Medicare Patients Rights and
Better Care Transitions
Michael Burgess
New York StateWide
Senior Action Council,
September 13, 2012
Nothing Short of a Revolution and
Change in Culture of Health Care
• Health Care is Quickly Moving from a Fee-forService World to a Coordinated Care Model
with a Bundled Payments to Providers
• Concerns about Quality of Care and Cost of
Care are leading to changes in the delivery of
care with heavy focus on care transitions,
coaching, primary care, prevention
• Shorter Stays in Hospitals are leading to the
need for greater community support
And yet,
• “Patients and family caregivers are not
adequately prepared to manage their
conditions during the transition between care
settings in the absence of health care
professionals, leading to symptom
exacerbation, an increased likelihood of crisis,
inappropriate health care utilization and
readmission to the hospital.” - Tompkins
County Rural Community Based Care
Transition Program
Problem situation
“Observation Status”
• Hospital admissions and re-admissions
practices have changed with an increase of
over 20% in “observation status” classification
• Beneficiaries impacted because status effects
Part A and Part B Medicare payments and full
out of pocket costs for nursing home rehab
without 3 day admission
• Little education and outreach regarding shift
Patient Centered Care and Community
Outreach and Services
• New Models are Based on Need for Patients
and Caregivers to Be More involved in care
• Education and Community Outreach to
patients though has not kept up with changes
• Hospitals are now becoming more involved
with community projects for intensive care
transitions involving nurses, coaches, to assist
in post hospital care
Local Innovative Approaches
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Care Transitions Demonstration with CMS
Community Supports Navigator
Health Coaches
Medical Homes
Target High Need Chronically Ill with Intensive
support
• Enhanced Prevention Efforts
• NY Connects
Targeting High Risk Patients
• Providing intensive support and monitoring of
high risk patients with serious chronic
conditions to make sure that they are getting
primary care, medications and support
services
• Focus is on patients with congestive heart
failure, COPD, pneumonia, diabetes
CMS Strategies to Improve Quality
and Reduce Costs
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Accountable Care Organizations
Health Homes
Financial Incentives to Reduce Re-Admissions
Wellness and Prevention Initiatives
Partnership for Patients
Care Transitions Grants
Community First Choice Independent Living
Patient Safety, Reduce Medical Errors
Reduce Medicare Fraud
Medicare Beneficiary Feedback (IPRO)
Communication/Care Coordination
• Option for short term rehab was never provided by
hospital
• Did not receive discharge planning while in hospital
• Discharged from hospital with no instructions
• Insurance pressure to discharge too soon
• Did not involve caregiver in discharge plan
• Cared for by many physicians in the hospital, none of
which were the primary; gave conflicting information
• Poor communication between providers, patient and
caregiver
• Sent home alone, was afraid did not know what to do
Medicare Beneficiary Feedback
Medication Reconciliation
• Too many medications to track and manage
• Medication not explained or did not understand
• Primary care physician changed dosages after I purchased
medications at discharge
• Insurance plan did not allow medications prescribed at
discharge
• Did not know I was being discharged with new medications
• Medication name was different on discharge summary that
what pharmacy dispensed
• Hospital gave prescription for same medication I was taking
at home but with different name and I took both
• Difficulty getting to pharmacy
Medicare Beneficiary Feedback
Follow-up Physician Visits
• Realized that more questions should have
been asked in hospital
• Having to wait several weeks to get
appointment
• Did not have transportation to appointment
• Difficulty getting a live person on the phone to
schedule appointment with doctor
• Confusion about which physicians to follow up
with: primary or specialists or all
Medicare Beneficiary Feedback
Caregiver Perceptions
• Lack of time for health workers to talk to patient
and caregiver
• Assumption that caregiver knows everything and
has no questions
• Assumption patient has caregiver at home who is
able to provide needed care
• Caregiver does not realize they are caregiver
• Power of attorney not honored
• Difficulty advocating for patient with Alzheimers
Community Collaboration –
Health and Aging Networks
• Formalize Relationships in the community
between health and aging networks
• “Care Transitions” Coalition to Bring Together
Hospitals, Health Providers and Aging Network
• Problem solving to discuss difficult cases
• Joint advocacy on health issues, i.e.
observation status