Transcript UM Committee Mary Black Hospital

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Describe an overview of Upstate Care
Transitions Coalition Program
Explain the current state of Upstate Care
Transitions Coalition
Define next steps for Upstate Care
Transitions Coalition
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History of CCTP
How our journey began – coalition partners
RCA
UCTC Population, Goals and Plans
Role of the UCTC Coach/Alignment with CTI
Application Process and Approval
Program “go live”
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The CCTP is a five-year program created by the
Affordable Care Act. Participants sign two-year
program agreements with CMS, with the option
to renew each year for the remainder of the
program, based on their success. As of the date
of this announcement, CMS continues to accept
applications and approve participants on a
rolling basis as long as funds remain available.
Taken from CMS announcement on January 15, 2013
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The Community-based Care Transitions Program
(CCTP), created by Section 3026 of the Affordable
Care Act, tests models for improving care transitions
from the hospital to other settings and reducing
readmissions for high-risk Medicare beneficiaries.
The goals of the CCTP are to improve transitions of
beneficiaries from the inpatient hospital setting to
other care settings, to improve quality of care, to
reduce readmissions for high risk beneficiaries, and
to document measurable savings to the Medicare
program.
Taken from Innovation Center website
http://innovation.cms.gov/initiatives/CCTP/index.html
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Four Participating Hospitals in three counties
(Spartanburg, Union and Cherokee)
◦ Mary Black Memorial Hospital
◦ Spartanburg Regional Healthcare System
◦ Upstate Carolina Medical Center (Gaffney
Medical Center)
◦ Wallace Thomson Hospital
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Appalachian Council of Governments
Catawba Council of Governments
Regional HealthPlus
Interim Home Health
Gentiva Home Health
Spartanburg Regional Home Health
White Oak Manor Spartanburg
Magnolia Manor Inman
Camp Care
Rosecrest
Oakmont of Union
Ellen Sagar Nursing Home
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Carolinas Center for Medical Excellence
(CCME) provided data revealing 80% of
the readmitted patients were shared
among the four partner hospitals.
So the journey began…
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Carolinas Center for Medical Excellence- Quality
Improvement Organization
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charts of readmissions for Medicare
Beneficiaries with the following diagnoses:
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Heart Failure (HF)
Acute Myocardial Infarction (AMI)
Pneumonia (PNE)
Chronic Obstructive Pulmonary Disease (COPD)
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Review began in hospitals with a tracer to
the post acute venues (HH & SNF)
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Used standardized review tool
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Focus groups with physicians
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Patient interviews
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Lack of patient chronic disease self-management
skills
◦ The majority of patients are discharged home with self-care
◦ Both objective and subjective data indicate patients would
benefit from an initiative to engage, educate and support them
to become competent and confident in self-care
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Inadequate communication between providers and
settings
◦ Both objective and subjective data support the need for
processes to support and enhance communication between
providers
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Process failures
◦ Both objective and subjective data support the need for
standardized processes internally and externally to improve
care transitions
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Education deficiency
◦ Objective and subjective data support the need for education
for providers, patients/families, and the community
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Socioeconomic factors
◦ Subjective data support the need for “safety nets” for lowincome patients to obtain medications, be transported to
follow-up medical appointments, assist with meal planning and
delivery, and meet basic life needs
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National Statistics and RCA at the four
participating facilities identified four principal
diagnoses for Medicare FFS and dual-eligible
beneficiaries including:
- HF
- PNE
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- AMI
- COPD
All three counties (Spartanburg, Union &
Cherokee) in the program include small, rural
and medically underserved areas.
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Community-based Care Transitions
Program Goals:
◦ Goal 1 – Reduce Unnecessary Readmissions
◦ Goal 2 – Improve Quality of Care
◦ Goal 3 – Improve Transition from Hospital to
Home
◦ Goal 4 – Document Measurable Savings
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Hospital case managers in all four
hospitals identify eligible candidates
Use of Eligibility Screening Tool upon
initial case management assessment
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Candidates for the program will have a
primary diagnosis of:
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AMI
HF
PNE
COPD
Candidates will have a financial class of
Medicare FFS or dual-eligible
Candidates are inpatient and discharged to
home with or without home health services or
to a skilled nursing facility for short term care
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Use the Boost Risk Assessment Tool to
identify eligible candidates
Problem medications
Psychological
Polypharmacy
Poor health literacy
Patient support issues
Prior hospitalizations in the last 60 days
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Hospice or Palliative care patients
Patients with secondary diagnosis of
psychotic disorders
Advanced dementia (unless they have an
engaged caregiver)
Patients with Medicare Advantage Plans
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UCTC Transitions Coach works directly
with case managers at the four hospitals
to identify eligible candidates
UCTC Transitions Coach meets patient in
hospital prior to discharge
The Program consists of a hospital visit,
home visit and three follow-up phone
calls over a 30 day period by the UCTC
Transitions Coach
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If patient is discharged with home health services or to
SNF for short-term rehabilitation, UCTC Transitions
Coach communicates with both patient and home health
or skilled nursing facility partner to ensure patient’s
needs are being met
UCTC program begins upon discharge from home
health services or skilled nursing facility with a home
visit
UCTC Transitions Coach serves as transition “navigator”
and
advocate/liaison
for
patient
to
ensure
communication among team of healthcare providers
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Help patient navigate lifestyle changes given by PCP
Reinforce teaching given to the patient at discharge
and if/when they are in contact with a home health
nurse or other ancillary provider
Assist patient with medication reconciliation
process and have patient work through lifestyle
goals
Coaches are not clinical and visits are not clinical in
nature
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UCTC Care Transitions Coaching model aligns
with Care Transitions Intervention (CTI)
◦ Developed by Eric A. Coleman, MD
◦ Four week program
◦ Patients with complex care needs
◦ Patient and family caregivers receive specific tools
◦ Work with UCTC Transitions Coach to learn selfmanagement skills that will ensure their needs are met
during the transition from hospital to home
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Four Pillars:
◦ Medication self-management
◦ Use of a dynamic patient-centered record, the
Personal Health Record (PHR)
◦ Timely primary care/specialty care follow-up
◦ Knowledge of red flags that indicate a
worsening in their condition and how to
respond
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Facilitate follow-up appointment with PCP
within stated time period (i.e. 7 – 10 days)
Ensure that patient has a medical home
Arrange transportation as needed to
assure patient gets to follow-up
appointment
Confirm receipt of discharge summary by
PCP prior to appointment
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Work with patient on medication management
Assist with formulating questions for follow-up
appointment with PCP
Work with patient on chronic disease management
and identifying red flags to contact PCP
Utilize Case Management at Area Agency on Aging
for patients in need of additional follow-up past
the 30 days provided through the program
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Use of short-term supplemental support
package for low income patients and those
lacking caregiver assistance
◦ Cafeteria-type package
 Nutrition (meals for 7 – 14 days)
 Transportation to PCP or medical appointment (1-2)
 Limited non-medical home care (i.e. 2 hours several
times per week)
 Phone cards with limited minutes for follow-up phone
calls and community case management/service
coordination
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Committee Work
◦ Steering Committee
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Budget Committee
Previous Experience Committee
RCA Committee
Intervention Committee
Implementation Committee
Submission of UCTC application – August
2012
Final application approval – January 2013
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CM Staff Education
◦ All four Directors of Case Management traveled to
all four hospitals
◦ Demonstrate community/unified effort to Case
Management Teams in all four hospitals
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Obtain coach access to hospitals
Official “go live” – April 22, 2013
◦ Initial go live with SRMC and Mary Black
◦ Wallace Thompson and Gaffney Medical Center go
live - August 2013
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Overview of UCTC Current State
Perfecting the Program – Process Improvements
◦ Enrollment
◦ Coach Workflow
◦ Home Health/UCTC Workflow
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All four hospitals now referring to UCTC
Coach Manager has hired three coaches and
recruiting for additional coach - workflows in place
UCTC referrals have been expanded to include
eligible patients being discharged home with home
health services
Ongoing biweekly teleconferences with Appalachian
COG, Coach Manager and Directors of Case
Management
Quarterly face-to-face meetings with Appalachian
ACOG, Coach Manager and Directors of Case
Management
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Ongoing process improvements as we plan,
do, study, act (PDSA)
◦ Process Improvements to impact enrollment
 Inclusion criteria now includes primarily diagnosis OR past
medical history of COPD, Heart Failure, Pneumonia or AMI
 Inclusion criteria now requires one risk factor (initially
required two)
 Coaches now have access to Medicare census to facilitate
screening of potential candidates (collaborative team
approach between hospital case managers and coaches)
 Coaches now have access to Medicare census and patient
information via secure e-mail and remote access (provides
for more timely screening and review of patient information)
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Process improvements related to workflow of
coaches
◦ Placement of a coach screener who does all hospital
visits for the larger hospitals
◦ Field coaches complete home visits by territory
(helps split up the large area served)
◦ Coaches paid per case once initial home visit
completed with opportunity for bonus $$ for
completed cases with no 30 day readmission
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UCTC expansion to patients discharged with
HHS
◦ Initial roll out of workflow plan to Interim, SRMC
and Gentiva Home Health Services – completed
August 2013
◦ Initial plan – hospital visit by UCTC coach with
coach/HHS champion communication until patient
discharged from HHS – UCTC coach home visit
following discharge from HHS
◦ Based on feedback from patients/families, UCTC
coach now sees HHS patients within first week of
discharge (patient/family education regarding the
difference between UCTC coach and HHS roles)
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Initially billing to CMS manually
Process now in place to allow for automated
billing
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Expansion of UCTC to eligible beneficiaries
discharging to short-term SNFs participating in
coalition
◦ Initial pilot with White Oak Manor Spartanburg
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Appalachian Council of Government RN to assist
with screening for potential UCTC candidates
Hiring of additional coaches as enrollment
numbers increase (anticipate a total of seven
coaches at full enrollment)
Roll out patient surveys
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Ongoing communication between
Appalachian Council of Government, Coach
Manager, and Directors of Case Management
through biweekly conference calls and
quarterly face-to-face meetings with
additional process improvement as needed
Readmission data analysis – aggregate data
for all four hospitals – goal = 20% reduction
in readmissions
Quarterly CCTP meetings with focus on
identifying best practices from CCTPs across
the nation
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Acknowledge the power of community
collaboration
Understand the value in RCA to drive action
Rely on evidence based practice and tools
Embrace process improvement (perfecting
processes) through PDSA – be willing to
change
Remember the ultimate focus – the patient
◦ (Patient Stories)
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So the journey continues…
This is a work in process and
we will continue to perfect our
processes to ensure quality and
safety for our patients as they
transition from hospital to next
level of care
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