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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Jun 182018
 

The Program to Improve Eldercare (PIE) at Altarum Institute is preparing to award several small contracts to healthcare organizations, Public Health Departments, Area Agencies on Aging, and community-based organizations (CBOs) to carry out guided planning efforts to improve care for frail elders though more effective use of existing data concerning persons living in their catchment areas. The overall goal is to help local management define and generate measures of the local system’s performance concerning eldercare.

The contracts will not require collecting any new data. Each site will work with their own data that is already on hand to conduct aggregated analyses for their own community and region. The results of all funded contracts will form the basis for a national White Paper on how communities across the United States can monitor and manage the arrangements for care for elders living with disabilities and chronic conditions through improved use of aggregated data from multiple sources, such as clinical care, surveys, and use of community services.

Our goal is to empower communities and therefore to fund pilot projects that show high promise using several different approaches to community management of eldercare. Throughout, we aim to work with the sites to identify and document business models in use at the partner sites to support existing or improved system performance for providing adequate supportive care services.

This effort is funded by the Gordon and Betty Moore Foundation through Grant GBMF5662 to Altarum Institute (“Aggregating Care Plans to Manage Supportive Care Services for Elders”), Joanne Lynn, M.D., Principal Investigator.

We invite organizations to contact us to discuss this in order to determine their interest in participating. Please contact us via email to [email protected]. We will be happy to help you determine if your community would be a suitable candidate for these projects.

Contracts will be awarded in two phases.

  1. Site Readiness Assessment Contracts (Performed from July 2018 through November 2018)
  2. Site Pilot Implementation Contracts (to be completed by June 2019)

Site Readiness Assessment Contracts (Performed from July 2018 through November 2018)

  • The Readiness Assessment contract phase will select up to ten geographically-focused organizations (“sites”) to receive a contract of $10,000 to participate in a structured strategic planning process to help the sites evaluate their current uses of data related to service provision for elders in their geographic region. We are looking for sites that at least begin to represent a geographic community’s population and that include at least some attention to both social supports and medical care. We are interested in entire catchment areas as a service delivery setting. With assistance from our national program staff, the sites will prepare a Readiness Assessment and strategic plan for improving quality and reducing cost for their eldercare system through better use of data and management information systems.
  • Our national staff will work with each of the sites to prepare a customized project plan that works backward from the seven strategic planning outputs we are studying for each site. The list of outputs in seven study domains is summarized in Appendix A, below. At the end of the planning process, each site will receive a Readiness Assessment report that will form the basis of our selection process for the next round of contracts, which will provide limited funding toward some costs of actual implementations in some sites.

Site Pilot Implementation Contracts (to be completed by June 2019)

  • This phase will award Pilot Implementation contracts at up to six sites to carry out pilot projects based on their Readiness Assessment results. The amount of the Pilot Implementation Contracts will vary depending on the projects proposed by the sites, but we expect that the minimum awards will be approximately $30,000 per site. Some sites may receive larger awards if their plans are complex. As with the Readiness Assessment contracts, our national staff will provide advisory assistance, but actual work will be done by the sites themselves to ensure that an ongoing capability is built locally in a sustainable manner. The Pilot Implementation contracts will probably not cover all implementation costs for every project. Local participation will be needed to ensure the pilot has some chance of being sustainable.
  • If, at the end of the Pilot Implementation, a site has built a working data flow environment and demonstration management information system and has shown that the analytics coming from it are of actionable value to decisionmakers, our national staff will explore with them ways to seek continuation funding to help them transition the pilot system to an ongoing management reporting system. Continuation funding is not guaranteed as part of this effort, so finding ways to create sustainable business models is an important part of the process.

How to apply to partner in this work

To apply, send Email to [email protected] AND [email protected] with the following information:

  • Subject line – “Community Eldercare Metrics, Planning”
  • State the contact email(s) and phone number(s) of the person or team applying.
  • Define the community you aim to serve.
  • Briefly explain your vision, governance, and data available to the project.
  • Send it soon! We will follow up with the more promising teams on a rolling basis and aim to have all teams identified within July 2018 and to have plans and contracts within August and September 2018, depending upon labor availability at the sites and in our staff.

Appendix A: Overview of Site Readiness Assessment Domains

The site Readiness Assessment planning process will provide sites with a $10,000 contract to work with our national staff to explore seven key domains that are essential to creation of an effective management reporting system for community eldercare. We do not expect that all sites will have advanced information technology capabilities in place. Information for this process is expected to be collected primarily by videoconferencing, with little or no travel expenditures for site personnel. The questions listed in this table will be explored during the Readiness Assessment contract period, and need not be answered as part of a contract application.

You may download a PDF file with details on the seven Site Readiness Assessment Domains.

You may download a PowerPoint presentation with further details on the process for Site Readiness Assessments and information on how to apply.

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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 12/11/2017 post at the American Society on Aging (ASA) website:

http://www.asaging.org/blog/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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May 232013
 

By Anne Montgomery

Leaning into the podium at the Graduate Center of the City University of New York on May 14, Judy Feder, professor of public policy at Georgetown University, is poised and intent.  She is speaking to a room full of researchers, advocates and academics who are hoping to ignite a national conversation about why now is the right moment for family caregivers to underscore their importance to the U.S. health and long-term care system.

But first, Feder administers a reality check: Despite ”overwhelming evidence” that caregivers are “the essential glue” in our health care system, they are often met with “disregard” or “disrespect” by large institutions and individual practitioners, she said.  Moreover, the very fact that family caregivers are the “dominant source” of help for 80% of ill, frail and disabled individuals living at home and in the community contributes to concerns about so-called “crowd-out” costs: The “fear of replacing” unpaid family caregiver labor, she said, has led policymakers and providers to count on their support as a “fiscal convenience.”

A classic example of this overreliance on family caregivers, according to Feder, is the massive (though rarely discussed) shift of responsibility that occurred following implementation of Medicare’s prospective payment system (PPS) for hospitals during the 1980’s.  As hospitals realized that it was in their financial interest to discharge patients more rapidly (often referred to as “quicker and sicker”) under a PPS system, the result for family caregivers was that they were asked to take on much more – often without any discussion, and with no preparatory training or sustained support. “All of this happened with no thought,” Feder said.

Concurrently, a growing body of evidence — including a recent survey conducted by AARP and United Hospital Fund (UHF) – has established that family caregivers are routinely undertaking ever-more complex medical and nursing tasks.  For example, it is now common for caregivers to be expected to assist with ostomy and wound care, administration of intravenous fluids and injections, preparation of foods for individuals on special diets who have trouble chewing or swallowing, and management of ventilators and tube feeding systems.  The net outcome, Feder observed, is that family caregivers find themselves under increasing pressure to “turn their homes into hospitals.” Changing this dynamic, she added, will require serious work.  In a call to action, Feder declared: “The support of caregivers should not be merely “assumed,” but rather it must be “thoughtfully considered….We need to turn this around and get past the lip service.”

Others at the UHF conference, titled “Transitions in Care 2.0,” (which culminated in the release of a ten-step action agenda) were in full agreement.  Susan Reinhard, Senior Vice President of AARP’s Public Policy Institute, observed that the recent AARP-UHF survey documents that more than two-thirds of respondents report significant difficulty with certain tasks — notably wound care, assisting with the use of incontinence equipment and preparation of special diets.  Helping a family member or friend cope with a colostomy is not a traditional ADL,” [Activity of Daily Living] Reinhard said.  The ADL assessment instrument, which focuses on basic, non-medical assistance with eating, dressing, toileting, bathing and transferring, was originally developed in the 1950’s as a way of measuring the help that patients recovering from hip fractures needed.

Mary Naylor, a professor and researcher at the University of Pennsylvania School of Nursing, argued that in the era of the “age wave,” providers should reframe their professional perspective to see themselves in part as “enablers of patients and family caregivers.”  Both Eric Coleman, professor of medicine at the University of Colorado and Luke Hansen, professor of medicine at Chicago’s Northwestern University, noted that it is still uncommon for physicians and hospitals to collect any data on family caregivers — and even rarer to train them. This presents problems, they acknowledged, in making various improvements in the care system “stick.”  Feminist author and caregiver Alix Shulman suggested that it is precisely the lack of “anticipatory guidance,” or training, which individuals who choose to make major changes to their lives in order to assist a seriously ill or disabled loved one find most difficult of all. “Specific conversations are needed,” she said. “Not just a list of websites or a stack of brochures.”

UHF’s David Gould and Carol Levine urged researchers and policymakers to join together to support caregiver assessments that include documentation of both the needs and limitations of caregivers as part of the routine delivery of health and long-term care services. Also needed, they said, are regular surveys of both the patient and the family caregiver’s experience with services, as well as a more sophisticated and systematic approach to identifying the networks of family, friends and neighbors who come together to form a “caregiver corps,” or circle of support, that can be assembled to collectively provide the right level of help at the right time.

Making the necessary adaptations to our rapidly evolving health and long-term care services systems in order to cost-effectively train large numbers of people who may be willing to volunteer some of their time to assist those who wish to age in place is not a simple matter.  Perhaps one way to move a conversation forward is to consider whether the Center for Elder Care and Advanced Illness concept of a Caregiver Corps of trained volunteers can be created to help teams of health care practitioners and direct care workers deliver a more seamless array of services and supports – while also giving families the confidence that they will be able to sustain assistance for the millions of frail elders and individuals with disabilities who want to remain a vital part of the community right up until the ends of their lives. Such a Corps, which would recruit volunteers young and old, would be a step toward addressing workforce shortage issues, and might give communities ideas and strategies they can adapt to solve pressing concerns. Now is the right time for family caregivers and their many allies to work together to think through the possibilities.

Key words:  United Hospital Fund, care transitions, family caregivers, Caregiver Corps, Mary Naylor, Eric Coleman

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Jan 232013
 

By Dr. Joanne Lynn

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

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

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

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

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

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

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

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Jan 072013
 

by Dr.  Joanne Lynn

When community coalitions apply for funding from the Community-Based Care Transitions program of the Centers for Medicare and Medicaid (CMS), they have to show that they will reduce hospital readmissions by 20% and will save money for Medicare. Funding recipients will be held to those two outcomes in evaluating the contract.

In general, CMS intends to evaluate these programs by applying the 20% reduction to the rate of rehospitalization: that is, rehospitalizations/[live discharges]. If a community’s baseline rate in 2010 was 15%, then 20% of 15% is 3% and they’d have to reduce rehospitalizations to 12%.

If hospitalization itself remains stable, these are the same goal numerically.

However, much of what is done to reduce 30-day rehospitalization also reduces hospitalizations beyond 30 days, and sometimes even hospitalizations without antecedent hospitalizations. If patients learn more self-care, use more hospice, obtain more support in the community, and so forth, then the use of hospitalization outside of that 30-day window may decline as well. And it does not take a lot of decline in that rate to mimic the decline in 30-day rehospitalization, making it a challenge to change the rate of rehospitalization/hospitalization.

Suppose, for example, that a community had 10,000 hospitalizations and 1,500 30-day rehospitalizations in 2010. Suppose the CCTP work changed the rehospitalization number by a full 20% – cutting it to 1200 per year by 2014. But that good work also cut down on hospitalization by 10% — yielding 9000 for the denominator. Then 1200/9000 would be just a 13.3% rate, and the team would have missed the goal of 12% — even though it had actually done a terrific job.

It is always risky to use a rate where the denominator is presumed to be stable but actually can respond to some of the same interventions as the numerator.

Using the N of 30-day rehospitalizations has its risks also – a bad flu year or a decline in community-based support could push it up, as could an influx of patients that increases the denominator. It can also have spurious improvement if many patients are moved from FFS to managed care.

For now, it seems that the prudent thing to do is to convince CMS that they should keep the question open and make it legitimate for CCTP and providers to pursue the reduction in numbers only rather than the reduction in the rate.

 

key words: CCTP, readmissions rates, CMS, care transitions

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