Home and Community
Innovative Strategies
for Safe Transitions and Care
W. June Simmons, CEO
Partners in Care Foundation
April , 2013
Care Coordination for your Older Patient Symposium
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Partners in Care
Who We Are…
• Partners in Care is a transforming presence, an
innovator and an advocate to shape the future of
health care
• We address social and environmental determinants
of health to broaden the impact of medicine
• We have a two-fold approach: evidence-based
models for practice change and for enhanced
self-management
• Changing the shape of health care through new
community partnerships and innovations
Active Patient Population Management
Traditional
Benefit-Based
Home Health
SNFist and
SNF
Program
Hospital & HospitalistExtensivist Programs
Communication
Care Transitions
ER interventions
Efficient hospital use
Ensuring Care Implementation in
the Community & at Home
•Home Social/Environmental
Factors
•Patient Coaching
•Transitions of Care
•Use of Community Resources
•Comprehensive Care Centers
Palliative &
Hospice Care
Complex Chronic
Illness
Home Care & High
Risk Clinic
Optimal
Discharge
(Hospital, ER,
SNF, other)
Patient- Centered
Shared Decision
Making
Mild Chronic Illness & Care
Support for Self Management
Episodic & Expected Care Preventive
Services & Urgent Care
Self-Care & Wellness Programs & Health Education &
Self-Serve Preventive Services
“System” Support: EHR, Data aggregation, Population Registries, Predictive Modeling, Decision Support , Practice Standards,
Quality Measurement and Reporting, Accountability, Tele-Medicine, Tele-Health
Caring for the whole person –
Non-medical services
• Health results come from both medical
interventions and non-medical drivers
• Much truth is found in the home
• The non-medical drivers are powerful:
– Environmental factors
– Social Factors
– Self-Management Factors
Stratify Services for Increasing Needs
Community Agencies = crucial partners
Networks for
Integrating
Healthcare with
Communitybased
Organizations
Evidence-based programs
• Stanford Chronic Disease Self-Management
(including online, Spanish, Arthritis, Pain,
Diabetes, HIV versions)
• Fall Prevention
– Matter of Balance & Healthy Moves
• Depression/Mental Health
– Healthy IDEAS & PEARLS
• Physical Activity
– EnhanceFitness, Fit & Strong
• Medication Safety
– HomeMeds
New Self Management Priorities
• New Medicare Peer Led Diabetes Program
• Chronic Pain Management
• New Target Populations for Spread
– Veterans
– UniteHere
Westside Care
Transitions
Collaborative
Partners in Care
Foundation and the
UCLA Health
System and Faculty
Practice Group,
including Ronald
Reagan UCLA and
Santa Monica UCLA
Medical Centers,
and St. John’s
Health Center
Westside Care Transitions Collaborative
Major Initiatives
 Identify patients at high readmission risk
 Redesign patient flow/discharge planning functions from
hospitals
 Create new gap-filling resources to smooth patient transfers
(e.g. Care transitions, new UCLA urgent care center for post-discharge;
in-home medical care program; home palliative care)
 Expand offerings of evidence-based models for self-care
(e.g., Stanford University’s Chronic Disease Self-Management Program)
 Develop standardized transfer tools, processes and quality
monitoring for SNFs
 Adopt home care best practices, including piloting and spreading a
standard of one-hour response time 24/7 for home health and hospice
admissions, whether discharged from hospital or ER
Westside Care Transitions Collaborative
A Root-Cause Analysis (RCA) found the following areas in need of
improvement:
• Coordination and communication among providers
• Medication management
• Timely support for patients discharged home
• Communication with patients and families about
post-hospitalization care needs and alternatives
• Patient activation to improve self-care skills
• Late life care and decision support services including advance care
planning for life-limiting illness
In-Home Assessment and Care
Coordination
•
•
•
•
Care Transitions Interventions
Coaching vs. Care Coordination
Identification of what is needed
Determination of best location to obtain what
is needed
• Natural supports
• Purchased services and supports
A Key Problem – Medications at Home
• Medication Errors at home are:
– Serious: They cause approximately 7,000
deaths per year in the US
– Costly: Annual cost of drug-related illness and
death exceeds $170 billion
– Common: Up to 48% of community-dwelling
elders have medication-related problems
– Preventable: At least 25% of all harmful
adverse drug events are preventable
A Solution – HomeMeds
• In-home collection of comprehensive medication list,
how each drug is being taken, plus vital signs, falls,
symptoms, and other indicators of adverse effects
• Use of evidence-based protocols and processes to
screen for risks and deploy consultant pharmacist
services appropriately – chosen for physician response
• Computerized medication risk assessment and alert
process with comprehensive report system
• Consultant pharmacist addresses problems with
prescribers
Care Transitions: Buy vs. Build
Hypothetical Los Angeles County Scenario
Patients discharged to geographically
disparate parts of the County
San Pedro
Lancaster
Considerations:





Driving distances to visit patients in home setting following discharge
Arranging for local services (transportation, meals, medical supplies, etc.)
Training and experience hospital (clinical) staff vs. community-based care
Language / Culture
Data collection / patient monitoring becomes more complex
Woodland Hills
Individual Hospital Approach
Each hospitals must hire, train,
manage and pay transitions directors
and health coaches
Regional Model = centralized, costeffective, efficient and experienced!
Challenges in Providing End-of-Life Care
• Fragmentation of care
• Aging population
• Costs of medical care
– 25% of Medicare revenue is spent on 5% who die each year
– Average cost of care in last year of life is $26,000 (1996
costs)
– Average cost of care in last 2 years $ 58,000
Home Based Palliative Care Model
• Bridge traditional medical care and Hospice
care
• In home end-of-life care for patients with one
year life expectancy
• Blended model of care
• Shift focus of care from hospital to home
• Honor patient choices for own care
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Core Components of Palliative Care
• Pain & other symptom management
– comprehensive primary care to manage underlying
conditions
– aggressive treatment of acute exacerbation per
patient and family request
• 24 hour phone support, visits if necessary
• Volunteer & bereavement services
• Transfer to hospice if appropriate
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Unadjusted Medical Service Use (n=297)
Mean Number of
Days/Visits
30
30
Palliative
Usual Care
25
20
15
12.39
10
5
0
9.11
7.34
0.290.67
*ED
2.2
*Hospital
* P<.01
3.18
1.77
SNF
4.42
*MD
Office
*Home
Visits
Total Service Costs
Palliative
$25,000
$20,000
$15,000
n=292
Usual Care • Adjusted costs of care
$20,221
$12,670
for those in PC were
32.6% less than those
receiving UC
• Saves $7,551
$10,000
$5,000
$0
All Costs
p<.001 F=16.66
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Percent Using
Acute Care Service Use (n=297)
60%
Palliative
50%
Usual Care
40%
32%
58%
36%
30%
20%
20%
10%
0%
*ED
* P<.01
*Hospital
Other Causes of Readmissions
• Discharge processes must be realigned
• Skilled Nursing Facilities and Home health
caused 30% of readmits in our targeted
hospitals
• Gaps in care must be identified and remedied
– Innovations are emerging
SNF Transitions Innovation: Results
By engaging in robust performance improvement,
Cedars-Sinai Health System identified interventions that reduced 30-day
readmissions for SNF & Home Health patients by more than 50%.
Baseline
30-day readmission rate
Pilot Period
30-day readmission rate
Discharged to
SNF
Home with
Home Health
25%
14%
11%
7%
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Root Causes for SNF Readmissions
A chart review of 150 SNF patients revealed recurring factors that likely contributed to
preventable readmission within 30 days.
• Infrequent visits by a physician or advanced practice nurse
• Patient not seen by physician within first week of discharge
• SNF nursing staff unable to communicate with physician when needed
• Patient/Family not communicating Red Flags to SNF staff
• Lack of clinical oversight on weekends
• Medication Management/Reconciliation between hospital and SNF
• Patients at end of life without an Advance Directive/POLST completed
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SNF Intervention: Enhanced Care Program
Pilot 1: October/November 2011
Pilot 2: January/February 2012
A Nurse Practitioner followed 115 CSMC patients in the SNF.
• They saw the patient in the hospital
• They saw the patient in the SNF 24 hours after discharge
• They saw the patient 1-2 times per week in the SNF
• When they saw something, they said something…
(to the patient’s MD, the SNF staff & to the family)
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Cycle I: October/November 2011
The first pilot demonstrated a 60% reduction in 30-day readmissions.
During these two months, readmissions occurred mostly on weekends,
when Nurse Practitioners were not working.
Readmissions
from
SNF
RCBH
Readmissions
to CSMC
(Baseline Data: Jan-Mar 2011)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
RCBH Readmissions
CSMC
Readmissions
fromto
SNF
(during TOC)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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Cycle II: January/February 2012
The second pilot, in which NP coverage was extended to include weekends,
yielded a 50% reduction in 30-day readmissions.
During this iteration, the NPs prevented 13 likely readmissions.
13 Potential readmissions averted by Nurse Practitioner
• Duplicate Medication Administration averted (Warfarin)
• Patient’s family’s concerns alleviated (2 different patients)
• Patient’s medication concerns addressed
• Weekend contact with MD with lab results & Rx dosage issues
• Patient code status changed to DNR/DNI, patient expired in SNF
• POLST form completed in SNF- patient expired in SNF
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Cycle I: Enhanced Home Health
WHO
All CSMC Discharges to a high volume Home Health agency
In-hospital visit by nurse + 6 touch-points after discharge
WHAT
WHEN
WHY
•
•
•
•
•
Home visit within 48 hours of discharge
Friday “Tuck-in” Phone call
Weekend Visits
Medication Reconciliation
24-hour call number staffed by a nurse
November 1 – 30, 2011
To determine if more rigorous home health services can
prevent readmissions. (Baseline = 19% readmit rate)
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Root Causes for Home Health Readmissions
A chart review of 45 Home Health patients revealed recurring factors that likely
contributed to preventable readmission within 30 days.
• Patients & families often turn away Home Health agencies after hospital discharge
• Inconsistency in frequency of home visits post-discharge
• 45% of readmissions occurred on a Saturday or Sunday
• Patient/Family not communicating Red Flags to Home Health agency
• Medication Management/Reconciliation
• Physicians not responsive when Home Health Agencies have questions/concerns
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Enhanced Home Health
Only 6.8% of the 59 TOC patients were readmitted within 30 days of discharge.
This rate is less than 50% of the baseline rate observed during FY 2011.
Patient Population
Time Frame
% Readmitted
(All-Cause)
CSMC discharges home with
Home Health (any agency)
Jul 2010 -Jun 2011
19%
CSMC discharges home with
TOC Home Health Agency*
Jul 2010 -Jun 2011
14%
November 2011
6.8%
Test of Change
(n=59 patients)
* The agency selected for the Test of Change had the highest proportion of Home Health referrals from Cedars-Sinai Medical Center .
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Conclusions
• Readmissions can be prevented when hospitals take the lead to
collaborate with partner agencies in the community.
• Intervening during the 14 days following hospital discharge is
crucial for preventing avoidable readmissions.
• Clinical resources in the community (SNF, Home Health) need to be
bolstered on weekends.
• Involvement & leadership from Primary MD are key in executing
improvements related to readmissions.
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The Time is Now – drive the change
For more information contact:
-June Simmons, Partners in Care Foundation
-jsimmons@picf.org
(818) 837-3775