Transcript ACA, Social Work, and Care Coordination

The Affordable Care Act:
A New Opportunity for
Social Work
December 13, 2013
The Affordable Care Act:
A New Opportunity for
Social Work
Robyn Golden, LCSW
Director, Health and Aging
Rush University Medical Center
ACA, Social Work, and Care
Coordination
 ACA provisions create opportunity for
new social work roles
• Avenues to sustainable care
coordination by social workers
increasingly available
 Provisions include:
• Changing incentives
• Changing payment structures
• Moving away from fee-for-service
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
Health Care’s Blind Side
 2011 Robert Wood Johnson
Foundation survey of 1,000 primary
care physicians8
• 85% feel social needs directly
contribute to poor health9
• 4 out of 5 not confident can meet
social needs, hurting their ability to
provide quality care9
• Rx for social needs, if they existed,
would be 1 in 7 Rx’s written9
 Psychosocial issues treated as
physical concerns10
 Social work operates in this blind side
Moving toward the Second Curve
First Curve
Second Curve
Direct
Contracts
with
Employers
Traditional Fee-for-Service
Payment System
Option on
the Health
Exchange
Medicare
Advantage
Plan
Readmission
Rate
Penalties
Population Health
Per Capita Payment
System
Bundled
Payment
Pilots
Accountable
Care
Organizations
Adapted from Ian Morrison
Patient Protection and Affordable
Care Act 2010
Reform
component
What it means
What we need to
work on
Readmissions
Financial penalties
for excess
readmissions
Quality and patient
safety
Value Based
Purchasing
Payment based on
performance on
core measures
Hospital Acquired
Conditions
1% reduction in
payment if in top
quartile
Care coordination
Evidence-based
care maps
Clinical
documentation
Patient Protection and Affordable
Care Act 2010
Reform
component
What it means
Coverage expansion
More patients with
insurance
Bundled payments
Lump sum payments
to providers for 10
conditions
Accountable Care
Organizations
Patient-centered
medical home
Manage care of
specified
beneficiaries;
quality/cost; share of
cost savings
Services, structures
and access for
continuous &
comprehensive care
What we need to
work on
Manage access
Alignment and
partnerships
Manage quality and
cost
Manage populations
Care coordination
Informatics
Avoidable Readmissions Penalty
 Incentive to improve care transitions & reduce avoidable
readmissions
 Lost reimbursement to drive performance improvement
• Penalty for each hospital based on risk-adjusted actual 30-day
readmission rate compared to expected readmission rate
• Reduced Medicare DRG payments by 1%, rising to 3% in 2015
• 3 target conditions starting in FY 2012, expanding to 7 in FY
2015
 Hospital-specific readmission rates posted on Hospital
Compare website for public viewing
 Expand to skilled nursing homes & home
health agencies
Community Based Care Transitions
Program (3026)
 Provides funding to hospitals & community-based
entities that furnish evidence-based transition
services to Medicare beneficiaries at high risk for
readmission
 Preference for medically underserved areas, small
communities, rural areas & AoA programs
 Services must include at least one of 5
interventions
• Arranging post-discharge services
• Providing self-management support (or caregivers
support)
• Conducting medication management review
 5 year program started in 2011
Bundled Payments
 Bundled payment pilot began 01/31/2013
• Single Medicare payment to cover all services for
an episode of care to be distributed among care
providers:
 Acute hospital services
 Physicians’ services
 Care coordination & transitional care services
 Post-acute services
 Home health care
 Skilled nursing facility services
 Inpatient rehabilitation services
 Pilot testing four variations on
bundling model over 3 years to assess efficacy
Medical Homes
 Change in outpatient care delivery toward
coordinated, chronic care, including the
following supportive services:
• Care coordination
• Case management
• Health promotion
• Transitional care
• Patient and family support
• Referral to community services
 Additional funding available for
coordination through greater reimbursement
Accountable Care Organizations
 Medicare Shared Savings Program (3022) creates
incentive for the establishment of Accountable Care
Organizations (ACOs)
• Networks of physicians and other providers
• Integrated, cooperative services designed to foster
collective accountability
• Share savings resulting from the ACO’s coordinated care
 Reduced Medicare expenditures
 Improved beneficiary health outcomes
 No consensus on vital components of an ACO
• Will have to address social issues to see true cost savings
• Opportunity for social work to achieve
savings and quality improvement
ACA: Who are the Dual Eligibles?
 Eligible for both Medicare & Medicaid
• About 12% of Medicare beneficiaries are near-poor
and do not have Medicaid or supplemental
insurance
 Sickest and poorest—use most health
services, most costly:
• 36% of Medicare spending, 1.5 X higher with
worst health outcomes
 Lack of coordination of 2 systems High rate
of inappropriate (potentially avoidable)
hospitalizations
Dual Eligibles as a Social Justice
Issue
 Very low income, women, African
Americans, Hispanics, multiple chronic
illnesses, and persons with disabilities
under age 65
 Greater medical needs, functional
limitations and cognitive limitations
 More likely to live in long term care
facility, use emergency rooms
Dual Eligibles – The Ultimate Case
Study:
Age + Poverty = Worse Health, Higher Cost
Sources: Centers for Medicare and Medicaid Services; Kaiser Family Foundation,
Medicare Payment Advisory Commission
Avoidable Hospitalizations for
Duals
Over $4 billion potentially
avoidable…not to mention the
patient suffering this
represents
Sources: Centers for Medicare and Medicaid Services; Kaiser Family Foundation,
Medicare Payment Advisory Commission
Reducing Costs & Improving
Continuity of Care
 Emphasis on integrating two systems of
care
 Expand home and community based
services
 Extend Money Follows the Person
Demonstration; supports for people to
move out of institutions into community
The CMS Innovation Center
(CMMI)
 Test innovative payment and service delivery models
• To reduce program expenditures
• To preserve or enhance the quality of care furnished to
Medicare and Medicaid beneficiaries
 Preference given to models that improve health care
coordination, quality, & efficiency
• Authority to expand any model
 Funding of $1 billion per year for 10 years
• Released through ongoing Funding Opportunity
Announcements
• Targeted distribution within priority areas
• Budget neutrality requirement waived during
testing
Thrive Under Reform
 Key elements to making the ACA
successful
• Engaging patients
• Prevention and wellness
• Not transactions but a journey
• Transparency of performance
• Focus on burden of treatment, not illness
• Cost and quality in the same breath
 Where does social work fit?
Social Workers and
Interdisciplinary Teams in Practice
 Social workers are both valuable contributors to a
team and effective leaders
 This can be seen in successful models utilizing social
workers as team coordinators
• Social Work and Mental Health
 BRIGHTEN: Virtual interdisciplinary program integrating
mental health into primary care
• Social Work and Transitional Care
 Bridge Model: Transitional care model provided by MSW’s
from a biopsychosocial perspective
• Social Work and Patient Centered Medical Homes
(PCMH)
 Ambulatory Integration of the Medical and
Social (AIMS Model): Primary-care based
care coordination
Social Work and Mental Health

Social workers can be a valuable member of the mental health team
•
Care manager
•
Therapist
•
Advocate and educator of the healthcare team

BRIGHTEN: Bridging Resources of an Interdisciplinary Geriatric Health Team via
Electronic Networking

Team-based approach to mental health in primary care

Along with the social workers, the team is comprised of:
•
Patient
•
Geropsychologist
•
Geropsychiatrist
•
Physical Therapist
•
Occupational Therapist
•
Nutritionist
•
Chaplain
•
Pharmacist
•
Primary Care Physician
Bridge Model: Primary Goals
Addressed by Social Work
3 guiding tasks to reach the goal of
preventing avoidable adverse events
post-discharge:
1. Ensure patients receive appropriate
services in their home post-discharge
2. Connect patients to their physician for
follow-up appointments
3. Support caregivers to reduce stress
and burden
Social Work and Transitional Care:
Bridge Model
 Bridge social worker serves as primary care
coordinator
• Manages care coordination tasks
• Facilitates inclusion of other team members
 Additional team members vary by client
• Inpatient case manager & attending
physician
• Primary care physician
• Pharmacist, therapists, other medical
providers
• Home health care provider
• Community service provider
Social Work and Patient Centered
Medical Homes (PCMH)
 Role for social workers in augmenting the patient’s primary
care encounter
• Address gaps in care resulting from insufficient time, staff, resources
• Provide compensatory support to meet patients’ medical and
psychosocial problems
• Assess patients’ psychosocial considerations and their impact on
medical status
• Educate providers how to support patient self-management
 This resource is central to PCMH success
• True improvement in care, health, and cost cannot be done without
addressing the factors that impede patients’ medical care plan
adherence
 Ambulatory Integration of the Medical and
Social (AIMS) Model at Rush
Outcomes of Social Work
Involvement and Leadership
 These three examples demonstrate
success as a result of social work
involvement
• BRIGHTEN: Lower PHQ-9 scores and
depression scores
• Bridge: Increased communication with
physicians & keeping medical appointments;
Decreased mortality
• PCMH Social Work: Increased well-being;
decreased stress; more time for medical issues
at next appointment
 However, social work evidence not
extensive: ongoing challenge for field
Gaps to Incorporating Social Workers in
Interprofessional Efforts (IPEP)
 Few evidence-based team models
incorporate social work participation
with a specified role
 Social work role and contribution not
clearly understood
 No financial incentives for social
work values and skills on teams
Getting to the Table
 What can social work education programs do
to get social work to the table?
• Find cross-institutional ways to collaborate
• Learn to communicate and market social work
• Frame social work from other perspectives
 Speak the language of other professions
• Vary the message to fit the mission of the
team
• Find ways to partner with other disciplines
 Example: delegating tasks to community
health workers so social worker can focus
on skilled activities
Future of IPEP and Geriatric Social
Work
 We must prove the value of social work
• Make clear business case
• Show return on investment from social work
involvement
 Clarify how social work helps to meet the Triple Aim of
better care, better health, lower cost
 Frame within social determinant of health language
and not just make it a guild issue
• Not social workers can do it better
• Social workers can do it, too
 Comparative effectiveness research to
show outcomes of not having social worker involved
The Imperative
 Critical to incorporate:
• The social determinants of health
• Prevention
• Care coordination
 It takes a village
• Need a team to meet the needs of increasingly
complex, older patient population
• Responsibility cannot solely reside with the
physician
 To meet this imperative, we must innovate
References
1.
Shi L, Singh D. The Nation’s Health. 8th ed. Sudbury, MA: Jones and Bartlett Learning, LLC; 2011.
2.
Gallant MP. The influence of social support on chronic illness self-management: a review and directions for
research. Health Educ Behav. 2003;30(2):170-95.
3.
DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol.
2004;23(2):207-18.
4.
Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health.
2002;92(5):758-68.
5.
American Public Health Association. The hidden health costs of transportation.
http://www.apha.org/NR/rdonlyres/A8FAB489-BE92-4F37-BD5D5954935D55C9/0/APHAHiddenHealthCosts_Long.pdf. Published February 2010. Accessed January 10,
2012.
6.
Centers for Disease Control and Prevention. CDC health disparities and inequalities report – U.S. 2011.
Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention,
2011.
7.
Robert Wood Johnson Foundation. Overcoming obstacles to health care.
www.commissiononhealth.org/PDF/ObstaclesToHealth-Highlights.pdf. Published February 2008.
Accessed January 10, 2012.
8.
Robert Wood Johnson Foundation. Health care’s blind side: the overlooked connection between social
needs and good health.
http://www.rwjf.org/files/research/RWJFPhysiciansSurveyExecutiveSummary.pdf. Published December
2011. Accessed January 10, 2012..
9.
Physicians highlight overlooked connection between social needs and health. Robert Wood Johnson
Foundation Web site. http://www.rwjf.org/vulnerablepopulations/product.jsp?id=73646. Published
December 8, 2011. Accessed January 10, 2012.
10. Ring A, Dowrick CF, Humphris GM, Davies J, Salmon P. The somatising effect of clinical consultation: what
patients and doctors say and do not say when patients present medically unexplained physical symptoms.
Soc Sci Med. 2005;61(7):1505-15.
Thank you!
Robyn Golden, LCSW
Director, Health and Aging
Rush University Medical Center
[email protected]
312.942.4436
The Affordable Care Act:
A New Opportunity for
Social Work
Sandy Atkins, VP
Institute for Change
Partners in Care Foundation
Health Reform: Moving From
Volume to Value
 Major consolidation – unpredictable future
 Infrastructures and reimbursement are
transforming; emphasis on prevention
 The roles of hospitals, physicians and payers are
blurring and social skills are more recognized
 The role of the community agency is growing –
bringing social work to the forefront
 New broader partnerships are essential within
medicine, within social services and
between both
Health Care + 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
• Time to probe, trust, different authority
• Cultural/linguistic competence
• Lower cost staff & infrastructure
• High impact evidence-based programs
Targeted Patient Population
Management
Home Palliative
Care
Advance Care
Planning
End of
Life
Hot Spotters!
Complex Chronic
Illnesses w/ major
impairment
Chronic Condition(s) with
Mild Functional &/or
Cognitive Impairment
Everyday SelfManagement Needed
Chronic Condition with Mild Symptoms
Well – No Chronic Conditions or Diagnosis
without Symptoms
Value of HCBS in Population Health
Management: Who Pays? Who Saves?
EOL
25% of all Medicare is Last Year of Life: Duals
Plans; Medicare Advantage SNP; ACO/MSSP
LTSS &
Caregiver
Support
Nursing Home Diversion for Duals Plans
Care Transitions
HomeMeds/Home
Safety Assessment
EB Self-Management:
CDSMP/DSMP; MOB; Healthy
IDEAS; EnhanceFitness;
PEARLS; Fit & Strong
Senior Center – meals, classes,
exercise, socialization
 ED/Hosp: Capitated Providers/Plans
 Readmission penalties: Hospitals
Chronic Disease Management:
Duals Plans; MA SNP
Prevention: MA Plans;
Capitated Med Groups
Building Our New Business Model:
Focus Areas
Self-Management
Assessments, Care
Coordination & Coaching
Provider Networks
For Efficient Delivery
System
Stanford CDSMP &
Diabetes/Pain
versions
Care Transitions
Interventions
Evidence-Based
Leadership Council
A Matter of Balance
HomeMeds
Care Coordination
Network
Savvy Caregiver
Home Safety Evaluation
LTSS Network
Arthritis Foundation
Walk with Ease
Short & Long-Term Service
Coordination
Care Transitions
Provider Network
UCLA Memory
Adult Day/CBAS Assessment
Powerful Tools for
Caregivers
Home Palliative Care
Focus Area #1
Self-Management Support
for Patients
and for Caregivers
Stanford Healthier Living (CDSMP):
Participant Health Outcomes
Randomized, controlled trial of 1,000 participants
Increase in
Exercise
Energy
Psychological well-being
Decrease in
Pain and fatigue
Depression
Shortness of Breath
Limitations on Social and role
activities
Overall Improved health
status & quality of life
Greater self-efficacy and
empowerment
Enhanced partnerships
with physicians
Sources: Lorig, KR et al. (1999). Med Care, 37:5-14; Lorig, KR et al.
(2001). Eff Clin Pract, 4: 256-52; Lorig, KR et al. (2001). Med Care, 39:
1217-23.
CDSMP Healthcare Utilization Effects
 Results showed more appropriate
utilization of health care resources
through decreased:
 Outpatient visits
 Emergency room visits
 Hospitalizations
 Days in hospital
 Ultimate Result: Reduction in health
care expenditures
Focus Area #2
Assessments, Care Coordination, and
Coaching
New Public and Private
Models
 Readmission penalties inspiring
rapid change
 CMS testing new CBO Medicare
models
 Moving to all cause/all payers
 Integrated regional delivery system
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)
Current MSSP Services Model:
(can be adapted for Duals as CMS rules change)
Purchased
Services
(Credentialed Vendors)
• Safety devices, e.g., grab
bars, w/c ramps, alarms
• Home handyman
• Emergency response
systems
• In-home psychotherapy
• Emergency support
(housing, meals, care)
• Assisted transportation
• Homemaker, personal care
and respite services
• Replace
furniture/appliances for
safety/sanitary reasons
• Heavy cleaning & chores
• Home-delivered meals –
short term
• Medication management
(HomeMeds)
Referred Services
Community
Care
Coordination
Social
Worker
RN
Client
&
Family
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
IHSS
Adult day health
Regional Center
Independent Living
Centers
Home Health
Palliative/Hospice Care
DME
Caregiver Support
Senior Center Programs
Evidence-based Health
Impacting Self-Care
programs
Long-term home-delivered
meals
Housing Options
Communication Services
Legal Services
Benefits Enrollment
Money management
Utilities
Focus Area #3
Comprehensive, Coordinated
Delivery System
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)
 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 the ACL and
the Hartford Foundation
 Initiative Overview
• Create networks of community-based
organizations (CBOs) to create an integrated
system of non-medical 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
Building Relationships and Contracts
HC Entity
Foot in the door
Contract Services
Medicaid Health
Plan
Health risk assessment;
board member; CMMI
CTI private contract;
ADHC FTF
assessment
Health System
Consulting on community
strategic plan; CMMI
Root cause analysis;
CCTP; Home visits
ACO/MSSP
Primary Care Redesign
Team; CMMI
CTI/In-Home Meds
Assessment
Home Palliative Care
Medical Group 1
HomeMeds, Home
Evaluation; consulting; EOL Safety Eval, Care
Transitions
Medical Group 2
Board member
DSMP; evaluation;
waiver pilot
Integrated Community Care
System
One Call Does It All!
Evidence-based
Self-Management
Workshops
Care & Service
Coordination
Comprehensive
Assessments
HomeMeds/Med
Reconciliation
Network
Office
Nutritious meals,
transportation,
home mods, etc.
Caregiver
Education &
Support/Respite
Implications for Social Work
Training and Practice
 Expand comfort zone – HomeMeds calls
for documenting meds and vitals
 Use technology to support efficiency
 Business opportunities require business
practices
• Metrics
• Rapid response
• CQI
Thank You!
Sandy Atkins, VP, Institute for Change
Partners in Care Foundation
[email protected]
818.632.3544