Community-based Health Organizations – An Innovation Path for Supportive Services

 Posted by on June 18, 2019  No Responses »  Tagged with: , , , , ,
Jun 182019
 
Portrait of Anne Montgomery
Anne Montgomery

By Anne Montgomery

Time is growing short to make big changes to basic processes for service delivery to elders, who will soon constitute one-fifth of the U.S. population. Basically, we have a mismatch between the health care delivery system and what many older adults actually need.

Typically, older adults typically see multiple clinicians working in many settings – e.g., primary and specialty care, hospital care and home care — and communication between these providers tends to be inadequate. This in turn contributes to fragmented care that can be frustrating and costly. Medical services are often disconnected from the life goals and treatment preferences of a given individual, and his or her need for various supportive services are often not documented. Finally, although numerous smaller-scale initiatives have shown that much of the disability and frailty associated with aging can be effectively managed (and sometimes delayed or prevented), innovative models that prioritize these goals have not yet been widely implemented.

This suggests it’s a good moment for policymakers to consider piloting designated entities, perhaps called community-based health organizations (CBHOs), in order to organize provision of cost-effective supports across a population of high-risk, high-cost elders living in a given area or region. Broadly similar to a model developed by Joanne Lynn, MediCaring Communities, [https://medicaring.org/book-online/] CBHOs, operating as an interconnecting network, could be chartered to prevent and delay more costly inpatient and institutional care, working in partnership with local medical care providers. They would likely begin at a modest scale, forming networks in order to further develop business acumen, acquire information technology that is essential for interoperability, and develop collaborative relationships and contractual arrangements that over time can transition into more formal integrated care systems. As a distinguishing characteristic, CBHOs could measure and reinvest savings in improving community care systems.

Funnel stacked from Health System to CHBO

Shifting the Entry Point Average Cost/Day [Click to enlarge]

One intriguing graphic, created by Preferred Population Health Management and reprinted here with permission, provides an illustration in one community of how delivery system entry points and costs might be re-thought. For vulnerable populations, which includes many older adults, it may make sense to consider looking at community-based organizations (CBOs) or Area Agencies on Aging (AAAs), as another entry point to a more tightly coordinated care system that prioritizes cost-effective services that reduce the risk of needing higher-cost interventions.

Funnel stacked from CHBO to Health System

Changing the Entry Point to Health [Click to enlarge]

Using grant funding, CBHOs could be charged with standing up coordinated, synergistic delivery systems for older adults and individuals with disabilities across a service area. Collaborations could take various forms: partnerships between AAAs/CBOs and PACE organizations; with Federally Qualified Health Centers (FQHCs); with Rural Health Clinics (RHCs), and other possible combinations. CBHOs would be tasked with analyzing available data on the needs of all older adults and individuals with disabilities who live in the area, filling in with more complete data over time. They would then create a five-year plan for serving older adults in the area, with approval requiring consultation and sign-off by a local coalition representing providers, advocates, and individuals currently needing (and/or anticipating needing) services. Approved grant funding would flow to CBHOs, and states would be asked to assist in tracking CBHOs and their performance vis-à-vis standardized metrics, costs, and outcomes for individuals. At the expiration of the grant period, the federal government, in consultation with states and community stakeholders, would determine which CBHOs could become permanent.

There are several indications that policymakers are starting to consider such approaches. For example, a Senate draft of the Older Americans Act reauthorization, which is now circulating for comment, includes language stipulating that future OAA demonstration projects must address determinants of health; reduce health care expenditures, “preserve or enhance” quality of care to individuals, and prioritize initiatives that focus on caregiver support, multigenerational engagement and community-based partnerships.

There are other hopeful signs in work that is being led by the Center for Medicare and Medicaid Innovation (CMMI), which is teeing up a range of possible alternative payment models, and adaptations of existing programs to recognize and address social determinants of health in vulnerable populations. For example, as noted in our blog last month, [https://medicaring.org/2019/05/08/2019-cmmi-proposals/] CMMI has announced two groups of models, called Primary Care First and Direct Contracting. As part of the Direct Contracting Model track, CMMI published a Request for Information on how geographic contracting could work. Because they are typically limited to services that are available locally, older adults living with serious chronic illnesses and functional limitations and younger people with disabilities are populations that would be well-suited for a geographically-organized care model.

If local governments were allowed to be contractors, this could open up new opportunities for the Aging Network. To date, nearly all major federal innovation efforts have been geared toward large organizations working within the medical care system, but this could change. About half of AAAs are embedded in local governments, and AAAs and CBOs already understand how supportive services for older adults and other vulnerable populations can be efficiently delivered in very different types of communities. Moreover, as the nation’s primary publicly-funded network of community-based supportive services providers, staff are trained to organize and provide services in the home, and are therefore attuned to the life circumstances of individual elders.

In another encouraging development, CMS published an updated Scope of Work (SOW) in March for organizations applying to be Quality Improvement Organizations/Quality Innovation Networks (QIOs/QINs). Notably, this SOW instructs applicants to “coordinate with existing community-based efforts and reach community stakeholders to form community coalitions…[that] include the recruitment and engagement of providers across all care settings” — including those delivering community-based supportive services. QIN-QIOs will be required to use “a population based measurement strategy to show targeted improvement of beneficiaries that reside within specified ZIP codes” and to reach at least 414 community coalitions across the country. This means that QINs/QIOs will be actively supporting organizing of community stakeholders (providers, beneficiaries, caregivers and their families, emergency responders and more) in order to gather data that aims to improve care transitions and achieve specific reduction targets in high-cost inpatient hospital utilization.

By 2035, there will be 80 million older adults 65+ in the U.S., and the population age 85 and older will reach 12 million. And since many older adults have complex social needs and about one-third are living with a disability, this is an important time to try to shift the pattern of services further toward provision of home-based medical care and a more organized system of supportive, flexible, community-anchored services.

If we do too little now to deliberately boost the ability of the supportive services sector to innovate, it seems likely that unmet need for basic supports among many community-dwelling elders in the large boomer cohort will skyrocket. If this happens, health care costs will likely balloon. To help forward-thinking pioneers in this sector move forward faster, let’s hope that policymakers will give a green light to spurring development of collaborative, population-based care systems that are mission-driven to keep older adults at home and out of medical crisis for as long as possible. It’s a doable challenge, and the potential societal return on investment is large.

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The April 2019 CMMI Proposals for Innovative Payment Models

 Posted by on May 8, 2019  No Responses »  Tagged with: , , ,
May 082019
 
Portrait of Dr. Joanne Lynn
Dr. Joanne Lynn MD

By Joanne Lynn

May 7, 2019

CMMI has announced that they will soon call for proposals for a bevy of new payment models, aiming to reduce hospitalization without harming quality by allowing a great deal of flexibility by practicing primary care clinicians for Part A and Part B services in Medicare and by allowing contracting for services for larger groups of beneficiaries. Effectively, CMMI is offering practitioners and other stakeholders a group of models that blend capitation and fee-for-service, with payments generally depending upon lowering hospital use, meeting quality standards, and making certain continuity services available (e.g., 24/7 on-call with the record and electronic records with interoperability). While many of the details are not yet clear, I believe that these models could offer some important opportunities for moving toward optimal care for elders living with serious illnesses and disabilities.
The publications so far have not really dealt with long-term care, supportive services in the community, or integration with Medicaid. But they also have not made these things any more difficult.
As a very brief overview, CMMI is offering two groups of models: Primary Care First and Direct Contracting. This table summarizes what I’ve been able to learn as to the characteristics of the proposed models. All models appear to require having some experience with value-based payments, having certified electronic records with interoperability and connection to the local HIE – and providing primary care. From one perspective, Primary Care First is a successor and spread of CPC+, and Direct Contracting is a successor and spread of NextGen ACOs. More information can be found on these URLs:

https://innovation.cms.gov/initiatives/primary-care-first-model-options/

https://innovation.cms.gov/initiatives/direct-provider-contracting/

And here is an introductory table.

2019 CMMI Proposals Table

Note that practices now participating in CPC+ cannot join Primary Care First until 2021. The areas where Primary Care First will be allowed in 2020 are these:

Alaska (statewide), Arkansas (statewide), California (statewide), Colorado (statewide), Delaware (statewide), Florida (statewide), Greater Buffalo region (New York), Greater Kansas City region (Kansas and Missouri), Greater Philadelphia region (Pennsylvania), Hawaii (statewide), Louisiana (statewide), Maine (statewide), Massachusetts (statewide), Michigan (statewide), Montana (statewide), Nebraska (statewide), New Hampshire (statewide), New Jersey (statewide), North Dakota (statewide), North Hudson-Capital region (New York), Ohio and Northern Kentucky region (statewide in Ohio and partial state in Kentucky), Oklahoma (statewide), Oregon (statewide), Rhode Island (statewide), Tennessee (statewide), and Virginia (statewide).

The RFI for the Geographic Direct Contracting Model is at https://innovation.cms.gov/Files/x/dc-geographicpbp-rfi.pdf DATES: Comment Date: To be assured consideration, comments must be received by Thursday, May 23, 2019 at 11:59 pm EST. ADDRESSES: Comments should be submitted electronically to [email protected].

There are dozens of ways to implement these, and I hope that CMMI will allow diversity and will be clever in the evaluations, aiming to harvest insight and wisdom as well as comparisons with past performance and unaffected beneficiaries. However, if they allow contractors to put together the geographic and the serious illness endeavor, we could have a model that would fit the seriously disabled or slowly dying elder well. We could have communities with exemplary performance within a few years, and tremendous experience to build upon.

I would very much like to know whether you, the reader, are in a position to encourage potential sites to be ready to submit a letter of intent soon after the RFPs come out in June (for all except the Geographic Direct Contracting). If you are interested in shaping the RFP for Geographic Direct Contracting, the deadline for comments is May 23, 2019. If our coordinating information is useful to you or a colleague, please be in touch with us at [email protected]. We aim to put together communications as appropriate in order to accumulate best practice ideas concerning eldercare and to devise approaches that might allow optimization of local care systems quickly! We are happy to help any organization focusing on elders who are living with frailty, disabilities, and illnesses that need long-term supports and services and generally are eventually contributing to the end of life.

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Pick up the PACE to a New World of Eldercare

 Posted by on August 21, 2018  1 Response »  Tagged with: , , , , ,
Aug 212018
 
Portrait of Christine Stanik
Christine Stanik

By Anne Montgomery, Sarah Slocum and Christine Stanik

What do you need to know in order to remain in your own home as the years advance? Where can you turn for good, reliable services in a costly, chaotic, constantly shifting health care system? One possible answer is PACE (the Program of All-inclusive Care for the Elderly) program. PACE is widely acknowledged to be the “gold standard” of comprehensive geriatric care – which is not just medical care, but also long-term services and supports (LTSS).

But PACE is not yet available in 19 states, and currently has limited capacity, serving about 45,000 beneficiaries (almost entirely elderly persons who are enrolled in both Medicare and Medicaid). Beyond the dually-eligible population, how can we expand PACE to a burgeoning population of Medicare-only beneficiaries, many of whom need some LTSS, and who would very much like to avoid spending down to Medicaid level?

Medicare Advantage

One area of likely growth for PACE is to partner with Medicare Advantage (MA) managed care plans. Recently, the Centers for Medicare and Medicaid Services (CMS) published guidance allowing MA plans to expand the range of supplemental benefits they may wish to offer to include a range of LTSS. MA plans could contract with PACE (or another service organization), to furnish PACE Center attendance and transportation to and from home; meals; and other services to help enrollees avoid hospitalization, emergency department visits, and maintain stability even during periods of decline. For working family caregivers, PACE can be a huge help, serving as a source of reliable respite. And increasingly, evidence is accumulating that such arrangements can reduce in-patient hospitalization and ED costs, and delay or prevent long-stay placement in nursing homes.

To serve current community needs and prepare for larger offerings through MA contracting, some PACE organizations provide services to non-PACE enrollees as a private pay offering. PACE plans have varying levels of experience providing a la carte or service packages to non-PACE enrollees. At the Program to Improve Eldercare, we are developing policy pathways and practical tools to help PACE organizations and MA plans prepare to work together to better serve frail elders. First we need to address the daunting Part D affordability barrier that faces Medicare beneficiaries wishing to enroll in PACE that Sonja Love Felton described in a previous blog. Fortunately, CMS is aware of the problem, and may be open to a system-wide solution. We invite you to encourage them (contact us for guidance at [email protected]).

Medicaid

Another set of challenges to accessing PACE for some Medicare beneficiaries is that they lack the personal resources to pay out of pocket for LTSS. Many in this group have just slightly more income than their state’s Medicaid income eligibility threshold permits. If their monthly medical expenses are high, and this can be documented, some of these beneficiaries can take advantage of the so-called “medically needy spend down” option 33 states have. However, in most states, this option requires a large monthly deductible leaving only small amount of income (as low as $400 per month in some states) to pay for all living expenses. The rest face the “Medicaid cliff” –with an absolute cut off level, usually 300% of the SSI limit, which is $2250 in 2018 and cannot qualify for Medicaid if they are one dollar over the limit. The predictable result is that many families wind up impoverishing themselves to gain access to LTSS – which may only be available in the highest-cost setting – a nursing home. To solve these dilemmas, the Program to Improve Eldercare is working with Medicaid experts to identify practical, workable policy solutions that can be readily implemented, and which can make PACE LTSS services available to many more Medicare beneficiaries. States will ultimately save Medicaid dollars and avoid premature nursing home placement by allowing people to avail themselves instead of lower cost PACE services.

In the course of analyzing these challenges, we have been speaking with Michigan families who generously agreed to tell us their stories. Michigan is a state with an absolute cut-off for Medicaid – if your income is more than $2250 per month, you cannot qualify, even if your medical costs and personal care needs alone are $3000 per month. We relied on family caregivers to speak for elders they are supporting. They provided us insights into what happens to families who find PACE attractive, but who do not qualify for Medicaid and do not think they can afford to pay for long-term services and supports (LTSS) out of pocket. To protect the privacy of those interviewed, we have changed the names below, and details from several individuals are combined in the two composite narratives.

Tom’s Story

We spoke with Tom less than six months after he had contacted PACE on behalf of his octogenarian mother. Because she was becoming increasingly frail and unable to live on her own, Tom moved his mother into his own home. Not yet at retirement age, he soon realized that the demands of caring for her were at odds with a job that kept him away from home for up to 10 hours a day. Tom called PACE to express concern for his mother’s safety when she was home alone, noting that her physical condition was likely to degenerate over time due to several worsening health conditions.

Although Tom and the PACE program concurred that enrolling his mother would be the right solution to an otherwise hazardous situation, the cost of PACE, more than $4000 per month, put it beyond their reach. This left Tom to piece together services as best he could. However, eventually his mother had a fall when he was away from home, breaking her hip. At the time of the follow-up interview, she was convalescing in a nursing home, and Tom was desperately trying to find a better alternative. He was deeply concerned that a lack of adequate rehabilitation at the facility was preventing his mother from regaining her mobility. Although he did not have a plan to keep her safe if she returned home, Tom was exploring options to try to bring his mother home and also obtain therapy that could help her regain strength and the ability to walk. Overall, from a family caregiver’s perspective, the options presented had gone from hazardous to punishing – reliable, ongoing supportive services in a safe environment that would have made both of their lives much better were simply unavailable, because they fell between having a bit too much income for Medicaid, but not enough to pay for PACE.

Sheila’s Story

We spoke with Sheila a couple of months after she had contacted PACE on behalf of her elderly father. After the death of her mother, Sheila became concerned about her father’s social isolation and depression. Declines in physical health and the beginning signs of cognitive impairment were limiting his ability to venture out on his own to see friends and attend medical appointments. Sheila believed the PACE program would be ideal for her father, given that the PACE Center could provide an easy way to access the social interaction he sorely needed, and his medical care would be managed and monitored, alleviating worries about making and tracking various appointments for medical services that created burdens both for him and for her.

Unfortunately, her father’s small pension made Sheila’s father ineligible for Medicaid — without providing enough money to pay the out-of-pocket monthly PACE fee. Given the difficulty of caring for her father’s health needs, and growing concern for his acute loneliness, Shelia made the decision to buy a larger home that would allow her father to live with her family. Unfortunately, this did not work out as well as she had hoped, in part because she and her husband had full-time jobs, and had difficulties transporting her father to various medical appointments that were always scheduled during business hours.

Sheila was also concerned about her father spending most of his days alone. He still drove his own car, but was starting to show signs of forgetting even the most familiar of routes, and she suspected he would soon be unable to drive at all. Sheila was highly motivated to do all she could to help her father maintain a good quality of life in his final years and reported that the PACE Center continued to be the most attractive option for both medical services management and for social interaction. At the time of our last call, she had begun looking into the feasibility of having her father’s pension reduced in order to try to qualify him for Medicaid, so she could enroll him in PACE.

Reflections and Next Steps

Tom and Sheila were both doing their best to care for parents who had reached advanced old age. Both parents worked all of their adult lives and had accumulated some resources for retirement, and the comprehensive care model of PACE was a terrific solution for addressing several concerns. PACE was by far the option – but under current rules, it was beyond their financial means, and no other set of services was adequate or available.

These stories show why we are working on advancing flexibility in PACE, both in Medicare and Medicaid. PACE is well-positioned to serve many more people in a long-lived society if we can get policymakers to agree to implement commonsense solutions that remove current barriers. We hope you will join us in the endeavor, and if you want more information about PACE innovations, please contact us at [email protected].

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Through a Glass Darkly: The Community-Based Care Transitions Program Evaluation

 Posted by on February 22, 2018  No Responses »  Tagged with: , , , , ,
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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PACE Flexibility Provisions that Would Help Medicare-Only Beneficiaries

 Posted by on July 10, 2017  No Responses »  Tagged with: , ,
Jul 102017
 
Stages of Analysis graphic
Stages of Analysis

A new analysis from The Center for Elder Care and Advanced Illness lays out the key regulatory flexibilities that are central to allowing a greater number of Medicare beneficiaries to enroll in PACE, and includes links to relevant regulatory and statutory policy.

The Program of All-Inclusive Care for the Elderly is a highly promising model that can be adapted to meet the needs of large numbers of older adults who require a mix of medical care and long-term services and supports. These beneficiaries need reliable, well-coordinated, geriatrically competent, longitudinal services that are delivered in the community. These services must be affordable to participating older adults and to U.S. taxpayers.

Click Here to View PACE Flexibility Provisions That Would Help Medicare-Only Enrollees

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Center for Elder Care and Advanced Illness Comments on MACRA

 Posted by on June 28, 2016  No Responses »  Tagged with: , , ,
Jun 282016
 

Geriatricians, as well as the  frail, sick, and disabled elders for whom they care, are at serious risk under the proposed implementation of the Medicare Access and CHIP Reauthorization Act (MACRA). To read Joanne Lynn’s comments on the Notice of Proposed Rulemaking for Merit-Based Incentive Payments and Alternative Payment Models under MACRA, click here.

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MediCaring Communities: Getting What We Want and Need in Frail Old Age at an Affordable Cost

 Posted by on June 20, 2016  No Responses »  Tagged with: , , , , , , , , , , , , , ,
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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From Hospital to Home: The Missing Element in Discharge Planning

 Posted by on January 4, 2016  2 Responses »  Tagged with: , , , , , , ,
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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Don’t Accept Medical Errors as the Standard of Care for Frail Elders

 Posted by on September 28, 2015  1 Response »  Tagged with: , , , , , , , , , , ,
Sep 282015
 

By Joanne Lynn, MD

If you are hoping for a good night’s sleep, don’t read the stories told by Marcy Cottrell Houle of her parents’ last years of life just before you go to bed. But do read The Gift of Caring: Saving Our Parents from the Perils of Modern Healthcare [http://www.thegiftofcaring.net/], which Houle wrote with geriatrician Elizabeth Eckstrom over a cup of coffee. That will get you fired up. The litany of catastrophes that occur in our poorly organized medical care system—preventable, avoidable suffering—is overwhelming. So far, though, no one is listening. No one is reacting in horror, and no one is changing the system to stop these errors. We need to turn up the volume of our protests!

Marcy’s father was once abruptly discharged from the hospital to a nursing home that lost him! The nursing home put him in a room at the end of a hall and simply forgot he was there! No hygiene, no food—nothing was provided for him. In fact, the staff forgot to give him water for so long that he developed renal failure. He was later drugged to manage his behavior, which was eventually traced to pain, readily treated with acetaminophen. His case spiraled on and on.

Marcy’s mother had all the geriatric complications: delirium, falls, anti-coagulation, terrible aides. Worse still were her run-ins with physicians who wouldn’t pause to make sense of sudden changes in mental status, because they just assigned every dysfunction to “old age” and “dementia,” even when her mother had been functioning quite well just a day before.

Yes, it’s all there, terrible and terrifying. Dr. Eckstrom writes a chapter after every calamity about how patients and families might prevent or cope better. The book is a rare gem to help people who must navigate our “care system” for frail older people.

But it is maddening.

If you bought a toy that fell apart in a dangerous way, you could report it to the U.S. Consumer Product Safety Commission, and they’d investigate. If a person has a near miss from a safety defect in a car, the National Highway Traffic Safety Administration wants to hear about it immediately. If a medication causes a serious side effect, the Food and Drug Administration has a consumer online reporting form. Indeed, any of these and more pop up when I search online. But just try reporting that your dad was lost in a nursing home. You have to be knowledgeable enough to find the ombudsman program or the Quality Improvement Network or know a lawyer willing to threaten to sue in order to call attention to a grave mistake.

The problems in care of the elderly are not just “errors” in the usual sense of unusual mistakes. In fact, they are baked right into our current delivery system. The errors are not just a nurse or aide slipping up on some critical step. Instead, all the nurses and aides and everyone else are working in a system that is so dysfunctional that actions that cause pain or neglect are not even called out as errors. Consider that I can go up to an ATM in the remote wilderness somewhere in the world, and the banking system will know whether I have money in my account; but if I am discharged from the hospital, my community physician won’t know anything about what happened to me in the hospital, often even if she’s been my physician for years and I told the hospital folks this.

Think about the profound errors that are made when medical professionals simply have no idea what matters to patients and their loved ones. They never ask! For example, consider two men living with the same advanced degree of disability from Parkinson’s disease. One might want to spend anything and do whatever is necessary in order to survive long enough to finish a personal project, while the other might really want not to leave his spouse impoverished. The second man might feel at peace with the fact that life is coming to its end and even to feel OK with letting it end a bit early in order to have things fall into place for those he loves.

Today, emergency room staff do not know any of this because of the way in which we have put this system together. Both these men experiencing a sudden deterioration, however, would have to use the emergency room, because we don’t have 24/7 on-call physicians organized to come to their homes. We don’t even have home-delivered meals for many elderly persons in need in most of the country; the waiting lists are routinely more than 6 months long, because we have not chosen to fund the Older Americans Act adequately.

What are we doing? And how can we complain effectively? Each family somehow believes that its situation is bad luck or “how things are.” There is no benchmark by which to set expectations, so the families accept the errors, dysfunctions, suffering, and impoverishment that so often come with disabilities in old age. Why are the errors of our system not being debated or even mentioned in political campaigns? How can we change this?

We can start by changing our abysmal expectations of the services that we get. Let’s question why the care system is so deaf to the priorities of our loved ones everywhere we can—in the newspapers, in the candidate debates, through social media. Let’s reengineer current services, build highly reliable care systems in our communities, and see what it really costs. Projections for the costs of a community-anchored care system that is person centered and flexible enough to bring most services into the home are not much different from current care arrangements. Let’s record stories, good and bad. Let’s figure out how family caregivers can become politically powerful. Why is it, for example, that Medicare has no standing advisory committee speaking for the interests of its millions of beneficiaries? If we are lucky, we will grow old. So it’s our future, too, not just our parents’!

We’ve started an initiative to get family caregiver issues on the party platforms in all states that generate party platforms. You can join the Family Caregiver Platform Project initiative. It takes very little time and gets leaders talking. Go to http://caregivercorps.org to sign up now.

There are some bright spots on which we can build: The Centers for Medicare & Medicaid Services has introduced payment for advanced care planning discussions between Medicare beneficiaries and their physicians. We agree that this is a good idea and strongly support it. But care planning is not just an end-of-life matter; it needs to be comprehensive and a standard practice. All health care providers and social services agencies should pursue the goals that the elder and family actually most want.

What else can you think of? We need other leverage points that would focus the pent-up frustration of millions of family members who have already witnessed the misery of ordinary elder care. What should have been available to Marcy as she helped her parents live their last years? Hers is a story that we can all absorb and tell others; then we can go out and insist that our care system change. Eventually, Marcy and her family found some exceptional paid caregivers, and together they achieved some good experiences, even triumphs. But this came after needless suffering. She would say that she’s lucky, and others would say that she’s especially skilled and capable. Most of us need a care system that does not require exceptionally skilled and capable family members or good luck. Read her book, and help us push for a care system that works reliably for our old age!

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Purchasing Value – Not Yet Right for Medicare’s Frail Elders

 Posted by on February 25, 2015  1 Response »  Tagged with: , , , , , , , , ,
Feb 252015
 

By Joanne Lynn

In late January, Department of Health and Human Services Secretary Sylvia Matthews Burwell announced that Medicare would purchase most services on the basis of value rather than volume, aiming for 90% of fee-for-service payments by 2018 [http://www.hhs.gov/blog/2015/01/26/progress-towards-better-care-smarter-spending-healthier-people.html]. Of course, paying on the basis of value is much better than paying on the basis of volume. But a moment’s reflection shows that this strategy requires figuring out what people value. For a child with a broken arm or a middle-aged woman with a gall-bladder attack, desirable outcomes are obvious, widely agreed upon, and readily measured. But this is just not the case for frail elders.

Consider a new heart attack affecting a 94-year-old living with multiple chronic conditions, self-care disability, and a lifetime of experiences and relationships. Different 94-year-olds will value very different things when it comes to treatment characteristics and quality-of-life goals; for example, some will desperately want not to go to the hospital, even if doing so would likely extend their lives, and others will welcome hospitalization with intensive care and every opportunity to get back to the way things were.

Even well-established quality metrics that are important to elder care, including avoiding delirium or the degree to which the person’s symptoms are addressed, are not yet used by Medicare, and the program has done little to develop ways to identify excellent care for frail elders. Rates of certain calamities and medical errors are currently measured, but elderly persons and their families expect that more will be monitored than mere safety. When we are old and frail and facing death, we need the quality of our care to be measured by whether it offers an opportunity to attend to important relationships, live comfortably, and pursue what matters most to each of us. Generic measures that reflect what someone else values won’t suffice.

Consider first what Medicare has set up as measures for this population. A starkly disturbing insight arises in the list of measures under consideration for implementing the Improving Medicare Post‐Acute Care Transformation (IMPACT) Act that are meant to measure outcomes and quality in after-hospital care. [List of Ad Hoc Measures under Consideration for the Improving Medicare Post‐Acute Care Transformation (IMPACT) Act of 2014, http://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=78784.] Given the short timeline, the Centers for Medicare and Medicaid Services (CMS) has proposed measures that have already been approved or that are in the process of approval. CMS proposes four measures, each applied in four care settings: the rate of pressure ulcers, the rate of falls with injury, the existence of functional assessment and whether there is a care plan with a goal that involves function, and readmissions.

But in setting out to talk with frail, elderly people leaving the hospital for a short-term stay in a nursing home before they go home, what do we imagine are their highest priorities? The four that Medicare proposes might make the list, except that the way we measure readmissions is seriously deficient, even with risk adjustment [ https://medicaring.org/2014/12/16/protecting-hospitals/; https://medicaring.org/2014/12/08/lynn-evidence/ ]. But most people have other priorities that are equally or more important, such as whether there is a workable plan to get the daily care and support needed (e.g., housing modifications, food, transportation, and personal care). Another question elders often ask is what the effects of their disabilities on the family will be, especially if family members have to provide more care. Elders may also want to be sure that they will have the symptom (pain) control, spiritual support, and reliable supportive care that they will need as their conditions get worse, whether they are in a care system that will maximally preserve their financial assets so that they have a lower risk of running out, and whether they will have to move to a nursing home. Medicare’s metrics don’t yet even try to address these concerns.

Even more troubling is the fact that Medicare does not yet have any methods to judge the match between the services given and the patient’s perspective as to what matters. Current metrics are all grounded in professional standards, and professionals have been slow to build standards that truly take into account the very different things that individuals want in late life. A high-quality service delivery system must try to match the priority needs and preferences of each elder.

As Medicare moves toward paying its providers on the basis of value, it is important to keep in mind what you value is often not what I value, and this difference becomes more pronounced as we have to live with physical and financial limitations and the increasing proximity of death. Here are some steps that we can take:

  • We should demand that Medicare invest in developing measures that matter for the frail phase of life before distorting the delivery system with incentives applying to everyone (e.g., to avoid pressure ulcers, falls, and readmissions) and to have and achieve goals concerning function.
  • CMS should be willing to be the “measures steward” or should fund another entity to do so, since the money available for frail elder care does not spin off strong organizations that can do the developmental work and then maintain updated measures.
  • Our health information systems (e.g., in Meaningful Use Stage 3) should at least start making room in medical records to document each patient’s priorities and the care plan that is supposed to reflect those priorities.

Buying on value is the right idea, but buying value for each elder requires knowing what each one values.

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