Transcript Slide 1

Healthy Aging and the
Importance of Transitions of
Care
Rob Schreiber MD
Chief Medical Officer, HSL
American College of Health Care Administrators
March 17, 2011
Objectives
• Environmental Scan: review the prevalence, cost
and impact of chronic Illness in our health
system.
• Discuss importance of prevention and health
promotion to reduce risk of chronic illness impact
• Discuss the opportunities for the Aging Service
Provider network to partner with medical system
through the ACA act to reinvent healthcare
• Discuss present and future innovative
opportunities that can redefine health care
delivery and improve health outcomes while
lowering costs
The New Reality
• Healthcare consumes now 18% of GDP and will
increase to 34% by 2040
• 79% of US healthcare $ spent on chronic care
• Medicaid expenditures are growing so rapidly that
states can not meet demand
• Nursing home beds are decreasing in the
communities
• Health care reform is going to result in payment for
outcomes and not service
We Face an Epidemic of Unparalleled
Proportions
• More than 1.7 million Americans die of a
chronic disease each year.
• One-third of the years of potential life lost
before age 65 is due to chronic disease.
• Four chronic diseases—heart disease, cancer,
stroke, and diabetes—cause almost two-thirds
of all deaths each year.
Mensah: www.nga.org/Files/ppt/0412academyMensah.ppt#18
Number of Chronic Conditions per Medicare
Beneficiary
Number of
Conditions
Percent of
Beneficiaries
Percent of
Expenditures
0
18
1
1
19
4
2
21
11
3
18
18
4
12
21
5
7
6
3
13
7+
2
14
63%
18
95%
NCOA Survey of Chronic Conditions:
Findings 2009
• The survey examines the attitudes of Americans with
chronic conditions and explores their quality of life, health
needs and experiences with the health care system
• A bleak and broken health care system for millions of
Americans suffering from a variety of chronic conditions.
• The survey also identifies barriers to self-care and what is
needed to better manage overall health.
• Points to need for cost-effective self-management
programs and support as part of comprehensive health
reform
http://www.ncoa.org/improving-health/chronicdisease/healthier-lives.html
Themes from People with Chronic Conditions
•
•
•
•
Diversity in who is affected and how.
Hurting, tired, depressed and stressed
Reliance on healthcare system that’s not working
Need help learning how to take better care of my health in a
way that works for me and my life
• Have multiple health problems and conditions make it difficult
for them to take better care of myself
• Struggles
– Delaying medical care
– Barriers to self-care
• Seeking realistic, practical, customized help
Life Expectancy by Health Care
Spending
Mensah: www.nga.org/Files/ppt/0412academyMensah.ppt#22
The IOM Quality report: A New
Health System for the 21st Century
• “The current care
systems cannot do
the job.”
• “Trying harder will not
work.”
• “Changing care systems
will.”
IOM Report: Six Aims for Improving
Health Systems
• Safe - avoids injuries
• Effective - relies on scientific knowledge
• Patient-centered - responsive to patient
needs, values and preferences
• Timely - avoids delays
• Efficient - avoids waste
• Equitable - quality unrelated to
personal characteristics
Retooling for an Aging America:Building the
HealthCare Workforce
• IOM 2008
• Report Calls for a
fundamental reform in
the way we care for older
adults
http://books.nap.edu/catalog.php?record_id=12089#toc
IOM Retooling Taskforce Three Prong
Approach
• Enhance the competence of all individuals in
the delivery of geriatric care
• Increase the recruitment and retention of
geriatric specialists and caregivers; and
• Redesign models of care and broaden
provider and patient roles to achieve greater
flexibility.
What Impacts Health Most?
Influence Factors on Health Status
Medical
Care 10%
Lifestyle
and
Behavior
50%
Human
Biology
20%
Environment
20%
Source: McGinnis and Foege, JAMA 1996 & the CDC
“Actual Causes of Death”
Behavioral Risk Factors
Behavior
– Smoking
– Poor diet & nutrition/
Physical inactivity
– Alcohol
– Infections, pneumonia
– Racial, ethnic, economic
Disparities
McGinnis & Foege, JAMA, 1993; Mokdad et al, JAMA, 2004
% of deaths, 2000
19%
14%
5%
4%
?
U.S Preventative Services Task Forces
Principal Findings
• Most effective interventions address personal health
practices: smoking diet, safety, physical activity,
substance abuse
• Need more selectivity guided by individual risk
factors
• Counseling and patient education are most
important criteria than certain diagnostic tests
• Preventative services could be incorporated into
visits for illness
• Patients need to assume greater responsibility for
their health
Healthy Aging ……More than a
program
Healthy aging is a systems change strategy, not
simply a program or service.
Challenges Facing Medical Care
Providers and Health Systems
• Payment for Quality, prevention and outcomes
• Penalized for bad outcomes
• Freezing of payments and/or cuts in Medicare
payments
• Public Report Cards show a significant gap in best
practice and the care delivered
• Being asked to restructure and redesign process
of care
• Dong more with less
Estimated Cumulative Percentage Changes in National
Health Care Expenditures, 2010 through 2019, Given
Implementation of Possible Approaches to Spending
Reform.
HIT denotes health information technology, NP nurse
practitioner, and PA physician assistant
Estimated Cumulative Percentage Changes in National Health Care Expenditures, 2010 through 2019,
Given Implementation of Possible Approaches to Spending Reform.
HIT denotes health information technology, NP nurse practitioner, and PA physician assistant
NEJM, November 26, 2009, Volume 361:2109-2011, Hussey et al.
“Patient Protection and Affordable Care
Act”
Focus on 4 issues relevant to healthcare reform
1. Providers
2. Self-Management
3. Care Coordination
– requires three “I”s: information, infrastructure, and
incentives
4. Research
–
–
Patient-Centered Outcomes Research Institute (PCORI)
Integration of the PCORI’s research findings with decision
supports, guidelines, and other aspects of EHR
“Patient Protection and Affordable
Act”
• Lays groundwork for wide-ranging continuum
of care reform
• Establishes framework for care coordination
• CLASS –Community Living Assistance Services
and Supports
• Office of Dual Eligible
• CMS Innovation Center
ACA Promoting Innovation
• Testing of programs that will lead to improvements in
care coordination
• Expand beyond a narrow medicalized scope of practice
toward connecting older adults in need of long-term
care to supportive service in the community
• Transformation of payment and delivery system models
of care such as ACO, medical health homes
• Bundling of payments for acute and post-acute services
• Funding to expand provider base to deliver long-term
care services through direct workforce investments
A Different Health System Evolving
• Self-management, self-determination, selfadvocacy
• Community-based, collaborative solutions
• Prevention in delay of sickness and impairment
• Evidenced based outcomes, comparative
effectiveness
• Development of Health Aging Communities
• Challenge ageism, health disparities
Value Proposition
• Quality/Cost
• “Outcomes not service” is the new mantra for
community based providers
– Jim Firman CEO of NCOA
• Health system is transforming-what will be
your role in it???
– Will you act or react?
– Goal is to be relevant, add value
Opportunities For Aging Service Providers:
Preventing Hospitalizations
• Preventing Readmissions-improving
transitions from Hospital to Home
– Care Transitions Program
– STARR Program
– MA QIO Homecare Intervention
– Project RED
– Project BOOST
• Avoidable hospitalizations through community
interventions
National Perpective
• 17.6% of Medicare beneficiaries are rehospitalized within 30 days of discharge,
accounting for $15 billion in spending
• Estimates show that 76% of these readmissions
may be preventable
• Of Medicare beneficiaries re-admitted within 30
days, 64% receive no post-acute care between
discharge and re-admission
Source: MedPAC:June 2007 Report To Congress: Promoting Greater Efficiency in
Medicare
Hospitals are Dangerous Places for
Elderly Patients
• A frail, demented 81 yo woman with frequent falls
and previous bleeding in her brain is incidentally
found to have AF on a routine cardiologist visit and is
admitted to the hospital for anticoagulation.
• A delirious 85 yo woman brought to the ED for blood
in her urine is restrained and given large doses of
antipsychotics for a head CT scan.
• A dying 90 yo woman with AD is given atenolol,
lisinopril, lipitor, and aspirin for heart disease.
Danger Also Lurks in Transitions to and
from the Acute Hospital
• Thyroid medication is never resumed upon
discharge. Patient is severely hypothyroid 6
months later.
• Hospital decision not to treat future
pneumonias in a 90 yo woman with endstage Parkinson’s Disease is never transmitted
to the NH and she is readmitted for
pneumonia 1 week later.
• Family is angry about early discharge to a
skilled nursing facility, unaware of a
rehabilitation plan.
Adverse Events Common Coming and
Going
• 46% of hospitalized patients have 1 or more
regularly taken medications omitted without
explanation. Potential for harm estimated at
39%.
– Cornish Arch Int Med 2005; 165: 424-9
• Transfers from NH to hospital have an average
of 3 med changes. 20% lead to adverse drug
events.
– Boockvar Arch Int Med 2004 (164) 545-50
• 19 % have 1+ adverse events within 3 weeks
of d/chg. 66% are adverse drug events.
– Forster et al. Annals of Internal Med 2003;138:161-7
Provider Issues
• Cookbook medicine and the fear of litigation,
demerits, or income penalties.
• Poor communication of patient meds, history,
and preferences.
• Losing the forest for the trees: No
quarterback, fragmentation of care by
subspecialties
• Lack of geriatric knowledge and perspective
• Failure to involve patients and caregivers
Why try to Reduce Hospitalizations in
the Nursing Home?
• Hospitalization is often bad for frail
nursing home patients
• Many hospitalizations can be avoided by
improving care in the NH setting
• Financial and regulatory incentives are
likely to change over the next few year
• We can improve care and avoid
unnecessary expenditures
– Savings can be re-invested to further
improve care
• Impact on quality MDS indicators
1 in 5 Medicare fee-for-service Hospitalized
patients are re-admitted within 30 days
N Engl J Med 2009; 360:1418-28
Clinical Causes of Rehospitalizations
• 70% of post-surgical hospitalizations are for
medical reasons such as pneumonia, heart
failure and sepsis
• Roughly 90% of hospitalization with in 3 days
appear to be unplanned and a result of clinical
deterioration
EB Interventions to Prevent
Rehospitalizations
• STARR Initiative
(IHI)
• Medicare 9th
Scope of Work
• Care Transitions
Program
• Project RED
• Project Boost
• Interact II Tool
• MOLST/POLST
STARR Initiative
(State Action on Avoidable Re-hospitalizations)
• IHI led Commonwealth Funded
• 3 states-MA, MI, WA
• Goals
– Reduce Statewide 30-day
rehospitalization rates by 30%
– Increase patient and family
satisfaction with transitions in care
and with coordination of care
– 20 hospitals in Commonwealth have
project teams
Medicare 9th Scope of Work
Care Transitions Initiative
• Fourteen state QIOs
• Goal:
– Prevent rehospitalizations and improve care
transitions
– Identify and work with one defined cohesive
cross-setting community with common referral
patterns for health care
• 10/14 Using the Care Transitions Program
Care Transitions ProgramTM
• 4 week process involving
– Care Transitions CoachesTM
– Implementation of the CARE (Continuity
Assessment Record & Evaluation) Tool
– Focus on medication self management, red
flags, followup, PHR
• RCT showing significant decrease in
rehospitalization rates at 30 and 90 days
Coleman et al., Arch Int Med, 2006, http://www.caretransitions.org/
Project RED (Re-engineered
Discharge)
http://www.bu.edu/fammed/projectred/
• Goal: Reduce rehospitalizations by using
– In hospital nurse discharge
– After Hospital Care Plan
– After Discharge Clinical Pharmacist Call
• AHRQ Funded RCT Results
– improved readiness for discharge
– improved PCP follow-up
– 30% decrease in overall hospital use (ER, inpatient)
A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A
Randomized Trial, Jack et al., Ann Intern Med. 2009;150:178-187.
MOLST/POLST
• Medical/Physician Orders for Life
Sustaining Treatment(MOLST)
• POLST paradigm exists in 20 states
• Goal: establish a standardized process
for communicating patient’s end of life
care wishes across the continuum
• Part of an advanced caring process
• Being piloted In MA
http://www.mass.gov/Ihqcc/docs/expert_panel/2009_06_08_MOL
ST_presentation.pps , http://www.polst.org/
Nursing Home Hospitalizations and
Readmissions: A Particular Problem
Hospitalization of
Nursing Home Residents
 Common
 Expensive
 Often traumatic to the resident and
family
 Fraught with many complications of
hospitalization
(e.g. deconditioning, delirium,
incontinence/catheter use, pressure
ulcers, polypharmacy)
 Sometimes an inappropriate use of the
emergency room and acute hospital
As many as 45% of admissions of nursing
home residents to acute hospitals may be
inappropriate
Saliba et al, J Amer Geriatr Soc
48:154-163, 2000
In 2004 in NY, Medicare spent close to $200
million on hospitalization of long-stay NH
residents for “ambulatory care sensitive
diagnoses”
Grabowski et al, Health Affairs
26: 1753-1761, 2007
Hospital Readmissions within 30
days from SNFs are common
 Of ~1.8 million SNF admissions in the U.S.
in 2006, 23.5% were re-admitted to an
acute hospital within 30 days
 In Massachusetts the rate is 26%
 Cost of these readmissions = $4.3 billion
Mor et al. Health Affairs 29 (No. 1): 57-64, 2010
Common Reasons for
Transfers






Medical instability
Availability of:
 On-site primary care providers
 Stat tests, IVs
Inadequate assessments to identify early changes
Communication gaps
Family issues/preferences
Lack of advance directives (DNR, DNH)
The Challenge of Decreasing
Hospitalizations
• Reducing hospitalizations from NHs will
be challenging due to lack of
infrastructure, on-site clinical support, and
incentives to manage residents without
transfer
• Current incentives all favor hospitalization
What are the Incentives for
Providers?
Hospital reimbursement
Qualification for skilled
nursing facility stay
Physician reimbursement
Liability
Value Proposition for Reducing
Avoidable Hospitalizations
HIGH
Quality
Reduced Avoidable
Acute Care Transfers
Improved Quality,
Reduced Costs
$ Incentives for
Providers
(Value Based
Purchasing or
“P4P”)
Costs Avoided
$
LOW
LOW
$ Costs
HIGH
How Much Can Be Saved to Reinvest in
Quality ?
Assume:
 Among 1.5 million NH residents in the U.S., ~1/3 will
be hospitalized in one year
= 450,000 hospitalizations

The cost of each hospitalization is ~ $6,500 for a
hospital DRG payment, plus a 30 day SNF stay for
1/3 of those hospitalized at $350/day
= $10,000 per hospitalization
Total cost: $ 4.5 billion
How Much Can Be Saved to Reinvest in
Quality?
% of hospitalizations
avoidable
Estimated Medicare
savings on avoidable
hospitalizations
30%
$ 1.4 billion
40%
$ 1.8 billion
50%
$ 2.3 billion
Two Tools to Decrease Hospitalizations
and Rehospitalizations
• Interact Toolkit
• Rehospitalization Avoidance Program
Interact II Toolkit
• Goal:
– Improve quality of care in nursing homes
– Reduce patients transfers form nursing homes to hospitals
• Major focus
– Improve clinical assessment skills by nurses
– Improve communication tools
– Increase advance care planning
http://interact.geriu.org/
A Toolkit to Improve Nursing Home Care by
Reducing Avoidable Acute Care Transfers and Hospitalizations
Developed based on interviews and ratings of avoidability, and
Expert Panel ratings of importance and feasibility
Care Paths
Communication Tools
Advance Care Planning Tools
A Rehospitalization Reduction
Program on a Geriatric Skilled Nursing
Unit
• Randi Berkowitz MD –lead physician
• Funded by Practice Change fellowship
Target Population
•
•
•
•
•
•
All admissions to the RSU subacute unit
1000 admissions a year
Multiple academic institution referral sources
Medical/Surgical patients
Predominant geriatric patients
3NP/3MD- geriatric and palliative care
certified
Why decrease readmissions?
I. Excellence in care
–
–
–
Decrease errors
patient satisfaction
staff satisfaction
II. Financial
–
–
–
–
Increased referrals
subacute beds
long-term care
census
reimbursement/patient
Reducing AVOIDABLE hospital transfers
Sharing lessons learned
IHI
Rehab - SNF
Admission
assessment
Unplanned discharge
Unit stay:
TIPS
Conference
Re-engineered
discharge
Reduce AVOIDABLE hospital transfers
Approach to the Problem:
Admission
•
•
•
MD standardized discussions
Communication family and PCP
High risk patients
– Automatic Palliative Care consult
– Flag for entire team
Reduce AVOIDABLE hospital transfers
Approach to the Problem:
Stay on the Unit
• Team Improvement for the Patient and
Safety (TIPS) conference
• Call to hospital
• Root cause analysis
Reduce AVOIDABLE hospital transfers
Approach to the Problem:
Home Discharge
• Project RED
– Written home care plan from electronic medical
record
– Making specific for geriatric use
• E.g. advance directives, diet, VNA, assistive devices
• Standardized discharge summaries
Process and Outcome Measures
• Admission
– 90% patients have discussion with MD
• prognosis
• rehospitalizations past 6 months
• Communication family and PCP
– Patient/ family satisfaction survey
Preliminary Data Unplanned Transfers
• January 2008- June 2009 compared with post
TIPS July 2009-November 2009
• Massachusetts 30 day 22-28%
Pre-intervention 16.9%
Post-intervention 12.7%
Rate Reduction
-24.7%
Opportunities For Aging Service Providers
and LTC Organizations: Care Coordination
• Care Coordination/Integration
• Referral to EBP Community Prevention
Programs
• Patient Centered Medical Homes
Evidenced based Programs
Disseminated in MA
• Healthy Eating for Successful
Living in Older Adults
• Stanford University’s Chronic
Disease Self-Management
Program (My Life, My Health)
• A Matter of Balance (Falls
Prevention)
• Fit For your Life (Physical Activity)
• Arthritis Foundation Exercise
Program
• Diabetes Self-Management
Program
National Initiative
Surgeon General
“Americans will be more likely to change their
behavior if they have a meaningful reward-something more than just reaching a certain
weight or dress size. The real reward is
invigorating, energizing, joyous health. It is a
level of health that allows people to embrace
each day and live their lives to the fullest
without disease or disability.”
- VADM Regina M. Benjamin, M.D., M.B.A.,
Surgeon General
National Initiative: Endorsement
• AoA
• CDC
• AHRQ (Agency for Healthcare
Research and Quality)
• ASA/ NCOA
• CMS
• ARRA Funds
Massachusetts Department of Public Health & The Executive Office of Elder Affairs
My Life My Health
A Chronic Disease Self-Management Program
In Massachusetts
Massachusetts Department of Public Health & The Executive Office of Elder Affairs
My Life My Health: EBP In Practice
Participant Benefits
Six Months Later
• Increased exercise
• Better coping strategies and symptom management
• Improvement in self-rated health, disability, social
and role activities and health distress
• Increased energy
• Decreased fatigue
• Decreased disability
• Fewer visits to the doctor and hospitalizations
My Life My Health: Chronic Disease Self-Management Program
Massachusetts Department of Public Health & The Executive Office of Elder Affairs
My Life My Health: EBP In Practice
Participant Benefits
Two Years Later
• No further increase in disability
• Decreased health distress
• Decreased visits to the doctor and emergency room
• Increased self-efficacy
• Saved from $390 to $520 per patient over the
two year study (1999)
My Life My Health: Chronic Disease Self-Management Program
EB Programs by the numbers …
• More than 400 community-based program leaders and
trainers through Massachusetts
• More than 90 community sites, including Senior Centers
and Councils on Aging, Residential Settings,
Neighborhood Health Centers, outpatient clinics, Family
Service Centers currently offer programs
• More than 3200 older adult participants throughout the
Commonwealth
Contact Information
1-800-892-0890
For participant referrals or to learn more about program
opportunities
Jennifer Raymond
Joan Hatem-Roy, LICSW
Director of Evidence-based Programs
Assistant Executive Director
Hebrew SeniorLife / Elder Services of the
Merrimack Valley, Inc.
Elder Services of the Merrimack Valley, Inc.
1200 Centre Street
Lawrence, MA 01843
Boston, MA 02113
978-683-7747
1-617-363-8319
[email protected]
[email protected]
360 Merrimack Street, Bldg. 5
Opportunities For Aging Service Providers:
Building Healthy Aging Communities
• Involvement with dissemination of Evidencedbased Programs
• Building healthy communities through chronic
care coordination, prevention and selfempowerment and efficacy
• Being part of the leadership solution for
implementing a chronic care model in
communities
• Getting best outcomes for populations involved
with caring for no matter what the setting
Conclusion
• ACA has changed the playing field
• Rehospitalizations are going to be a prime focus
of health care in the coming years
• New system paradigm will be needed to meet the
demand for prevention of readmissions
• Critical role of Community Providers of Aging
Network and LTC organizations for care
coordination and self-management
• Healthy Aging Communities need to be a goal and
bringing the hospital into the community will be
one significant approach