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ACOs, Transitions of Care, Patient Centered Medical Homes, Care Transitions: What Do They Mean for Home Health

The document discusses the current challenges in healthcare, particularly focusing on care transitions, patient-centered medical homes, and chronic care models aimed at improving patient outcomes while reducing costs. It highlights the complexities faced by patients, like the case of Mrs. Ruth Smith, emphasizing the need for better coordination and integration of care across various providers and settings. Innovations and strategies proposed include enhancing care transitions, utilizing care coaches, and adopting payment models that prioritize patient health needs over service volume.

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ACOs, Transitions of Care, Patient Centered Medical Homes, Care Transitions: What Do They Mean for Home Health? Presented by: Susan Carmichael MS, RN, CHCQM, COS-C, ICM, FAIHQ EVP, Chief Compliance Officer SELECT DATA
Objectives Patients are receiving disjointed care in the present expensive system. Changing the model: – Identifying the components of The Transformed System; affordable, accessible, seamless, and coordinated plus high quality, person and family centered, and clinically supportive – Listing ways to develop partnerships that create strong symbiotic teams – Creating Care and Operation Interventions that integrate with Care Transitions, Guided Care in the PCMM(H), and ACO models
THE STATE OF HEALTH CARE Scary, Expensive, and Inconsistent
The Scary: Safety is an issue – Airline Safety: > 99.999999 • Airline Baggage Handling: > 99.999 • B-Blocker p MI: 70 – 99% • Immunization: 55 – 94% • MD Hand Hygiene in ICU: 3 – 40% REALLY!
Quality, Safety, Efficiency – Imagine: • Imagine an industry (or a company within an industry) with poor quality (or safety); would you invest ? – Categories of Poor Quality (Safety) in Healthcare • Underuse: Vaccines, Beta-Blockers • Overuse: Spine Surgeries, Cardiac Procedures • Misuse: Calcium Channel Blockers as First-Line for Hypertension • Safety: Healthcare Associated Infections, Medication Errors – Inefficiencies may mean different things to payors, providers and patients due to misaligned incentives . . . – High Performance, Safer Care most efficient for all, especially in the emerging “limited warranty” environment of healthcare
INTRODUCTION As a percentage of GDP, health care expenditures are about 18%. By 2019, the national health care expenditures will be 19.3% and approaching an unsustainable level. Innovative approaches to quality healthcare must be found. Let’s discuss these new Chronic Care Models in general and Transitions in Care, ACOs, and the Patient Centered Medical Model in particular
Chronic Illness in the US – The ACA Improving Chronic Illness Care is dedicated to the idea that United States health care can do better. – Over 145 million people - almost half of all Americans - suffer from asthma, depression and other chronic conditions. – Over eight percent of the U.S. population has been diagnosed with diabetes. – All of this is possible by transforming what is currently a reactive health care system into one that keeps its patients as healthy as possible through planning, proven strategies and management. We must find new meaningful REAL interventions
The Experts Say… – That in 10 years hospitals will essentially focus as ICUs – Med Surg will basically be provided in the home – Expect costs to be bundled into episodes; from hospital admission to post acute to home care – Expect costs to be measured in full care of clinically defined episodes – Clinical continuums will replace length of stay based care – Agencies will be measured by care transition capabilities and the value of their outcomes
THE REASON FOR CHANGE Here is
Overview • T
Mrs. Ruth Smith • 77 year old widow alert oriented • Retired school teacher, lives alone • Receives pension, SS, Medicare • 4 chronic conditions • Three physicians • Son lives 12 miles away with wife and 3 children • Mrs Smith is a part of a disjointed healthcare system
Mrs. Ruth Smith: In 2012 • 14 prescriptions, 9 meds – 10 physician and clinic visits – 1 hospital admit – 1 23 hour observation – 4 weeks sub acute care – 2 nursing homes – 6 months home health care – 2 home health agencies – Overseen by: 7 physicians, 6 social workers, 5 PTs, 3 OTs, 42 nurses – Who is coordinating her care?
Mrs. Ruth Smith –Medicare –Paid $89,000 for this risky fragmented care
Everyone is in a Hurry – No one individual sits with her and hears her concerns and needs. – Hurried, one problem physician visits – Discharges from each level of care with discontinuity through the transitions of care – As a nation, it is felt that we can do better and it is expected that we will.
Let’s Look at Care Another Way • Presently, here is what is driving healthcare: • Policy and Regulation What do you think of when the surveyor arrives? • Payment Methodology means • Provider Care = The Patient’s Health Care? • • Future Delivery of Care Must be Driven in the Following Order: • Patient’s Health Needs • Provider Care • Payment Methodology • Policy and Regulation • • •
Research Showing….. – Current Healthcare Delivery System is ineffective and Riddled with Gaps – Trying Harder Using the Present System will Change Little – THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM – Technology is Not the Solution. It is a Tool for the New Care Delivery Systems
Chronic Care Needs – Almost half of all Americans - suffer from asthma, depression and other chronic conditions such as Heart Failure, COPD, CAD, and over eight percent of the U.S. population has been diagnosed with diabetes. – All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning, proven strategies and management: proactive. – The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
What we do know…… • Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care • Care Complexity will Rise • Poor Transition between Levels of Care • Poor Coordination between Levels of Care • Poor Use of Evidenced- Based Care • Care is Provider Directed not Patient Centered • Clinicians Attempt to “Teach” Patients with Poor Understanding of How Individuals Learn
CMS Mandates Quality Initiatives The CMS “Triple Aim” Goals 1. Better Health for the Population 2. Better Care for Individuals 3. Lower Cost through Improvement of Care Delivery
Institute of Medicine 2012 – Need to improve re Falls, Medication Reconciliation, Pressure Ulcers, Depression, and NUTRITION Yes, NUTRITION – Medicare Patients now see average of 7 physicians, including 5 specialists amongst 4 different practices (Pham et al, 2008) – Multiple providers means poor coordination, confusion as to care, and poor accountability
The Transformed System must be  Affordable Individual and Family Centered Accessible Seamless and Coordinated Quality of Care delivered Support to Patients and Clinicians, yes, Clinicians
CMS Created the INNOVATION CENTER The purpose is to “test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished.” Coordination is emphasized Funding FY2011 - 2019 is $10 Billion The goal is to take successful project models and move them to the national level http://www.healthcare.gov/center/programs/partnership/joinin/index.html
Method of Payment F Fee-for Service- For a specific volume of service there will be a negotiated fee Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs, quality, and patient experience Risk –Sharing- Sharing of savings and losses Full Capitation- All losses and wins shared by the provider
TO SHARE THE RISK Be Prepared
Innovations Federal Coordinated Care: 15 State Demonstrations Acute with Post Acute Bundled Payment Episodes for Care Pre Hospital Assessments Health Information Exchange Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting Medicare Shared Saving Program for Accountable Care Organizations
Several Innovative Projects Community-based Care Transitions Program (CCTP) and 6 models = 1.Care Transitions Programs = 2.Patient-Centered Medical Home = 3.Guided Care Nurse-Physician Models = 4.Comprehensive Care Coordination Models = 5.Innovative Academic Partnerships = 6.Coaching Role Skill Transfer
The Shift is – Moving from Volume to Value – Knowing Your Numbers such as the cost to deliver home care fro each diagnostic category with an expected outcome – Knowing how to operate at the granular level – To post acute care within 12-24 hours – Moving toward Self care management – Data Integration with specific outcomes measurement – Specific education in home care
inadequate information and training at discharge were themes that spanned all groups, – Transitions – To home
CARE TRANSITIONS MODELS What might work best for your agency?
Care Transition Model – Where did the model originate? Colorado, 2000 – Dr Eric Coleman wrote extensively and validated research regarding the model. It has solid aims: • Support patients and families • Increase skills among healthcare providers • Enhance ability of health information technology to promote health information exchange across care settings • Implement system level interventions to improve quality and safety • Develop performance measures and public reporting mechanisms and • Influence health policy at a national level • DO YOU RECOGNIZE MANY OF THESE MEASURES?
American Geriatrics Society defines Transitional Care as… – A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. May include (but not limited to) hospitals, sub acute and post acute nursing facilities, the patient’s home, primary and specialty care offices, and long term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition.
The Coleman Model – Heavily funded by both the John A. Hartford and Robert Wood Johnson Foundation, this is a patient-centered, interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
The Four Pillars of the Model – 1. Medication self management. Patient is knowledgeable about their meds and has a med management system – 2. Uses a dynamic patient-centered record. Understands and uses their record to facilitate communication and ensure continuity – 3. Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions – 4. Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
Sample items on Discharge preparation checklist I have been involved in decisions about what will take place after I leave the facility I understand where I am going after I leave the facility and what will happen once I arrive I have the name and phone number of a person I should contact if a problem arises during my transfer I understand the potential side effects of my medications and whom I should call if I experience them I understand how to keep my health problems from becoming worse. And there are a few more…
Transitional Care is… – The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete – Within settings: Primary Care to Specialty Care – Between Settings: Acute to Sub-acute facilities to Ambulatory clinics – Across Health Care Settings: Curative Care to Palliative Care to Hospice to Home to Assisted Living
Obtain more information Dr. Eric Coleman on Transitional Coaching http://www.caretransitions.org Dr. Chad Boult on the Guided Care Nurse http://www.guidecare.org
The Care Transition(TM) Coach – This is a proprietary Training Program on the Care Transitions Program – Many programs using these concepts are also using a coach – If working with a Certified Care Transitions Program, one will use the 15 item uni-dimensional measure to assess quality of the care transition. This measure has had psychometric testing to validate findings from one location to another level – Medication Discrepancy Tool
Care Transitions Interventions – Recognized by Dr Eric Coleman – One day course in Aurora, Co – To become Trainer to Train others • Must complete CTI training • Be employed in Healthcare • Complete app to become trainer and submit w DVD conducting home visit using CTI • Take trainer course • Complete another 30 CTI and second home visit DVD
Another transitional care type training: ICM – Integrated Care Management provided by Sutter Center for Integrated Care – 1 day course – To be qualified as Train the Trainer:  Must complete 1 day course  Must complete 4 on-line modules on  Heart failure  Diabetes  COPD  Depression Must Complete online Exam and pass within 80%+
National Transitions of Care Coalition • Resources to assist to establish a Transitional Care Program • NTOCC provides tools and resources • www.ntocc.org • NTOCC reports “Yesterday, May 22, 2012, the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda, a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make better-informed health decisions.”
NTOCC Seven Essential Intervention Categories 1. Medication Management 2. Transition Planning 3. Patient/Family Engagement/Education 4. Information Transfer 5. Follow-up Care 6. Healthcare Provider Engagement 7. Shared Accountability across Providers and Organizations Http://www.ntocc.org/Toolbox/browse/?attributes=61
Partnership for Patients Secretary Sebelius has launched a nationwide public- private partnership to improve care transitions. By the end of 2013, goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20% compared to 2010. Achieving this goal would mean more than 1.6 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge. Potential savings $35 B over 3 years.”
Expect – To retrain the Workforce to Move to a Strategic Outcome Focus – If your Program is not Evidence Based or Best Practice driven, expect not to be considered – Residual and Preventive Care will be the focus – Expect scrutiny at all levels
Community-based Care Transition Program (CCTB)
Vanguard Health Systems – Already actively involved with fixed episodic payment charges for knee and hip replacements – Have obtained physician buy in – Home health must provide evidenced based programs with proven outcomes or not considered – Expect home care rehab in 3-7 visits – Patients pay $150.00 co-pay to be a part of the program – Use of Care Navigating Nurse
CCTB – For more information and guidance on starting programs, visit http://www.cms.gov/DemoProjectsEvalRots /MD/itemdetail.asp?itemID-CMS1239313 – Direct questions to CMS regarding Care Transition Programs at – CareTransitions@cms.hhs.gov
Websites you may wish to explore http://caretransitions.org http://www.ipro.org/index/ct-care-transitions http://www..cfmc.org/integratingcare/toolkit.htm http://innovations.cms.gov/initiatives/Partnerships-for- Patients/CCTP?index.html http://nextstepincare.org
A PRACTICAL APPROACH
Dominican Sisters Family Health Service – Looked at their Care Transition Intervention Program – They looked at reducing rehospitalizations – 1 in 5 hospitalizations occur within 30 days of hospital discharge – 64% post acute care patients need visits sooner and need to be at self-management level – 1 in 4 hospitalizations are avoidable – JAMA, April 10, Commonwealth Fund, 2009
They Looked at the Patient Perspective From the AARP Report on Chronic Care: A Call to Action Nearly 1 in 4 reported a medical error Nearly 1 in 7 received no follow up appointment post hospital discharge Nearly 1 in 5 said their transitional care was not well coordinated (IPRO, 2011)
The Dominican Sisters Family Health Program Looked at: Effective Medication programs, the PHR, PCP follow up appointment, any Red Flags, and results They looked at the reconciled Med list, Goals, if the patient brought the PHR to all physician programs, any wt gains because of the patient DX, and patient satisfaction They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR They used a Home Visit Transition Nurse Coach Look at the common theme; a COACH
The Dominican Sisters Family Health Service Identified Goal: To “empower patients and caregivers to have the skills, knowledge, and confidence to manage their care and to communicate their needs effectively to their health care team.” Per Eric Coleman, MD, MPH, there were 20-40% decrease in hospital readmissions with improved patient confidence in managing their care
Care Transition Programs w Coaches University of Colorado, Transition Coaches Annual cost savings $300,000 At St Luke’s Hospital in Iowa, Enhanced assessment of post discharge needs on admission. Rate of compliance for Med reconciliation increased 75% Louisiana Health Care using a Health Coach, day hospital readmission rates from 19% to 4% Is there an opportunity for your home health agency if coaches are being considered at the hospitals? ARE they being considered?
PATIENT CENTERED MEDICAL HOME (PCMH) Perhaps you want to work with Physicians
Care Coordination Barriers – Practitioner level barriers such as… – System level barriers such as… – Patient level barriers such as…
Many Physicians Believe •There is a better way… They are looking to transform their primary care practices into Patient Centered Medical Homes What does that mean?
CMS and PCMH, rests on five pillars 1. Patient-centered orientation directed toward their unique needs, culture, values, and preferences… 2. Comprehensive, team-based care that meets the majority of each patient’s physical and mental health needs… 3. Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community 4. Superb access to care… 5. A systems approach to quality and safety…
Improving Care Transitions through PCMH PCMH is intended to result in more personalized, coordinated, effective, and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location by: – Taking collective responsibility for patient care – Providing for the patient’s health care needs; and – Arranging for appropriate care with other qualified clinicians.” http://www.ncqa.org/Portals/0/PCMH%
Back to Mrs. Smith: The Patient and the Family Mrs. Smith has no one plan to stay healthy and no one plan of care She is confused by the care and the meds She is concerned about the cost Her son is uncertain who to call for a global view of her care He has called three pharmacists regarding her meds He is upset and getting angry
Mrs. Smith and Disjointed care Mrs. Smith has no main contact, no single practice monitoring her condition Has harried single problem office visits, poor follow up on labs Discontinuity through transitional levels of care Limited guidance for self-management No support for families Mrs. Smith is at risk for care fragmentation resulting in an error or poor care Mrs. Smith is a prime candidate for a Patient-Centered Medical Home
The PCMH Patient-Centered Medical Homes are expected to seek quality outcomes of healthcare – Requires an interdisciplinary team to take responsibility to improve access, continuity, and coordination of care – Patients and family members are engaged through education and supporting self-care and disease management
Mrs. Smith is referred to a PCMH – The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person – This program is comprehensive, team based primary care reducing cost geared toward a collaborative model, easy to implement, capable of providing excellent care to patients with multiple chronic conditions – The physician applies to become a PCMH – The application is indepth and patient centered
Guided Care – Specially trained RNs based in the PCMH physician offices as Guided Coaches – The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions – The nurse and her “back-up” RN partners with the patient for the rest of the patient’s life – This model was initiated in 2002 by John Hopkins University
Guide and Coach are the words RN will converse, assess, and create an evidence-based Care Guide (notice they chose “guide” not “plan”) The Guided Care RN coordinates care with other care providers, HH providers, clinics, and hospitals The Guided Care RN educates and supports family and caregivers This RN also identifies community services that are most appropriate for this patient and her needs
Guided Care Training John Hopkins – A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs: – An online course for nurses. This six-week, 40-hour, web-based course prepares registered nurses to become Guided Care Nurses. It features self-paced modules, live webinars and support from expert faculty. After passing an online exam, nurses receive a “Certificate in Guided Care Nursing” from the American Nurses Credentialing Center (ANCC). The course is offered by the Institute for Johns Hopkins Nursing. – An implementation manual titled “Guided Care: A New Nurse- Physician Partnership in Chronic Care” provides detailed, practical information and advice on assessing practice readiness, preparing to launch, providing and managing Guided Care. An orientation booklet for patients and families titled "Transformation: A Family's Guide to Chronic Care, Guided Care, and Hope," that describes what Guided Care is and how it can help them
Physicians planning Guided Care Free Technical assistance is available at: www.GuidedCare.org/adoption.asp Online courses from John Hopkins Nursing available for RNs, There are also Physician and family courses Order the free Implementation Manual: Guided Care: A New Nurse-Physician Partnership in Chronic Care There are also free books and material for families
NCQA GUIDED CARE PROGRAM Another option
NCQA PCMH Program – Physician and Nurses become Patient-Centered Medical Home Certified Content Experts – Already 5,000 recognized practices nationwide – Provides deliberate strategies and efforts to transform a practice into a medical home with PCI content experts – Must attend 2 seminars 21/2 days: – NCQA Facilitating Patient Centered Medical Home Recognition (1.5 days covering standards) – NCQA Advanced Topics in PCMH: Mastering NCQA’s Medical Home Recognition
NCQA PCMH Program – Complete online application after completion of the seminars – Prepare for and schedule your exam $395 – Prepare for the survey of the practice – Keep up to date with NCQA PCMH Standards and Guidelines – Last Advanced Topics in PCMH: Mastering NCQA’s Medical Home Recognition was in New Orleans 1/13
NCQA PCMH CONTENT EXPERT AND JOHN HOPKINS GUIDED CARE NURSE COACH You may want to become certified as an
NCQA PCMH CONTENT EXPERT –Can receive certified status and work with physicians in this model –Review more on NCQA –www.ncqa.org/Programs/REcognition/Patie ntCenteredMedicalHomePCMH.aspx
Guided Care at John Hopkins • Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002. In creating the Guided Care model, the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management, disease management, self-management, transitional care, geriatric evaluation, and caregiver support models into primary care. Guided Care integrates these successful innovations into primary care to make evidence-based, state-of-the-art chronic care available from professionals the patient trusts
Guided Care – With Guided Care, a registered nurse, who is based in a primary care office, works closely with 3-4 physicians and health information , as well as technology to provide state-of-the-art care for 50- 60 chronically ill patients. In partnership with the primary care physician, the Guided Care Nurse Coach is responsible for the following clinical processes: –Assesses the patient at home, this will be completed by the physician practice Guided Care Nurse
Guided Care Continued – Create an evidence-based comprehensive “Care Guide” (a tool for providers that summarizes the patient’s conditions and medications, care providers, family members, and other important data in a succinct and professional format) and “Action Plan” (a patient-friendly version of the Care Guide). – Monitor the patient monthly. – Promote patient self-management. – Smooth the patient’s transitions between sites of care. – Coordinate the efforts of all the patient’s health care providers. – Assess, educate, and support family caregivers. Facilitate access to community resources – What is the role for home health?
Guided Care – The Guided Care nurses used a secure web-based EHR that was created to support Guided Care. The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions. The Guided Care nurses used the EHR to do the following: – Enter new information about their patients, such as initial assessment data, changes in health status and medications, laboratory test results, specialists’ reports, and reminders for future events. – Check patients’ medications for possible adverse interactions. – Generate new and revised evidence-based Care Guides for providers and Action Plans for patients. – Document contacts with patients, families, and health care providers. – Check for reminders of events or actions scheduled for each day
Guided Care Training: John Hopkins – Go to http://www.ijhn.jhmi.edu/Images/Documents/FA QGuidedCareNursing.pdf – The course is 40 hours and costs $1900.00
Home Health Should Be willing and available with leadership and clinicians to “up-skill.” Be flexible. Be rapid in response. Be willing to work COLLABORATIVELY Agree to have certain clinicians trained in PCMH constructs The HH agency should see improvements in goals attained The HHCAHPs should reflect the patient satisfaction Are you preparing the patients for the HHCAHPS survey?
PCMH and Your Agency Look for innovative partnerships NOW Offer same day access and response Look at creative tools needed; specialized programs like heart failure, MI follow up Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs and consistent communication methods and processes Establish proactive, prepared, practice teams Be willing to break away from the traditional Medicare m Model of care Consider having Guided Coach Nurses Consider shared risk
ACCOUNTABLE CARE ORGANIZATION (ACO) What about the
The ACO – The Coker Group (2012) defined the ACO as an “integrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targets.” – If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals – ACOs will choose who they will work with to deliver care. You need to have programs and outcomes they need.
Looking for Excellence in Healthcare • The Final Rule requires CMS to “assess the ACO’s quality and financial performance based on a population’s use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark population.”(CMS, Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP). • What excellence can your agency demonstrate?
ACO Count – There were 35 ACOs nationwide in June, 2012, over 50% in California. As of 1/10/13, there were 106 New ACOs announced by Medicare. As of 4/14 over 360. – There are 33 quality measures that an ACO must report on to CMS. These measures are collected by: Patient surveys (7 measures), data calculated using claims (3 measures), determined via EHR (1 measure), and via Group Practice Reporting Option Web Interface (22 measures). These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks. – There are now over 300 +ACOs nationwide and growing
Risk: TRACKS Various CMS approved risk programs: In Track 1, the one sided model, ACOs will h have an upside shared savings opportunity with no downside risk. but the shared savings opportunity is less with this model. – Track 2 is a two sided model requiring the ACO to share in 60% of both savings and losses with a cap.
ACOs – At HomeCare 100 in January, 2013, there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups. The landscape is changing and changing fast. – You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed, what you plan to do, what resources you have, and what resources you need. Then make a plan, choose the strategy, and BEGIN! BEGIN! – –
ACOs – Tim Rowan, Editor of Home Care Technology Report stated at HomeCare 100, “ Through lower reimbursement rates and more aggressive Z-PIC audits, CMS seems to be trying to reduce the number of certified HHAs from the current about 11,000 to as few as 6,000. Survival will largely depend on ACO partnerships, but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their area” (January, 2013).
Be Proactive – It was stated at HomeCare100 that “as a home health leader, you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your area.”
What other leaders are saying… – Bob Fazzi recently stated, “As a home health leader, you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must – Initiate strategies that position your agency to be one of the chosen in your area” (February, 2013). – Don’t be passive…start gathering data. Be proactive. BEGIN!
Leaders say – Make reducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders – Hospitals are being financially penalized for having excessive rehospitalization rates – Home Health can provide excellent care in the home at a variety of levels. – We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified – You need to know the cost to deliver that care so you can negotiate smartly
HOSPITAL READMISSION REDUCTION PROGRAM Focus is Quality
Hospital Readmissions Reduction Program – Payment reduction to hospitals capped at 1%FY 2013, 2% FY2014, 3% FY 2015 – Readmission measures apply first to: – Acute MI 30 day risk standardized readmission measure; – Heart failure 30 day risk standardized readmission measure; – Pneumonia 30 day risk standardized readmission measure
Readmission Measures – Readmission measures are National Quality Forum endorsed measures – CMS began counting the specific readmissions 1//1/2012 that occurred within 30 days of discharge from the index hospitalization
Home Health Responses – MI post acute follow up programs, evidenced-based as well as collaborative prevention oriented programs – Heart Failure post acute follow up programs, evidenced-based as well as prevention oriented programs – Pneumonia as above – Be certain agency coding is at highest level of specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code, not just the primary diagnosis.
Transitioning into Homecare – Let’s look at Heart Failure – Hospitals are motivated to have patients discharged to post acute care with a commitment to quality, positive outcomes, and maintaining patient in the home safely – That means a strong post acute heart failure program at your home health agency
Visualize the Value – Don’t throw out the great things you are doing now…Just show the stats in a stronger manner: – Med reconciliation what was found? What interventions? What outcomes? Share the info! – Show the powerful holistic evaluation of the patient in their home; 2 floors, 4 dogs, son-in-law who smokes and lives there. Physical, Social , Emotional, Environmental challenges and supports need to be shown
Visualize the Value – Keep the Focus on programs that support: – The Quality Measures: Ambulation and transferring as well as med management – All outcome measures at or above 85% – The Process Measures: The Heart Failure Program, The Wound Care Program, – The Pressures Ulcer Prevention Program, The Medication Teaching Program, – The Falls Risk Program, The Depression Risk Program. The Immunization Program, The Diabetic Foot Care Program or the Diabetic/Systemic Care Program
Visualize the Value – The Patient Experience (HHCAHPS): Make certain clinicians are talking about Pain, Medications (What they are, What they do, When to Take, What symptoms are green, yellow, red- What to do and who to call for each)
Initiate an Accelerated Strategic Plan • You must be strategically focused. Gather your team together. Brainstorm. • Conduct the community gap analysis. • Note augmented programs that you can make possible • You have choices. Create new programs that reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
IT IS AN EXCITING TIME!!! It is a Time of Opportunities
Things to DO – Assess your community. What is needed? Where can/does your agency fit? – Assess your agency. What are the strengths; operationally, compliance wise, financially, HR wise – Assess the gap between need and have. List the assets and those needed – Assess Technology and Touch. Now look at gaps again.
Integrated Chronic Care Managed Model Four Pillars – Build Relationships in community, with patients and personnel. High Touch Care is achieving High Results. – Change Behavior: Supporting Patient Self Management means few smart not many goals, – Accessing Expertise: Means Coordinating Care, Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies) – Maximizing Technology such as telemonitoring
Exciting Changing Times – Hospitals need Home Care but they need to see your value. Visit the CEOs, COOs, CNOS – Demonstrate Your Value – Be Prepared for their changes Be Creative, assertive with new programs that augment theirs with TRUE VALUE – Do you know that over 30% of clinicians are expected to be certified in Integrated Chronic Care Management by end of year? Will you employ some of those?
Self Management Will you be able to state and prove you promote self management of patients and that you Assess Patient/Families for Current level of self management, for health literacy, for readiness to change, and for problem solving ability Teach and coach on needed strategies and activities such as Community support groups, provide written material based on EBP, Life style modifications and health promotion/ maintenance needs
Be PROACTIVE – Care Transition, Patient Centered Medical Models, ACOs and Home Care…It is an exciting time. Be a proactive part of the exciting time. – Look at the new seamless, coordinated, quality, person/family-centered model with your administrative and clinical teams. Where does your agency fit now? Where will it fit in the future? – You must BEGIN!
Q and A – Questions? – Thoughts? – Comments?
Thank you – Contact Susan at – susanc@selectdata.com – Call 714.524.2500x235 or 949.584.6296 cell – Thank you.

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ACOs, Transitions of Care, Patient Centered Medical Homes, Care Transitions: What Do They Mean for Home Health

  • 1.
    ACOs, Transitions ofCare, Patient Centered Medical Homes, Care Transitions: What Do They Mean for Home Health? Presented by: Susan Carmichael MS, RN, CHCQM, COS-C, ICM, FAIHQ EVP, Chief Compliance Officer SELECT DATA
  • 2.
    Objectives Patients are receivingdisjointed care in the present expensive system. Changing the model: – Identifying the components of The Transformed System; affordable, accessible, seamless, and coordinated plus high quality, person and family centered, and clinically supportive – Listing ways to develop partnerships that create strong symbiotic teams – Creating Care and Operation Interventions that integrate with Care Transitions, Guided Care in the PCMM(H), and ACO models
  • 3.
    THE STATE OFHEALTH CARE Scary, Expensive, and Inconsistent
  • 4.
    The Scary: Safetyis an issue – Airline Safety: > 99.999999 • Airline Baggage Handling: > 99.999 • B-Blocker p MI: 70 – 99% • Immunization: 55 – 94% • MD Hand Hygiene in ICU: 3 – 40% REALLY!
  • 5.
    Quality, Safety, Efficiency –Imagine: • Imagine an industry (or a company within an industry) with poor quality (or safety); would you invest ? – Categories of Poor Quality (Safety) in Healthcare • Underuse: Vaccines, Beta-Blockers • Overuse: Spine Surgeries, Cardiac Procedures • Misuse: Calcium Channel Blockers as First-Line for Hypertension • Safety: Healthcare Associated Infections, Medication Errors – Inefficiencies may mean different things to payors, providers and patients due to misaligned incentives . . . – High Performance, Safer Care most efficient for all, especially in the emerging “limited warranty” environment of healthcare
  • 6.
    INTRODUCTION As a percentageof GDP, health care expenditures are about 18%. By 2019, the national health care expenditures will be 19.3% and approaching an unsustainable level. Innovative approaches to quality healthcare must be found. Let’s discuss these new Chronic Care Models in general and Transitions in Care, ACOs, and the Patient Centered Medical Model in particular
  • 7.
    Chronic Illness inthe US – The ACA Improving Chronic Illness Care is dedicated to the idea that United States health care can do better. – Over 145 million people - almost half of all Americans - suffer from asthma, depression and other chronic conditions. – Over eight percent of the U.S. population has been diagnosed with diabetes. – All of this is possible by transforming what is currently a reactive health care system into one that keeps its patients as healthy as possible through planning, proven strategies and management. We must find new meaningful REAL interventions
  • 8.
    The Experts Say… –That in 10 years hospitals will essentially focus as ICUs – Med Surg will basically be provided in the home – Expect costs to be bundled into episodes; from hospital admission to post acute to home care – Expect costs to be measured in full care of clinically defined episodes – Clinical continuums will replace length of stay based care – Agencies will be measured by care transition capabilities and the value of their outcomes
  • 9.
    THE REASON FORCHANGE Here is
  • 10.
  • 11.
    Mrs. Ruth Smith •77 year old widow alert oriented • Retired school teacher, lives alone • Receives pension, SS, Medicare • 4 chronic conditions • Three physicians • Son lives 12 miles away with wife and 3 children • Mrs Smith is a part of a disjointed healthcare system
  • 12.
    Mrs. Ruth Smith:In 2012 • 14 prescriptions, 9 meds – 10 physician and clinic visits – 1 hospital admit – 1 23 hour observation – 4 weeks sub acute care – 2 nursing homes – 6 months home health care – 2 home health agencies – Overseen by: 7 physicians, 6 social workers, 5 PTs, 3 OTs, 42 nurses – Who is coordinating her care?
  • 13.
    Mrs. Ruth Smith –Medicare –Paid$89,000 for this risky fragmented care
  • 14.
    Everyone is ina Hurry – No one individual sits with her and hears her concerns and needs. – Hurried, one problem physician visits – Discharges from each level of care with discontinuity through the transitions of care – As a nation, it is felt that we can do better and it is expected that we will.
  • 15.
    Let’s Look atCare Another Way • Presently, here is what is driving healthcare: • Policy and Regulation What do you think of when the surveyor arrives? • Payment Methodology means • Provider Care = The Patient’s Health Care? • • Future Delivery of Care Must be Driven in the Following Order: • Patient’s Health Needs • Provider Care • Payment Methodology • Policy and Regulation • • •
  • 16.
    Research Showing….. – CurrentHealthcare Delivery System is ineffective and Riddled with Gaps – Trying Harder Using the Present System will Change Little – THERE IS A NEED TO CHANGE THE HEALTHCARE SYSTEM – Technology is Not the Solution. It is a Tool for the New Care Delivery Systems
  • 17.
    Chronic Care Needs –Almost half of all Americans - suffer from asthma, depression and other chronic conditions such as Heart Failure, COPD, CAD, and over eight percent of the U.S. population has been diagnosed with diabetes. – All of this is possible by transforming what is currently a reactive health care system into one that is health driven through planning, proven strategies and management: proactive. – The US health system is geared for Acute Care NOT Chronic Care and that is about to Change
  • 18.
    What we doknow…… • Chronic Disease continues to Rise yet our healthcare system is geared toward ACUTE care • Care Complexity will Rise • Poor Transition between Levels of Care • Poor Coordination between Levels of Care • Poor Use of Evidenced- Based Care • Care is Provider Directed not Patient Centered • Clinicians Attempt to “Teach” Patients with Poor Understanding of How Individuals Learn
  • 19.
    CMS Mandates QualityInitiatives The CMS “Triple Aim” Goals 1. Better Health for the Population 2. Better Care for Individuals 3. Lower Cost through Improvement of Care Delivery
  • 20.
    Institute of Medicine2012 – Need to improve re Falls, Medication Reconciliation, Pressure Ulcers, Depression, and NUTRITION Yes, NUTRITION – Medicare Patients now see average of 7 physicians, including 5 specialists amongst 4 different practices (Pham et al, 2008) – Multiple providers means poor coordination, confusion as to care, and poor accountability
  • 21.
    The Transformed Systemmust be  Affordable Individual and Family Centered Accessible Seamless and Coordinated Quality of Care delivered Support to Patients and Clinicians, yes, Clinicians
  • 22.
    CMS Created theINNOVATION CENTER The purpose is to “test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished.” Coordination is emphasized Funding FY2011 - 2019 is $10 Billion The goal is to take successful project models and move them to the national level http://www.healthcare.gov/center/programs/partnership/joinin/index.html
  • 23.
    Method of Payment FFee-for Service- For a specific volume of service there will be a negotiated fee Sharing of Savings- CMS and the investing provider will share if interim costs are less than targeted amount Performance-based-fee-for-service- Negotiated payment for volume of care plus additional incentives for managing costs, quality, and patient experience Risk –Sharing- Sharing of savings and losses Full Capitation- All losses and wins shared by the provider
  • 24.
    TO SHARE THERISK Be Prepared
  • 25.
    Innovations Federal Coordinated Care:15 State Demonstrations Acute with Post Acute Bundled Payment Episodes for Care Pre Hospital Assessments Health Information Exchange Medicaid Home Health State Plan Options- 26 Core Measures to be tied to Quality Reporting Medicare Shared Saving Program for Accountable Care Organizations
  • 26.
    Several Innovative Projects Community-basedCare Transitions Program (CCTP) and 6 models = 1.Care Transitions Programs = 2.Patient-Centered Medical Home = 3.Guided Care Nurse-Physician Models = 4.Comprehensive Care Coordination Models = 5.Innovative Academic Partnerships = 6.Coaching Role Skill Transfer
  • 27.
    The Shift is –Moving from Volume to Value – Knowing Your Numbers such as the cost to deliver home care fro each diagnostic category with an expected outcome – Knowing how to operate at the granular level – To post acute care within 12-24 hours – Moving toward Self care management – Data Integration with specific outcomes measurement – Specific education in home care
  • 28.
    inadequate information andtraining at discharge were themes that spanned all groups, – Transitions – To home
  • 29.
    CARE TRANSITIONS MODELS Whatmight work best for your agency?
  • 30.
    Care Transition Model –Where did the model originate? Colorado, 2000 – Dr Eric Coleman wrote extensively and validated research regarding the model. It has solid aims: • Support patients and families • Increase skills among healthcare providers • Enhance ability of health information technology to promote health information exchange across care settings • Implement system level interventions to improve quality and safety • Develop performance measures and public reporting mechanisms and • Influence health policy at a national level • DO YOU RECOGNIZE MANY OF THESE MEASURES?
  • 31.
    American Geriatrics Societydefines Transitional Care as… – A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. May include (but not limited to) hospitals, sub acute and post acute nursing facilities, the patient’s home, primary and specialty care offices, and long term care facilities. Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition.
  • 32.
    The Coleman Model –Heavily funded by both the John A. Hartford and Robert Wood Johnson Foundation, this is a patient-centered, interdisciplinary intervention model consisting of a structured preparation checklist used when moving from one level to another and includes a patient self-activation and management session with a TRANSITION COACH who is an RN which includes follow up visits to either the SNF or home
  • 33.
    The Four Pillarsof the Model – 1. Medication self management. Patient is knowledgeable about their meds and has a med management system – 2. Uses a dynamic patient-centered record. Understands and uses their record to facilitate communication and ensure continuity – 3. Patient schedules and completes follow up with the primary care physician and specialists and is empowered to be active participant in interactions – 4. Knowledge of RED Flags or indicators that their condition may be worsening and how to respond
  • 34.
    Sample items onDischarge preparation checklist I have been involved in decisions about what will take place after I leave the facility I understand where I am going after I leave the facility and what will happen once I arrive I have the name and phone number of a person I should contact if a problem arises during my transfer I understand the potential side effects of my medications and whom I should call if I experience them I understand how to keep my health problems from becoming worse. And there are a few more…
  • 35.
    Transitional Care is… –The movement of patients from one health care practitioner or setting to another in care of conditions and patients changing needs should be complete – Within settings: Primary Care to Specialty Care – Between Settings: Acute to Sub-acute facilities to Ambulatory clinics – Across Health Care Settings: Curative Care to Palliative Care to Hospice to Home to Assisted Living
  • 36.
    Obtain more information Dr.Eric Coleman on Transitional Coaching http://www.caretransitions.org Dr. Chad Boult on the Guided Care Nurse http://www.guidecare.org
  • 37.
    The Care Transition(TM)Coach – This is a proprietary Training Program on the Care Transitions Program – Many programs using these concepts are also using a coach – If working with a Certified Care Transitions Program, one will use the 15 item uni-dimensional measure to assess quality of the care transition. This measure has had psychometric testing to validate findings from one location to another level – Medication Discrepancy Tool
  • 38.
    Care Transitions Interventions –Recognized by Dr Eric Coleman – One day course in Aurora, Co – To become Trainer to Train others • Must complete CTI training • Be employed in Healthcare • Complete app to become trainer and submit w DVD conducting home visit using CTI • Take trainer course • Complete another 30 CTI and second home visit DVD
  • 39.
    Another transitional caretype training: ICM – Integrated Care Management provided by Sutter Center for Integrated Care – 1 day course – To be qualified as Train the Trainer:  Must complete 1 day course  Must complete 4 on-line modules on  Heart failure  Diabetes  COPD  Depression Must Complete online Exam and pass within 80%+
  • 40.
    National Transitions ofCare Coalition • Resources to assist to establish a Transitional Care Program • NTOCC provides tools and resources • www.ntocc.org • NTOCC reports “Yesterday, May 22, 2012, the Patient-Centered Outcomes Research Institute (PCORI) Board of Governors approved the final version of its National Priorities for Research and Research Agenda, a framework to guide the funding of comparative clinical effectiveness research that seeks to give patients and those who care for them the ability to make better-informed health decisions.”
  • 41.
    NTOCC Seven Essential InterventionCategories 1. Medication Management 2. Transition Planning 3. Patient/Family Engagement/Education 4. Information Transfer 5. Follow-up Care 6. Healthcare Provider Engagement 7. Shared Accountability across Providers and Organizations Http://www.ntocc.org/Toolbox/browse/?attributes=61
  • 42.
    Partnership for Patients SecretarySebelius has launched a nationwide public- private partnership to improve care transitions. By the end of 2013, goals of preventable complications during a transition from one care setting to another should be decreased such that all hospital readmissions would be reduced by 20% compared to 2010. Achieving this goal would mean more than 1.6 million patients from illness without suffering a preventable complication requiring rehospitalization within 30 days of discharge. Potential savings $35 B over 3 years.”
  • 43.
    Expect – To retrainthe Workforce to Move to a Strategic Outcome Focus – If your Program is not Evidence Based or Best Practice driven, expect not to be considered – Residual and Preventive Care will be the focus – Expect scrutiny at all levels
  • 44.
  • 45.
    Vanguard Health Systems –Already actively involved with fixed episodic payment charges for knee and hip replacements – Have obtained physician buy in – Home health must provide evidenced based programs with proven outcomes or not considered – Expect home care rehab in 3-7 visits – Patients pay $150.00 co-pay to be a part of the program – Use of Care Navigating Nurse
  • 46.
    CCTB – For moreinformation and guidance on starting programs, visit http://www.cms.gov/DemoProjectsEvalRots /MD/itemdetail.asp?itemID-CMS1239313 – Direct questions to CMS regarding Care Transition Programs at – CareTransitions@cms.hhs.gov
  • 47.
    Websites you maywish to explore http://caretransitions.org http://www.ipro.org/index/ct-care-transitions http://www..cfmc.org/integratingcare/toolkit.htm http://innovations.cms.gov/initiatives/Partnerships-for- Patients/CCTP?index.html http://nextstepincare.org
  • 48.
  • 49.
    Dominican Sisters FamilyHealth Service – Looked at their Care Transition Intervention Program – They looked at reducing rehospitalizations – 1 in 5 hospitalizations occur within 30 days of hospital discharge – 64% post acute care patients need visits sooner and need to be at self-management level – 1 in 4 hospitalizations are avoidable – JAMA, April 10, Commonwealth Fund, 2009
  • 50.
    They Looked atthe Patient Perspective From the AARP Report on Chronic Care: A Call to Action Nearly 1 in 4 reported a medical error Nearly 1 in 7 received no follow up appointment post hospital discharge Nearly 1 in 5 said their transitional care was not well coordinated (IPRO, 2011)
  • 51.
    The Dominican SistersFamily Health Program Looked at: Effective Medication programs, the PHR, PCP follow up appointment, any Red Flags, and results They looked at the reconciled Med list, Goals, if the patient brought the PHR to all physician programs, any wt gains because of the patient DX, and patient satisfaction They looked at the effectiveness of the interdisciplinary tool and the comments of all in the PHR They used a Home Visit Transition Nurse Coach Look at the common theme; a COACH
  • 52.
    The Dominican SistersFamily Health Service Identified Goal: To “empower patients and caregivers to have the skills, knowledge, and confidence to manage their care and to communicate their needs effectively to their health care team.” Per Eric Coleman, MD, MPH, there were 20-40% decrease in hospital readmissions with improved patient confidence in managing their care
  • 53.
    Care Transition Programsw Coaches University of Colorado, Transition Coaches Annual cost savings $300,000 At St Luke’s Hospital in Iowa, Enhanced assessment of post discharge needs on admission. Rate of compliance for Med reconciliation increased 75% Louisiana Health Care using a Health Coach, day hospital readmission rates from 19% to 4% Is there an opportunity for your home health agency if coaches are being considered at the hospitals? ARE they being considered?
  • 54.
    PATIENT CENTERED MEDICAL HOME(PCMH) Perhaps you want to work with Physicians
  • 55.
    Care Coordination Barriers –Practitioner level barriers such as… – System level barriers such as… – Patient level barriers such as…
  • 56.
    Many Physicians Believe •Thereis a better way… They are looking to transform their primary care practices into Patient Centered Medical Homes What does that mean?
  • 57.
    CMS and PCMH,rests on five pillars 1. Patient-centered orientation directed toward their unique needs, culture, values, and preferences… 2. Comprehensive, team-based care that meets the majority of each patient’s physical and mental health needs… 3. Care that is coordinated across all elements of a complex health care system and connects patients to both medical and social resources in the community 4. Superb access to care… 5. A systems approach to quality and safety…
  • 58.
    Improving Care Transitionsthrough PCMH PCMH is intended to result in more personalized, coordinated, effective, and efficient care by establishing an ongoing relationship with a single physician who leads a team at a single location by: – Taking collective responsibility for patient care – Providing for the patient’s health care needs; and – Arranging for appropriate care with other qualified clinicians.” http://www.ncqa.org/Portals/0/PCMH%
  • 59.
    Back to Mrs.Smith: The Patient and the Family Mrs. Smith has no one plan to stay healthy and no one plan of care She is confused by the care and the meds She is concerned about the cost Her son is uncertain who to call for a global view of her care He has called three pharmacists regarding her meds He is upset and getting angry
  • 60.
    Mrs. Smith andDisjointed care Mrs. Smith has no main contact, no single practice monitoring her condition Has harried single problem office visits, poor follow up on labs Discontinuity through transitional levels of care Limited guidance for self-management No support for families Mrs. Smith is at risk for care fragmentation resulting in an error or poor care Mrs. Smith is a prime candidate for a Patient-Centered Medical Home
  • 61.
    The PCMH Patient-Centered MedicalHomes are expected to seek quality outcomes of healthcare – Requires an interdisciplinary team to take responsibility to improve access, continuity, and coordination of care – Patients and family members are engaged through education and supporting self-care and disease management
  • 62.
    Mrs. Smith isreferred to a PCMH – The PCMH is patient centered providing healthcare that is relationship based with an orientation toward the whole person – This program is comprehensive, team based primary care reducing cost geared toward a collaborative model, easy to implement, capable of providing excellent care to patients with multiple chronic conditions – The physician applies to become a PCMH – The application is indepth and patient centered
  • 63.
    Guided Care – Speciallytrained RNs based in the PCMH physician offices as Guided Coaches – The RN collaborates with 3-5 physicians in caring for 45-60 high risk older patients with multiple chronic conditions – The nurse and her “back-up” RN partners with the patient for the rest of the patient’s life – This model was initiated in 2002 by John Hopkins University
  • 64.
    Guide and Coachare the words RN will converse, assess, and create an evidence-based Care Guide (notice they chose “guide” not “plan”) The Guided Care RN coordinates care with other care providers, HH providers, clinics, and hospitals The Guided Care RN educates and supports family and caregivers This RN also identifies community services that are most appropriate for this patient and her needs
  • 65.
    Guided Care TrainingJohn Hopkins – A limited supply of the following resources are available for free to organizations that plan to implement the principles of Guided Care as they become ACOs: – An online course for nurses. This six-week, 40-hour, web-based course prepares registered nurses to become Guided Care Nurses. It features self-paced modules, live webinars and support from expert faculty. After passing an online exam, nurses receive a “Certificate in Guided Care Nursing” from the American Nurses Credentialing Center (ANCC). The course is offered by the Institute for Johns Hopkins Nursing. – An implementation manual titled “Guided Care: A New Nurse- Physician Partnership in Chronic Care” provides detailed, practical information and advice on assessing practice readiness, preparing to launch, providing and managing Guided Care. An orientation booklet for patients and families titled "Transformation: A Family's Guide to Chronic Care, Guided Care, and Hope," that describes what Guided Care is and how it can help them
  • 66.
    Physicians planning GuidedCare Free Technical assistance is available at: www.GuidedCare.org/adoption.asp Online courses from John Hopkins Nursing available for RNs, There are also Physician and family courses Order the free Implementation Manual: Guided Care: A New Nurse-Physician Partnership in Chronic Care There are also free books and material for families
  • 67.
    NCQA GUIDED CAREPROGRAM Another option
  • 68.
    NCQA PCMH Program –Physician and Nurses become Patient-Centered Medical Home Certified Content Experts – Already 5,000 recognized practices nationwide – Provides deliberate strategies and efforts to transform a practice into a medical home with PCI content experts – Must attend 2 seminars 21/2 days: – NCQA Facilitating Patient Centered Medical Home Recognition (1.5 days covering standards) – NCQA Advanced Topics in PCMH: Mastering NCQA’s Medical Home Recognition
  • 69.
    NCQA PCMH Program –Complete online application after completion of the seminars – Prepare for and schedule your exam $395 – Prepare for the survey of the practice – Keep up to date with NCQA PCMH Standards and Guidelines – Last Advanced Topics in PCMH: Mastering NCQA’s Medical Home Recognition was in New Orleans 1/13
  • 70.
    NCQA PCMH CONTENTEXPERT AND JOHN HOPKINS GUIDED CARE NURSE COACH You may want to become certified as an
  • 71.
    NCQA PCMH CONTENTEXPERT –Can receive certified status and work with physicians in this model –Review more on NCQA –www.ncqa.org/Programs/REcognition/Patie ntCenteredMedicalHomePCMH.aspx
  • 72.
    Guided Care atJohn Hopkins • Guided Care was developed by an interdisciplinary team of health care professionals at Johns Hopkins University in 2002. In creating the Guided Care model, the group infused the most current evidence-based guidelines for managing chronic conditions and the most effective principles from case management, disease management, self-management, transitional care, geriatric evaluation, and caregiver support models into primary care. Guided Care integrates these successful innovations into primary care to make evidence-based, state-of-the-art chronic care available from professionals the patient trusts
  • 73.
    Guided Care – WithGuided Care, a registered nurse, who is based in a primary care office, works closely with 3-4 physicians and health information , as well as technology to provide state-of-the-art care for 50- 60 chronically ill patients. In partnership with the primary care physician, the Guided Care Nurse Coach is responsible for the following clinical processes: –Assesses the patient at home, this will be completed by the physician practice Guided Care Nurse
  • 74.
    Guided Care Continued –Create an evidence-based comprehensive “Care Guide” (a tool for providers that summarizes the patient’s conditions and medications, care providers, family members, and other important data in a succinct and professional format) and “Action Plan” (a patient-friendly version of the Care Guide). – Monitor the patient monthly. – Promote patient self-management. – Smooth the patient’s transitions between sites of care. – Coordinate the efforts of all the patient’s health care providers. – Assess, educate, and support family caregivers. Facilitate access to community resources – What is the role for home health?
  • 75.
    Guided Care – TheGuided Care nurses used a secure web-based EHR that was created to support Guided Care. The EHR incorporates evidence-based guidelines for the 15 most prevalent chronic conditions. The Guided Care nurses used the EHR to do the following: – Enter new information about their patients, such as initial assessment data, changes in health status and medications, laboratory test results, specialists’ reports, and reminders for future events. – Check patients’ medications for possible adverse interactions. – Generate new and revised evidence-based Care Guides for providers and Action Plans for patients. – Document contacts with patients, families, and health care providers. – Check for reminders of events or actions scheduled for each day
  • 76.
    Guided Care Training:John Hopkins – Go to http://www.ijhn.jhmi.edu/Images/Documents/FA QGuidedCareNursing.pdf – The course is 40 hours and costs $1900.00
  • 77.
    Home Health Should Bewilling and available with leadership and clinicians to “up-skill.” Be flexible. Be rapid in response. Be willing to work COLLABORATIVELY Agree to have certain clinicians trained in PCMH constructs The HH agency should see improvements in goals attained The HHCAHPs should reflect the patient satisfaction Are you preparing the patients for the HHCAHPS survey?
  • 78.
    PCMH and YourAgency Look for innovative partnerships NOW Offer same day access and response Look at creative tools needed; specialized programs like heart failure, MI follow up Look at the most frequent diagnoses and programs you can offer that respond to the care needs of PCMHs and consistent communication methods and processes Establish proactive, prepared, practice teams Be willing to break away from the traditional Medicare m Model of care Consider having Guided Coach Nurses Consider shared risk
  • 79.
  • 80.
    The ACO – TheCoker Group (2012) defined the ACO as an “integrated healthcare delivery system that contracts to provide a full continuum of services to a defined patient population with specific financial incentives established for meeting both quality and cost targets.” – If you cannot provide Quality with Better Cost you will not be invited to Participate in the ACO thus no referrals – ACOs will choose who they will work with to deliver care. You need to have programs and outcomes they need.
  • 81.
    Looking for Excellencein Healthcare • The Final Rule requires CMS to “assess the ACO’s quality and financial performance based on a population’s use of primary care services at the end of each year to determine whether a particular ACO should be credited with improving care and reducing growth in expenditures compared to a benchmark population.”(CMS, Summary of Final Rule Provisions for ACOs under the Medicare Shared Savings Program (SSP). • What excellence can your agency demonstrate?
  • 82.
    ACO Count – Therewere 35 ACOs nationwide in June, 2012, over 50% in California. As of 1/10/13, there were 106 New ACOs announced by Medicare. As of 4/14 over 360. – There are 33 quality measures that an ACO must report on to CMS. These measures are collected by: Patient surveys (7 measures), data calculated using claims (3 measures), determined via EHR (1 measure), and via Group Practice Reporting Option Web Interface (22 measures). These 33 measures are a part of reporting for this year but in years following the ACOs performance will be directly tied to certain of the quality measures as well as the following of one of two tracks. – There are now over 300 +ACOs nationwide and growing
  • 83.
    Risk: TRACKS Various CMSapproved risk programs: In Track 1, the one sided model, ACOs will h have an upside shared savings opportunity with no downside risk. but the shared savings opportunity is less with this model. – Track 2 is a two sided model requiring the ACO to share in 60% of both savings and losses with a cap.
  • 84.
    ACOs – At HomeCare100 in January, 2013, there were several speakers discussing new ACOs or other care transitions involving themselves and several hospital groups. The landscape is changing and changing fast. – You must conduct an analysis as to needs in your community then conduct an internal agency gap analysis as to what is needed, what you plan to do, what resources you have, and what resources you need. Then make a plan, choose the strategy, and BEGIN! BEGIN! – –
  • 85.
    ACOs – Tim Rowan,Editor of Home Care Technology Report stated at HomeCare 100, “ Through lower reimbursement rates and more aggressive Z-PIC audits, CMS seems to be trying to reduce the number of certified HHAs from the current about 11,000 to as few as 6,000. Survival will largely depend on ACO partnerships, but two speakers told of two ACOs that elected to work with only 4 of the 104 HHA in their area” (January, 2013).
  • 86.
    Be Proactive – Itwas stated at HomeCare100 that “as a home health leader, you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must initiate strategies that position your agency to be one of the chosen four in your area.”
  • 87.
    What other leadersare saying… – Bob Fazzi recently stated, “As a home health leader, you need to become more educated and more aggressive in recognizing the changes that are taking place in your service area and you must – Initiate strategies that position your agency to be one of the chosen in your area” (February, 2013). – Don’t be passive…start gathering data. Be proactive. BEGIN!
  • 88.
    Leaders say – Makereducing hospitalization the Key to your partnering strategy with ACO or PCMH leaders – Hospitals are being financially penalized for having excessive rehospitalization rates – Home Health can provide excellent care in the home at a variety of levels. – We need to demonstrate creatively the extent of the care with significant outcomes that can be quantified – You need to know the cost to deliver that care so you can negotiate smartly
  • 89.
  • 90.
    Hospital Readmissions ReductionProgram – Payment reduction to hospitals capped at 1%FY 2013, 2% FY2014, 3% FY 2015 – Readmission measures apply first to: – Acute MI 30 day risk standardized readmission measure; – Heart failure 30 day risk standardized readmission measure; – Pneumonia 30 day risk standardized readmission measure
  • 91.
    Readmission Measures – Readmissionmeasures are National Quality Forum endorsed measures – CMS began counting the specific readmissions 1//1/2012 that occurred within 30 days of discharge from the index hospitalization
  • 92.
    Home Health Responses –MI post acute follow up programs, evidenced-based as well as collaborative prevention oriented programs – Heart Failure post acute follow up programs, evidenced-based as well as prevention oriented programs – Pneumonia as above – Be certain agency coding is at highest level of specificity with the best sequencing possible and be certain there is accurate complete documentation to support EACH code, not just the primary diagnosis.
  • 93.
    Transitioning into Homecare –Let’s look at Heart Failure – Hospitals are motivated to have patients discharged to post acute care with a commitment to quality, positive outcomes, and maintaining patient in the home safely – That means a strong post acute heart failure program at your home health agency
  • 94.
    Visualize the Value –Don’t throw out the great things you are doing now…Just show the stats in a stronger manner: – Med reconciliation what was found? What interventions? What outcomes? Share the info! – Show the powerful holistic evaluation of the patient in their home; 2 floors, 4 dogs, son-in-law who smokes and lives there. Physical, Social , Emotional, Environmental challenges and supports need to be shown
  • 95.
    Visualize the Value –Keep the Focus on programs that support: – The Quality Measures: Ambulation and transferring as well as med management – All outcome measures at or above 85% – The Process Measures: The Heart Failure Program, The Wound Care Program, – The Pressures Ulcer Prevention Program, The Medication Teaching Program, – The Falls Risk Program, The Depression Risk Program. The Immunization Program, The Diabetic Foot Care Program or the Diabetic/Systemic Care Program
  • 96.
    Visualize the Value –The Patient Experience (HHCAHPS): Make certain clinicians are talking about Pain, Medications (What they are, What they do, When to Take, What symptoms are green, yellow, red- What to do and who to call for each)
  • 97.
    Initiate an AcceleratedStrategic Plan • You must be strategically focused. Gather your team together. Brainstorm. • Conduct the community gap analysis. • Note augmented programs that you can make possible • You have choices. Create new programs that reduce hospitalizations or augment present hospital programs or create new outcome oriented programs that bring additional value
  • 98.
    IT IS ANEXCITING TIME!!! It is a Time of Opportunities
  • 99.
    Things to DO –Assess your community. What is needed? Where can/does your agency fit? – Assess your agency. What are the strengths; operationally, compliance wise, financially, HR wise – Assess the gap between need and have. List the assets and those needed – Assess Technology and Touch. Now look at gaps again.
  • 100.
    Integrated Chronic CareManaged Model Four Pillars – Build Relationships in community, with patients and personnel. High Touch Care is achieving High Results. – Change Behavior: Supporting Patient Self Management means few smart not many goals, – Accessing Expertise: Means Coordinating Care, Learning motivational interviewing (Sutter Home Health and Hospice Care and All Maine Health Agencies) – Maximizing Technology such as telemonitoring
  • 101.
    Exciting Changing Times –Hospitals need Home Care but they need to see your value. Visit the CEOs, COOs, CNOS – Demonstrate Your Value – Be Prepared for their changes Be Creative, assertive with new programs that augment theirs with TRUE VALUE – Do you know that over 30% of clinicians are expected to be certified in Integrated Chronic Care Management by end of year? Will you employ some of those?
  • 102.
    Self Management Will yoube able to state and prove you promote self management of patients and that you Assess Patient/Families for Current level of self management, for health literacy, for readiness to change, and for problem solving ability Teach and coach on needed strategies and activities such as Community support groups, provide written material based on EBP, Life style modifications and health promotion/ maintenance needs
  • 103.
    Be PROACTIVE – CareTransition, Patient Centered Medical Models, ACOs and Home Care…It is an exciting time. Be a proactive part of the exciting time. – Look at the new seamless, coordinated, quality, person/family-centered model with your administrative and clinical teams. Where does your agency fit now? Where will it fit in the future? – You must BEGIN!
  • 104.
    Q and A –Questions? – Thoughts? – Comments?
  • 105.
    Thank you – ContactSusan at – susanc@selectdata.com – Call 714.524.2500x235 or 949.584.6296 cell – Thank you.