Transcript SSA`s mission is to foster independence and enhance the quality of

Partnering to Reduce
Hospital Readmissions
for Seniors
NYS Senior Nutrition Conference
October 16, 2015
Gretchen Moore Simmons, MA
[email protected]
Senior Services of Albany
SSA’s mission is to foster independence and enhance the quality of life of
older adults by providing innovative services and caregiver support. For
over 60 years, SSA has developed and delivered an array of valuable,
relevant and cost effective services to seniors of the Capital Region.
• Meals on Wheels
• Transportation Services
• Friendly Home Visits & Grocery Shopping Assistance
• Community Case Management
• Social Adult Day Care Services (3 locations)
• Community Dining and Senior Activities
• HIICAP (Health Insurance Counseling)
• Support Services for seniors and their caregivers
Quiz
1.
Approximately how many Americans are 65 or over?
a) 12 million b) 22 million c) 35 million d) 46 million
2.
What percentage of America’s seniors live in isolation?
a) 10% b) 25% c) 50% d) 75%
3.
What percentage of hospitalized Medicare beneficiaries
are readmitted within 30 days?
a) 5%
b) 10% c) 20% d) 50%
4.
Noncompliance with medications and diet, as well as
inadequate social support accounts for what percentage
of hospital readmissions ?
a) 10-15% b) 20-25% c) 30-40% d) 45-50%
5.
One in every three Medicare patients discharged from
hospitals is readmitted within 90 days. True
False
Statistics
• One in every five Medicare patients discharged from
hospitals is readmitted within 30 days (20%)
• One in three is readmitted in 90 days (33%)
• These costs account for one sixth the total Medicare budget
• According to the American Journal of Geriatric Cardiology,
“noncompliance with medications and diet, as well as
inadequate social support are among the most common
reasons for early re-hospitalization…, accounting for up to
50% of such re-admissions.”
• Studies show that persons who live alone have a 50%
higher risk of hospital readmission compared to those living
with others.
Why is this important?
United Way grant
Senior Services of Albany applied for a Community
Investment grant through United Way of the Greater
Capital Region to do the following:
Provide seniors discharged from the hospital with vital
nutrition, transportation services, shopping and friendly
home visits, and case assistance which would improve
healing time, reduce the number of hospital readmissions,
and decrease admission rates to nursing homes.
• 21-month grant (October 2014 – June 2016)
• applied for $72,495 (to serve approx. 250)
• received $52,500 (to serve approx. 175)
The PASST Program
Providing Assistance and Support to Seniors in Transition
Within 2 weeks of discharge from a hospital/rehabilitation
facility, based on referrals from healthcare agencies, eligible
patients will be provided with:
• Home-delivered meals (through Meals on Wheels) for an
average of 30 days
 Senior caregiver is eligible for 2 weeks of meals
• Transportation to doctor’s appointments for 30 days
• Grocery Shopping Assistance/Friendly Home Visits
• Community Case Assistance
How to get participants?
• Identify Partner organizations
Hospitals
Visiting Nurse Agencies
Rehabs/Nursing Homes
Home Health Care Agencies
Physician groups
• Establish Memorandum of Agreement (started with 6)
 Provide referrals
 Notify SSA of patient rehospitalization
• Conduct PASST in-service
Discharge planners
Nurses
Social workers
• Provide information and necessary forms
Referral Form
Program Process Form
Eligibility Checklist
PASST Brochure
Referral Process
• Receive referral from Partner Agency (or through Meals on
Wheels)
• Complete Assessment (by phone or in person)
• Determine if the person is eligible and what services the person
needs/wants
• Participant signs off on Participation Agreement
Program is short-term (30 days)
Participant will notify SSA of any changes, including
rehospitalization
Participant will actively participate in follow up assessments
and program evaluation
• Set the person up for appropriate services within SSA* (determine
start and end dates) for themselves and caregiver (if eligible)
*can begin as soon as next day in most cases
Follow Up Process
• Follow-up with referring agency
 Person was deemed eligible
 Authorized services, Start/End dates (MOW; Transportation;
Grocery Shopping/Friendly Home Visits; Case Assistance)
 Person was deemed ineligible
 Reason (out of catchment area, didn’t meet eligibility criteria;
person didn’t want services; unable to contact patient)
• Follow-up with participant
 30-Days; 60 Days, 90 Days
Was patient readmitted to hospital?
 Is participant still receiving any services (which ones)?
 Participant Satisfaction Survey (phone or mail)
 Assist participant in accessing long-term services
Challenges
• Difficult to get Partners on board
 Especially difficult to develop and maintain
relationships with hospitals
 Need to establish champions within the organization
(frequent flyer referrers)
• Takes longer than anticipated to receive referrals
• Higher than expected number of referrals declined to
participate (didn’t think they needed the services)
• Ability to provide services outside of a relatively small
catchment area (rural and remote are too costly)
• Moving people onto long-term services
Successes
Successes
“PASST program provides a necessary link for isolated
seniors after their hospitalizations. Staffed by caring and
knowledgeable professionals, the program contains
tangible supports, psychosocial assessment, education,
and reassurance that often lacks during one’s chaotic
discharge process. PASST is often the very first phone call
or a home visit for older adults returning home and finding
themselves overwhelmed after their hospitalization. I
highly recommend and support this program!”
– Tatyana Schwartz, LCSW, C-ASWCM
Elder Care Consultant
CHOICES Program at St. Peter’s Hospital
Results to date
• 2/15 – 10/15: PASST has received 77 referrals
(average of 7-10/month)
• 28 deemed ineligible or declined to participate (35%)
• 49 participated in program for an average of 30 days
• 6 reported a hospital readmission within 30 days (12%)
• 12 satisfaction surveys were returned (25% return rate)
• 9 months remaining on grant (grant ends June 30, 2016)
anticipate serving another 90 – 100 referrals
• 7 primary referral sources (St. Peter’s Hospital; Eddy VNA
Coaches; OrthoNY; Capital Care Physicians; Sunnyview
Nursing & Rehab; Whitney Young Health Center)
Future of PASST
 Grant ends in June 2016
o How to fund continuation of services
 Look to healthcare organizations/insurance companies
• Reducing hospital readmissions affects their bottom line
Try to integrate into DSRIP program (9 PPS’s in NYS)
Adirondack Health Institute, Inc.
Advocate Community Providers, Inc.
Albany Medical Center Hospital
Alliance for Better Health Care, LLC
Bassett Medical Center
Bronx-Lebanon Hospital Center
Central New York Care Collaborative, Inc.
Finger Lakes Performing Provide System, Inc.
NYU Lutheran Medical Center
Questions