HEALTH CARE AND HUMAN SERVICES POLICY, RESEARCH, AND CONSULTING - WITH REAL-WORLD PERSPECTIVE. December 16, 2009 Care Transitions Workgroup Overview of Care Transitions Models for ADRCs: Logistics and Sustainability

Community-based organizations such as ADRCs play critical role in helping people navigate both health and social support

Information on CMS Rehospitalization Penalties in health reform legislation H.R.3962 – Sec “REDUCING POTENTIALLY PREVENTABLE HOSPITAL READMISSIONS” READMISSION —The term ‘readmission’ means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge. PENALTY – In order to account for excess readmissions in the hospital, the Secretary shall reduce the payments that would otherwise be made to such hospital SUPPORT FOR CARE TRANSITIONS PROGRAMS IN HOSPITALS? docs.house.gov/rules/health/111_ahcaa.pdf (Starts on Page 441)

ADRC includes intervention in critical pathways (hospitals, NFs, physicians’ offices, ERs, etc.) Many ADRCs have critical pathway providers on advisory boards Some have developed formal referral protocols New ADRC solicitation includes person centered hospital discharge planning as “key operational component”

Invite critical pathways providers to be part of ADRC advisory committees and councils Provide consumers with information to empower themselves and family members through transitions in care Contact state QIO to determine what initiatives they have going with community based organizations and if ADRC can be involved Develop formal referral protocols with critical pathways providers Assign specific ADRC staff to operate out of critical pathway locations Implement/support a care transitions model

Hospital Based Transition Models Coleman’s Care Transition Intervention Naylor Transitional Care Model Primary Care Based Transition Model Boult’s Guided Care Model Randomized Study Utilizing Transition Model Project RED (Re-engineered discharge) Care Transitions Resources and Technical Assistance BOOST (Better Outcomes for Older Adults through Safe Transitions)

What activities do all of these models provide (with minor differences)? Care Transitions Activities Medication Management Assessing Patient's Understanding/Ability to Follow Care Plan Discharge Support Coaching for Primary Care Physician Visit Use of Home Visits (with the exception of Project Red) Screening for cognitive ability Use of Centralized Health Record Involving Family and Informal Caregivers Arranging Community-Based Support Services

Where might these models differ significantly? Point of Entry Patient Eligibility Criteria Length and Frequency of Intervention Principal Coordinator of Care and their Credentials Use of Best Practices Emphasis on Self-Empowerment and Training Family/Informal Caregivers Cost

What sustainability questions important to consider? Can your care transitions program help hospitals avoid CMS penalties? What is the length and extent of the intervention? Who provides care transitions services? Nurse, Case Manager or Other? How much emphasis is put on training family/informal supports? What will the financial and medical eligibility criteria be? To what extent can your program join forces with existing care transitions activities in hospitals/medical practices? Will your QIO support your efforts? How much ongoing support/training will the model’s creators provide? Are there evaluation activities/tools available to evaluate the efficacy of program?

So what is distinct about these models?

Coleman’s Care Transition Intervention Point of Entry – Hospital Length and Frequency of Intervention – 4 Week Program (1 home visit, 3 phone calls, 1 role playing session with patient for PCP appointment) Patient Eligibility Criteria - Age 65 years or older, Non-psychiatric-related hospital admission, Community-dwelling, Close enough to hospital for home-visit, Have a working telephone, Have at least one of 11 diagnoses Principal Coordinator of Care and their Credentials – “Nurse Transitions Coach” but model is open to person not being nurse. Caseload is patients. Use of Best Practices – Backed by clinical research and focus groups. Includes a Care Transitions Measure (CTM), which is used to measure performance. Cost - Annual Cost= $74,310 for 379 patients ($196 per patient). Estimated Annual Cost Savings: $844 per patient “ The intervention is compatible with both Medicare Advantage and traditional Medicare fee-for-service payment systems.” Emphasis on Self-Empowerment and Training Family/Informal Caregivers – Caregivers are involved in the Care Transitions process and trained alongside participants. Text in Green = Impacts Cost/Sustainability Website:

Naylor Transitional Care Model Point of Entry – At hospital admission Length and Frequency of Intervention – On call seven-days per week for home visits and telephone access for one to three months of home follow-up (two months on average) Patient Eligibility Criteria – Older adults that are cognitively intact with 2 or more risk factors, including: poor self-health ratings, multiple chronic conditions and a history of recent hospitalizations. Principal Coordinator of Care and their Credentials - The Transitional Care Nurse (must be nurse - caseload is 18 patients on average) Use of Best Practices - Findings from three NIH funded, multi-site Random Controlled Trials have shown positive economic and medical results through reductions in hospitalizations. Cost - The total intervention cost was $115,856 ($982 per patient). One study demonstrated mean cost savings of $5000 per patient. Emphasis on Self-Empowerment and Training Family/Informal Caregivers – Model involves long- term interaction/training of consumer/family caregivers. Text in Green = Impacts Cost/Sustainability Website:

Boult’s Guided Care Model Point of Entry – Primary Care Physicians’ Office Length and Frequency of Intervention - Long-term/indefinite, the program claims the length of contact is usually for life. Patient Eligibility Criteria – “Persons with medically complex health conditions” Principal Coordinator of Care and their Credentials - “Guided Care Nurse” is co-located among several primary care practices. (Must be nurse) Use of Best Practice - Randomized Controlled Studies from pilots in DC and MD indicate positive results and entities have decided to extend the program for another year. Cost – Randomized studies indicate cost savings of $1364 per patient ($75,000 per nurse) Emphasis on Self-Empowerment and Training Family/Informal Caregivers- Intensive, structured services (including support group meetings) to caregiver supports. Text in Green = Impacts Cost/Sustainability Website:

Project RED (Re-engineered discharge) Project RED is a series of Randomized Controlled Studies at the Boston University Health Center Point of Entry - Hospital Length and Frequency of Intervention – An hour or so (plus time for preparation and documentation) – contact by pharmacist a few days later. Patient Eligibility Criteria – Depends on study Principal Coordinator of Care and their Credentials – “Discharge Advocate” (must be nurse) Use of Best Practices – The model is associated with a randomized study and evaluated as the programs are implemented/operated. Results have been positive. Cost – Randomized Studies showed cost savings of $380 per patient Emphasis on Self-Empowerment and Training Family/Informal Caregivers- Caregivers/family members are involved in process if necessary. Does not focus on long-term training of caregivers. Text in Green = Impacts Cost/Sustainability Website:

Project BOOST (Better Outcomes for Older Adults through Safe Transitions) “We recognize that each institution is unique in terms of their experience conducting quality improvement programs, available resources, and existing discharge procedures and processes.” Project Boost is not a rigidly structured, formalized model Project Boost has produced an open-ended intervention to tailor to your circumstances and resources. Website includes a step-by-step institutional assessment and process mapping resource to best tailor an intervention Does not explicitly require someone to staff a care coordinator position, but rather aims to be implemented into daily processes of organizations. Website: tions/CT_Home.cfm

Summary Some models have more intensive support to family/informal caregivers. Some models are brief and distinct interventions while others are more long-term and open-ended interventions. A care transitions program can target patients with varying levels of need. While targeting higher need patients may cost more, doing so might also result in more savings. All of these program have random controlled studies that demonstrate cost savings. The Care Transitions Intervention (Coleman Model) includes a tool to evaluate your own health system. Project Boost provides information and resources to customize a care transitions intervention. Does not pre-suppose the use of a care coordinator.

How are ADRCs Planning to Support Care Transitions Interventions? From the Pre-Workgroup Survey... Which of the following services does your ADRC plan to provide within your care transitions program? Arranging community-based support services 16100% Conducting telephone follow-ups 16100% Informal caregiver support/education 1488% Making sure consumers understand their medical care plan 1169% Coaching consumers before follow-up primary care appointments 956% Helping consumers keep track of their medical records 850% Conducting home visits 744% Medication management 638%

Discussion From “How to Save a Bundle on Hospital Readmissions” (Managed Care, July 2009) One barrier that limits the efficacy of care transitions interventions is that... “Hospitals generally do not have working relationships with community organizations that could support patients in caring for themselves after discharge” /index.php?startid=#/18