Transcript Our CMS Community - Wide Care Transitions Intervention

Finger Lakes Health Systems Agency
CMS Community-Wide Care
Transitions Intervention
April 6, 2016
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Overview
• 1. How we got here
• 2. What we are doing
• 3. What is important to support success
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FLHSA: Vision, Mission & Strategy
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Vision: A local health-care system that makes people healthier
and saves money, by delivering the right care, in the right
place, and at the right time for everyone in the community.
•
Mission: We are an independent organization working to
improve health care in Rochester and the Finger Lakes region,
by analyzing the needs of the community, bringing together
stakeholders and organizations to solve health problems, and
measuring results.
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FLHSA Community Health 2020
Commission
Shifted focus from individual CON applications to a
determination of the aggregate community need
Recognized the unsustainable trend in growth
driven by failure of optimal care in the community
Bed approvals scaled back and a commitment to
“community investment” to alter the trend by
improving care in the community
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FLHSA 2020 Commission
The 2020 Commission recommended
FLHSA convene the 2020 Performance
Commission “to engage all stakeholders
in a process that will result in
community initiatives and requisite
investments to improve access to care,
avoid unnecessary hospital use, and
eliminate disparities in health status
across the region.”
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Interactive Components
Community
HS/Plan
Organization of Health Care
Delivery Decision Clinical
Resources and Selfinformation
policies management system support
systems
design
support
HS/Plan’s Job
Informed,
activated
patient
Provider’s Job
Productive
Interactions
Prepared,
proactive practice
team
Quality and value outcomes; ROI;
engaged, satisfied participants
HS = health system; ROI = return on investment.
Wagner EH. Effective Clinical Practice. 1998;1(1):2-4.
Community Investment Goals
• The 2020 Commission created specific goals for the
community
– A decrease of 15% in the number of low acuity (nonurgent) visits to emergency rooms
– A decrease of 25% in the number of admissions for
Ambulatory Sensitive Conditions that are manageable in
outpatient settings – 2350 admits in 2011
– A decrease of 20% in the number of low acuity admissions
to Monroe County hospitals of residents from outlying
communities
• Recommended creation of the 2020 Performance
Commission to guide community activities to reach the
established goals
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Three Dimensions of Value
Population
Health
Experience
of Care
• Access
• CAHPS surveys
April 6,
6, 2016
2016
April
• Readmissions
Per Capita
Cost
• ED use
• PQI admissions
• Admissions from
outlying communities
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Measures Defined by 2020
Performance Commission
• Agreed Upon Measures for 2014:
– PQI admissions: goal to decrease by 25%
– Low acuity ED visits: goal to decrease by 15%
– Low acuity admissions to Monroe County hospitals: goal to
decrease by 20%
• Implied goal: have the right bed available 99% of the time
(this was the measure used to calculate the beds needed to
determine bed need)
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Reducing Avoidable Admissions:
Disease Condition as a Variable
Hospitalizations
per 100,000 population,
Percent of
age adjusted
All PQI Admissions
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Respiratory Condition
Heart Conditions
Diabetes
Other
• All Adult PQIs
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657.7 (<US)
439.3 (<US)
153.7 (<US)
278.0
1,528.7 (<US)
43%
29%
10%
18%
100%
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Reducing Avoidable Admissions:
Insurance Status as a Variable
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Reducing Avoidable Admissions:
Geography as a Variable
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Reducing Avoidable Admissions:
Ethnicity as a Variable
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Reducing Avoidable Admissions:
SES as a Variable
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PQI – Finger Lakes Region
• Adult Respiratory and Circulatory conditions account for
over 70% of all PQI Admissions in the six county Finger
Lakes Region.
• Between 2004-2006, 13% of all hospital discharges were
PQI discharges.
• Each day 295 hospital beds in the region were filled by
patients who potentially could have avoided
hospitalization.
• This equates to 10% of Hospital charges for these
admissions (charges not costs).
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Conclusions from FLHSA Data
• Patients with PQI admits are generally older and
insured
• Rochester’s inner city has significantly higher rates
of PQI admits
• African-Americans and to a lesser degree Latinos
experience increased PQI admits
• Lower socioeconomic status is an important
contributor to PQI admits
• Reaching the target reduction in PQI admits requires
decreasing PQI admits in the white population as
well as in underserved minority populations
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Conclusions from National Data
• Rehospitalization is the low hanging fruit of PQI
hospitalization reduction
• Most admissions are related to cardiovascular
and respiratory diseases
• Major factors in reducing Medicare rehospitalizations are:
– Having a primary care practitioner
– Seeing that practitioner often post discharge
– Having a team to coordinate care
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CMS Community-Wide Care Transitions Program Goals
• Improve transitions of Medicare FFS beneficiaries from
the inpatient hospital setting to home or other care
settings
• Improve quality of care
• Reduce readmissions for high risk beneficiaries
• Document measurable savings to the Medicare program
and expand program beyond the initial 5 years
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The Care Transition Intervention
Coaching models, when applied to transitions in care, have been
shown to reduce readmissions by 20-40%.
Patient/family coaching actively engages patients and their
families to be full partners in insuring improved health and
decreasing unnecessary dependence on hospitals and
emergency departments.
Community organizations and home care agencies will lead the
effort, fulfilling Wagner’s model of optimally treating chronic
conditions.
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Our Phased Approach to a Community-wide
Care Transition Intervention
• Insurers pilot Commercial and Medicare Advantage
• Monroe Plan for Medicaid Services pilot for Medicaid
HMO
• HEAL 19 funds the uninsured and Medicaid FFS patients
• CMS CTTP grant for Medicare FFS patients target
launch June 2012
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Self – Reported Aggregate Coaching Data
Oct – Dec 2010
Jan – March 2011
Totals through
March 2011
219
351
670
130
230
360
Acceptance rate
59%
65%
62%
# completing program
104
195
299
% completing
80%
84%
82%
Measure
Patients agreeing to
coaching in hospital
Patients who Accepted
Coaching - (Defined as
patient seen at home)
# readmitted to
15
Incomplete
hospital with in 30 days
% readmitted in
14.4
Incomplete
30 d
#/% T&R from ED in 30
6/6
Incomplete
d*
*Based on coaching organizations data tracking, not health plan data
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Initiatives at Hospitals
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2.
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4.
5.
6.
7.
8.
Identify and Track Reasons for Readmissions
Risk Assessment Stratification
Medication Reconciliation
Provider Checklist for High Risk Patients
Teach backs
Community Standards for Discharge Planning
Timely PCP Follow up Appointments
Hospitalist to SNF Communication
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FLHSA CMS Community-wide Process
• Coordinated community meeting: 60 regional representatives
• Agreed to scope of work:
Build upon previous experience; expand & spread
• Defined work
• Determined patient eligibility criteria based on data review
• Designed and Clarified hospital integration with CTI
• Integrated Community based services
• Calculated costs of intervention and ROI
• Designed tracking and reporting processes
• Talked, talked, talked, and…… talked more!
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Our CMS Community - Wide Care Transitions Intervention
• Lifespan ; an AOA –funded non-profit organization
• Five hospitals:
– Rochester General, Unity, Strong Memorial, Highland and
Newark-Wayne
Target Population:
Medicare FFS beneficiaries with an active PQI diagnosis having
2 or more characteristics at risk of re-hospitalization:
– 3 co-morbid chronic illnesses
– 5 prescription medications
– 2 hospital admissions within the last 12 months
– Failure to teach back
– Special Circumstances subject to interdisciplinary judgment
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Putting your plan into Action
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Secure and maintain leadership commitment
Form multi-disciplinary workgroups
Analyze root cause analysis
Understand processes
Anticipate and confront resistance / barriers
Identify improvement opportunities
Develop a measurement plan
Estimate ROI
Employ and Commit to Continuous Quality Improvement
Establish Trust
Go for it!!!
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Establish and Maintain Trust
Clearly define and agree to your goals
Explicitly define guiding principles and
adhere to core values
Use data to guide and inform your work
Anticipate concerns, encourage and solicit
input, and provide a feedback loop
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Finger Lakes Health Systems Agency
Thank You!!!
Melissa Wendland
Associate Director, Planning and Research
Finger Lakes Health Systems Agency
1150 University Avenue
Rochester, New York 14607-1647
[email protected]
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Finger Lakes Health Systems Agency
The triangle represents our agency’s role as a fulcrum—the point on which a
lever pivots—boosting the community’s health by leveraging the strengths of
all stakeholders. The fulcrum is also a point of equilibrium, reflecting our
ability to balance the needs of consumers, providers and payers on complex
health matters. The inner triangle also evokes the Greek letter delta—used in
medical and mathematical contexts to represent change—with a forward lean
as we work with our community to achieve positive changes in health care.
Give me a lever long enough and a fulcrum on which to place it,
and I shall move the world. —Archimedes
1150 University Avenue • Rochester, New York • 14607-1647
585.461.3520 • www.FLHSA.org
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