Get Started: How You Can Improve the Lives of Frail Elders and their Families Today

 Posted by on March 21, 2012  No Responses »  Tagged with: , , , , ,
Mar 212012
 

By Janice Lynch Schuster

During two days of sessions at the Institute for Healthcare Improvement’s 13th International Summit, I was struck by repeated messages from plenary speakers and learning lab leaders. No matter the particulars of their presentation, each riffed in one way or another on the fact that we can all act now to change and improve health care so that we obtain better care, better outcomes, and lower costs. More than that, each pointed to the unique convergence of social, political, and health care factors that have set us up to get it right this time, to improve care for patients and their loved ones, to create a better environment for health care providers, and to imagine and implement a system in which health and health care are seen as human rights.

In his keynote address, former CMS Administrator and IHI founder Don Berwick, MD, left the audience with five principles on which to base change. In a nutshell: Put the patient first. Protect the disadvantaged. Start at scale—think big and act big. Return the money—drive waste out of the system and return that money to the community. And act locally.

In the spirit of acting locally, Altarum’s Center for Elder Care and Advanced Illness has developed two guides that we hope will help you to apply Dr. Berwick’s five principles to your work. The first of these is our “Get Started” guide (https://medicaring.org/action-guides/get-started/) to help activist service providers and community leaders imagine, design, and implement community-based systems to improve care transitions. The second of these, “The Agitator’s Guide,” (https://medicaring.org/action-guides/agitators-guide/) offers specific things you can do—RIGHT NOW—to improve the lives of frail elders in your community. Both documents embody the principles Dr. Berwick outlined, and give you an opportunity to test out the improvement mantra: What can you do by Tuesday?

If you test these ideas, we’d like to hear about and report your experiences, insights, and progress. Send a note to ([email protected]).

Key Words:  IHI, Don Berwick, Agitator’s Guide, local improvement

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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Community-Based Care Transitions Program – Section 3026 funding

 Posted by on July 8, 2011  No Responses »  Tagged with: , , , , , , , , , , , ,
Jul 082011
 

Despite widespread interest in the $500 million budget allotted for Community-Based Care Transitions Program (CCTP) under the Affordable Care Act, many stakeholders are confused about the exact nature of the program. What does it aim to do? Who is eligible to apply for the funds?

Aim: CCTP aims to improve the reliability and effectiveness of care transitions as evidenced by reducing hospital readmissions. CCTP participants are paid to improve services targeted fee-for-service Medicare beneficiaries, the population requiring the most frequent care transitions. The backbone of the program in most places will be cooperation of service providers in a geographic community, since the participation and engagement of many stakeholders who share in the care of the area’s patients appears to be essential for sustained excellence.

Eligibility: To be eligible for funding, every applicant must have a minimum of one Community-Based Organization (CBO) and one hospital. While a hospital on CMS’s list of high readmission hospitals by state can lead a proposal, the payment will still go to the CBO, making lead authorship rather trivial. Priority will be given to eligible entities participating in programs run by the Administration on Aging (AoA), or that serve the medically underserved, small communities, or rural areas.

Financing: Foremost, this is not a grant! Payment is based on a blended rate proposed in the response to the solicitation, paid “per eligible discharge” and heavily based on the type of intervention. The blended rate can reflect different costs for different categories of patients and can include such elements as ongoing supervision, monitoring, administrative costs, and so on. Most important, however, it does not include initial training: Sites must have some previous experience with care transitions, so they must have paid for initial training. CMS payment also cannot directly support travel expenses for attending the required meetings in Baltimore (the cost of this must come from some other source).

Applicants are required to use the worksheet provided by CMS. No payments will be made more than once in 6 months for each beneficiary. In other words, CMS will not pay for re-treatment of patients for whom first efforts to prevent rehospitalization failed. Keep in mind that, although the program will run for 5 years, the initial award is only for 2 years, with possibility of renewal annually thereafter.

Intervention: CCTP interventions must target Medicare beneficiaries who are at high-risk for readmissions, based on criteria provided by HHS, or for substandard care post-hospitalization. Interventions cannot duplicate already required services. You must be willing to participate in collaborative learning and redesign (including data collection). Finally, and not surprisingly, your intervention must save money overall, and show savings within two years.

CMS’s measures so far include:

Outcome measures

  1. 30-d Risk-adjusted all-cause readmission rate (currently under development)
  2. 30-d unadjusted all cause readmission rate
  3. 30-d risk-adjusted AMI, HF, and Pneu readmissions

Process measures

  1. PCP follow-up within 7 days of hospital discharge
  2. PCP follow-up within 30 days of hospital discharge

“HCAHP items” – (note – includes more than HCAHPS)

  1. HCAHPS on medication info
  2. HCAHPS on discharge info
  3. Care Transitions Measure (3 – item)
  4. Patient Activation Measure (13-item, see:    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361231/table/tbl1/)

Note: There are some areas where the solicitation is unclear or internally inconsistent.

Key words: hospital readmission, care transitions, 3026 funding, evidence-based intervenitons, patient activation measure, budget worksheet, financing, medicare beneficiaries, payment rate, CMS

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Evidence-Based Interventions: Replicate or Adapt?

 Posted by on June 14, 2011  No Responses »  Tagged with: , , , , , ,
Jun 142011
 

In a complex system such as  transitions of sick and fragile patients from one setting to another, we are often so grateful for the few carefully done and reported research endeavors that funders and researchers easily fall into the trap of insisting upon slavish replication, assuming that this is the way to achieve the same results. If we were working with a highly standardized “system,” such as how heart cells respond to a drug, then we could reasonably assume that the curve of responses in Maine would be just about the same as the curve of responses in Arizona, and that what works for a dozen will work as well for a hundred.  Sometimes, of course, even those assumptions are wrong, but it is rare for an unmeasured characteristic of the population to greatly alter drug effects or metabolism.

However, there is every reason to assume that carefully done research on small numbers in a few settings will not be enough to guide practical implementation of process redesign.  There are two main reasons for this.  First, our paradigm for good studies is the randomized controlled trial (RCT), but some of its characteristics actually undercut the utility of the findings for guiding replication.  Specifically, the effective restrictions (stated and unstated) for eligibility make it likely that only a small sub-set of actual patients will be eligible for the trial.  Second, the fact that one is willing to randomize within one setting is good for blinded trials, but undercuts the galvanizing of the will that is often essential in fueling system reform. Consider this example – could you really generate the outrage that allows  a nursing unit to make changes to stop repeated mistakes in transitions to stop the suffering of their discharged patients — and simultaneously be expected to continue to do it wrong for all but a few of the patients?

Another challenge in the usual RCT is that the numbers affected are small — often only a small subset of the patients in the test site.  While this works for a proof of concept, improvement experts quickly note that scaling up is never just a matter of applying the same changes to a lot more people!  Instead, scaling up poses its own problems.  As one scales up improvements in care transitions, one has to work on incorporating many elements of the work into job descriptions and job routines so that the workflow is smooth.  One has to figure out fail-safe strategies, develop broad consensus in the community as to standards, train a populace to take a more active role in managing transitions for themselves and their loved ones, right-size the community’s supportive services, and a dozen additional elements.  The research model is usually a discrete “add-on” patch to a dysfunctional system.

Indeed, an RCT relies upon not changing the underlying dysfunctional system.  As one tries to implement the improvement approach more broadly, efficiency dictates that it become part of the system wherever possible.  Often, this also means that the highly skilled and motivated people involved in the research are replaced by less skilled, and, often, less motivated personnel providing routine services, with lower pay and more stresses.  Adapting the work of a research nurse practitioner to a regular home care RN, or of a skilled professional to a retiree volunteer, is real work that takes testing, innovation, and creativity.  In the work of the Quality Improvement Organizations (QIOs), for instance, as they implemented evidence-based interventions, many substantial adaptations were required.  One team trained certain nurses in a home health agency to be the bridging nurses in an adaptation of Naylor’s model. One team used senior volunteers as trained coaches for patient activation in an adaptation of the Coleman model. I don’t believe that any of the 14 communities were able to implement a research-based intervention exactly as it had been done in the research report.  The research was still quite important for laying down the path, but following the path with larger numbers in varied contexts required adaptations.

Perhaps the most substantial challenge in our work is that small numbers do not threaten the hospitals’ overall patient flow, while broad implementation could cut into occupancy rates and cause serious financial problems, especially if done too quickly for the system to adapt and right-size its services.  Scaling up requires considering the financial impact. The good news is that there are usually good reasons to absorb this impact, including the fact that most rehospitalizations and medical hospitalizations of Medicare patients do not make the hospital money, or at least not much money.

Keywords: quality improvement, model adoption, evidence-based, eldercare, community-based, Naylor Model, Coleman Model

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