and Medicaid costs, for longer terms of illness, not depending upon hospitalization as the trigger, and including long-term services and supports.

What Can You Do Now?

If you agree, let’s talk about how to make improvements to the metric with the National Quality Forum, CMS, hospitals, and other interested organizations and colleagues. Feel free to add comments and suggestions here, too. Let’s build a commitment to evolving toward measures that really reflect optimal care, rather than staying with the under-performing and often misleading ones we have.

Want to know more?

Jencks et al.’s New England Journal of Medicine article on readmission statistics:
http://www.nejm.org/doi/full/10.1056/NEJMsa0803563

The Hospital Readmissions Reduction Program:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

The Community-based Care Transitions Program:
http://innovation.cms.gov/initiatives/CCTP/

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