Care Transitions:
Strategies that are Working
National Readmission Conference
May 7th, 2014
June Simmons, CEO
Partners in Care Foundation
Partners in Care Foundation
Who We Are
• Partners in Care Foundation is a non-profit
center of innovation whose mission is to
change the shape of health care. We pursue
our mission by developing and advancing
transformational models of care that promote
health, independence and quality of life
Health Reform: Moving From
Volume to Value
• Infrastructures and reimbursement are transforming; emphasis on
prevention
• Major consolidation – unpredictable future
• The roles of hospitals, physicians and payers are blurring
• The role of the community agency is growing
• New broader partnerships are essential
Social Factors and Health Outcomes
Societal-level social determinants have individual-level impact1
Issue
Outcome
Low education, lack of social
support, and social exclusion
Poor self-management2 and
reduced care plan adherence3
Housing4 and
transportation5 issues
Increased health care costs
and utilization
Health disparities
and psychosocial issues
Preventable hospitalizations6
and mortality7
Low Ratio of Social to Health Service
Expenditures in U.S.
Bradley E H et al. BMJ Qual Saf 2011;20:826-831
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.
Health Care’s Blind Side
RWJF Survey of 1,000 PCPs:
• 86% said “unmet social needs are leading directly to worse
health”.
• 80% “not confident in their capacity to address their
patients’ social needs.”
• 76% wish the healthcare system would cover cost of
connecting patients to services to meet health-related
social needs.
• 1 of 7 prescriptions would be for social supports, e.g.,
fitness programs, nutritious food, and transportation
assistance.
Health Care’s BLIND SIDE - The Overlooked Connection between Social Needs and
Good Health, Robert Wood Johnson Foundation, December 2011,
http://www.rwjf.org/content/dam/farm/reports/surveys_and_polls/2011/rwjf71795
Because of the Concentration of Risk
and Spending, Home and Community
Care Principles and Practices are
Central to Improving Quality and
Reducing Cost
CBOs as part of the healthcare system
• CBOs need to play a new role connecting the home
with the healthcare system
– Home provides unique perspective otherwise unavailable to
healthcare providers.
– Quality measures for health plans and providers relate to
issues such as medication use and fall prevention – HEDIS,
Medicare Advantage Star Ratings
– Meds are major factor in readmissions – home is key
– New focus on population health – identifying and
proactively addressing health for high-risk patients
Home and Community Based Services
(HCBS) are High Value
• Improves quality: Staying home is concordant with
people’s goals.
• Evidence-based interventions like HomeMeds,
Stanford self-management programs and care
transitions programs reduce ED & hospital use
• Based on 25 State reports, costs of Home and
Community-Based LTC Services less than 1/3 the
cost of Nursing Home care.
Health Care + CBO/Social Services =
Better Health, Lower Costs
• Address social determinants of health
–
–
–
–
Personal choices in everyday life
Isolation, family structure/issues, caregiver needs
Environment – home safety, neighborhood
Economics – affordability, access
• Social service agencies have advantages
–
–
–
–
Trust, time to probe, different authority
Cultural/linguistic competence
Lower cost staff & infrastructure
High impact evidence-based programs
Readmissions: Social Issues
• “Compassionate” admissions – elder with no
caregiver
• Gentleman with mild cognitive impairment tries
to be adherent by taking all meds – including
sleepers – at breakfast – starts falling
• Appointment made by hospital – but daughter
can’t make it – no transportation
• Can’t afford meds
• No food in home – especially none that matches
diet orders
Role of Agencies like Partners in Care
• “Eyes and ears” in the home
• Skilled at building trust and relationships
• Gather data and information that is not shared in a
medical setting or encounter
• Link in medication issues with evidence based
intervention
• Cultural competence in local communities
• Comprehensive psychosocial & environmental evaluation
• Attention to caregivers – special services, support, respite
Major Causes of Readmissions… and what
CBOs can do about them
• Patient and family lack of understanding about managing
patient conditions
• Provide information about “red flags” and self-care
• Missed post-discharge physician appointments
• Transportation assistance; consider family schedules
• Medication errors
• Misunderstanding, language barriers, affordability, multiple
prescribers – meds already in the home, OTCs
• Lack of communication among providers after the discharge
• Patients coached to share information with PCP
• Lack of food or inappropriate diet
• Arrange home-delivered meals for special diet
Care Transitions Coaching & Support
• Evidence-based home & social services models
proven to reduce readmissions
• Medication Review: HomeMedsSM or
HomeMeds-Plus to include comprehensive
psychosocial & environmental evaluation
• Coaching (Coleman Care Transitions
Intervention) for those who are capable (or have
caregivers)
• Social services (Rush U. Med Center Bridge
Program) for those who are not
– Connect patients to services and supports for
recuperation, rehabilitation, education
Partners’ HomeMedsSM-Plus Program
Description
 Comprehensive assessment
 Meds, ADL, PHQ-2/9, cognitive,
sensory, social & behavioral
health indicators
 Comprehensive report, service plan
for LTSS, self-management &
behavioral health
 HomeMedsSM Pharmacist review
 Contact with member’s physician
and other health providers
Outcomes/Experience
 Compared to those who screened in
and didn’t get the intervention:
 Readmission rate 22% lower
 ED use rate 12.7% lower
 ROI = 53% (net)
 63% post-acute had med-related
problems.
 77% had a home safety issue
 54% had other issues (financial,
caregiver, depression, etc.)
 9% had depression
Medications & Care Transitions
• 72% of post-discharge adverse events are
related to medications—and close to 20% of
discharged patients suffer an adverse event. *
• 35% of Medicare patients taking 5 or more
medications experience adverse drug events*
• HomeMeds program – a social work solution
*Mary Andrawis, PharmD, CMMI, presentation to Drug Safety Panel, May 10, 2011 (Forster et al., Annals of Internal Medicine.
2003; 128: 161-167./ CMAJ FEB 3, 2004;170-3)
HomeMeds℠ - Bridge between Home and
Healthcare
• HomeMeds℠ is designed to enable community agencies to keep
people at home, out of hospital & nursing home, by addressing
medication safety
• Practice change with workforces that already go to the home –
more cost effective use of existing effort
• Targets problems for significance, accessibility to in-home staff, and
likelihood of positive prescriber response.
• Focuses on adverse effects (falls, confusion, dizziness, vitals) … then
determines if medications may be part of the cause.
• Cost-effective use of geriatric pharmacist for complex problems
HomeMeds-Plus Targeting Criteria
1. Age 65+ and
2. ED/hospital use in 6 months, plus 2 or more:
a) Hospital LOS > 6 days; or
b) Six or more prescribed meds; or
c) Warfarin/antiplatelet or insulin/diabetes meds; or
d) Dx CHF, COPD, depression, anxiety, bipolar, psychosis; or
e) DX of diabetes, dialysis, hemodialysis, renal failure, CKD,
ESRD, CAD, COPD or CHF; or
f) Mild cognitive impairment; or
g) Recent treatment for fall or confusion; or
h) Age 80+; or
i) Limited caregiver support
Meds in the Home 101
Adherence Problem: 4 prescriptions – patient says “yes”
when pharmacy calls for refill – obviously not taking meds
Meds in the Home 101
 Spanish
speaker
 English labels
 Neighbor
helping
 Bottles get
moved
 Trouble
ahead!
Meds in the Home 101
Patient stored all morning meds in the
same container
The Role of Caregivers
• Family Caregivers
1
– Adult children, spouses, other relatives, friends/neighbors
• Older adult spouses at risk for physical & mental health issues
– 46% of family caregivers perform medical/nursing tasks for
relative with multiple physical and cognitive conditions
– 78% manage medications
• 60% report learning how to manage medications “on their own”
• 47% said they NEVER received training from any source.
• Paid Caregivers
– 60% in recent study could not fill pill box correctly
– 1/3 had difficulty reading and understanding health information
1. Home Alone: Family Caregivers Providing Complex Chronic Care. AARP. October 2012
2. Inadequate Health Literacy Among Paid Caregivers of Seniors. J Gen Intern Med. 2011 May; 26(5): 474–479.
Addressing Readmissions through a
Comprehensive, Coordinated
Delivery System
Managing Readmissions – Not Easy Alone
• HSAG finds 27.5% readmitted to a different hospital
– Efficiency demands coordination and a broader geographic
approach
• Many issues NOT in skill set of healthcare
• It takes a multi-pronged approach
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Hospital
Home Health
SNF
CBO
PCP, etc.
Bringing Local Person-Centered
Services to Large Regional Systems
• National movement to change the business model of
the Aging & Disability Services Network
– U.S. Administration for Community Living (ACL)
•
•
•
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Add upstream value to save downstream costs
Local knowledge, trust, experience
Low-cost models
But…how do you create an efficient
system with dozens of smallish agencies?
A Possible Solution: Led by ACL & the John
A. Hartford Foundation
• Initiative Overview
– CBO networks to create an integrated system of nonmedical care and services
– Contract with healthcare organizations (Medicare
Advantage, Medi-Cal managed care, duals plans, large
medical groups, ACOs/Medicare Shared Savings,
commercial insurance)
– Measure & document value added
– National dissemination & technical assistance
Care Transitions SoCal
• Glendale Healthier Community Coalition - Glendale Hospital plus
Partners in Care and 2 additional hospitals
• Hollywood Area - AltaMed Health Services Corp plus 4 hospitals
• Kern/Bakersfield: Partners in Care + 5 hospitals
• Orange County Care Transitions Partnership - SeniorServ plus 4
hospitals
• San Diego Care Transitions Partnership - AAA plus 11 hospitals
• San Fernando Valley Transitions Coalition - LA Jewish Home plus
3 hospitals
• Ventura County Care Transitions Community Partnership - AAA /
Camarillo Health District plus 5 hospitals
• Westside Care Transition Collaborative - Partners in Care+3 hosp
“My coach helped me make
continuing health a priority – and
having her support made me feel
important despite my age.”
Patient Lolita
• Regional network covers LA, Ventura,
Orange, San Diego & Kern Counties
• Hospital-to-home coaching for
optimal post-discharge recovery
• Patient empowerment:
• PCP follow-up, meds management,
ER avoidance education, healthy
behaviors activation
• Contracted to serve 40 hospitals
• Served 1,000s of patients in first year
• Projected results: 20% reduction in
FFS Medicare readmission rate
Self-Management Support
The actions that individuals living
with chronic conditions must do in
order to live a healthy life.
Physical Activity
Problem-Solving
Medications
Planning
Family Dynamics & Support
Managing Fatigue
Communication
Working with Health
Professionals
Understanding Emotions
Managing Pain & Symptoms
Healthy Eating
High-Level Evidence-Based Programs
Offered by CBOs
SELF-MANAGEMENT
• Chronic Disease Self-Management
• Tomando Control de su Salud
• Chronic Pain Self-Management
• Diabetes Self-Management Program
PHYSICAL ACTIVITY
• EnhanceFitness & EnhanceWellness
• Healthy Moves
• Fit & Strong
• Arthritis Foundation Exercise & Walk
With Ease Programs
• Active Start
• Active Living Every Day
MEDICATION MANAGEMENT
• HomeMeds
FALL RISK REDUCTION
• A Matter of Balance
• Stepping On
• Tai Chi Moving for Better Balance
DEPRESSION MANAGEMENT
• Healthy IDEAS
• PEARLS
CAREGIVER PROGRAMS
• Powerful Tools for Caregivers
• Savvy Caregiver
NUTRITION
• Healthy Eating
Diabetes Self-Management Program
• Developed at Stanford by Kate Lorig, RN, Dr.PH
• Patients learn to take control of their diabetes.
• Peer-led workshop develops tools to:
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Learn about disease & self-care & monitoring
Understand and deal with emotions
Manage medications
Work with health care providers
Make action plans for exercise and healthy eating
• One year after 6-week workshop:
– Improvements in stress management, self-reported health, aerobic
exercise, health distress, self-efficacy, communication with
physicians
– Fewer hospital days; more PCP visits
Chronic Pain SelfManagement Program
Medication isn’t the only treatment….
• Developed by Stanford & Memorial Univ. of
Newfoundland
• Patients learn to manage & decrease chronic pain.
• Outcomes:
– Less Pain & Lower Dependency on Others
– More Energy
– Improved Mental Health
– Increased satisfaction with life
– More involvement in everyday activities
Contact Us
June Simmons, CEO
Partners in Care Foundation
732 Mott St., Suite 150, San Fernando, CA 91340
Main #: 818.837.3775
jsimmons@picf.org
www.picf.org
www.HomeMeds.org