Care Transitions Initial – 6 Month Evaluation June 20,

COA Care Transition Model A. Coleman CTI evidence-based model B. Integration with: Local Hospitals Primary Care Physician Health Information Exchange COA funded In-home services Care Coordination Caregiver Support 2

Summary of Results High participation rate (86% of those eligible) 85% of eligible clients were admitted with a diagnosis considered to be high risk for readmission (AMI, CHF, Pneumonia) and/or with multiple chronic conditions 30-day readmission rate of 7.5% for individuals in the COA Care Transitions Intervention (compared to 20% for Medicare fee-for service) 0% readmission rate for individuals admitted with a high risk diagnosis 3

Ineligibility due to: Client disenrollment from COA programs Acuity related complications Mental health complications Dementia Eligibility Requirements: Age 60+ Current COA PASSPORT or Hamilton County ESP client Admitted to a participating hospital Agree to participate Care Transitions Eligibility 75.5% of all Patients Visited were Eligible n=106 4

Care Transitions Participation 86% Participation Rate for Eligible Patients n=106 5 Of the 26 who were not eligible for CTI: 9 (35%) required a more intensive program or mental health support (such as Naylor or a specified community mental health program)*, 10 (38%) were entering hospice or preparing for a long-term nursing facility stay, and 7 (27%) were not identified as a good fit for any specific program/model or were no longer COA clients. Of the 80 who were eligible for CTI: 69 (86%) chose to participate. Of those 69, a total of 67 (97%) have either completed or are near completion of CTI. 11 (14%) declined participation. Note: 4 (15%) of those not eligible were found to have a mental health issue.

Admitting Diagnoses for Eligible Clients (n=80) 6 15% (n=12) 25% (n=20) 60% (n=48) 85% had either an admitting diagnosis of AMI, CHF or Pneumonia and/or had multiple chronic conditions

Secondary Diagnoses (Eligible vs. Participants) Eligible (n=80) CTI Clients (n=69) Average # of Secondary Diagnoses33 #%#% Hypertenstion (HTN)4758.6%4058.0% Diabetes (DM or DMII)3847.5%3347.8% Arthritis1822.5%1623.2% Congestive Heart Failure (CHF)1721.3%1521.7% Chronic Obstructive Pulmonary Disease (COPD)1215.0%1115.9% Stroke (CVA)1113.8%1014.5% Coronary Artery Disease (CAD)1012.5%913.0% AFIB67.5%68.7% 7

Admitting Diagnoses for Participants (n=69) 8 Admitting Diagnosis Source: Council on Aging of Southwestern Ohio, 6/7/11 n= 69 Note: Respiratory includes shortness of breath, pulmonary edema, bronchitis and related issues. 28% of the total were admitted with a diagnosis considered to be high risk for readmission by CMS. Overall, 90% of CTI participants had issues when reconciling medications.

Our Initial Results: Sources: New England Journal of Medicine and Council on Aging of Southwestern Ohio, June 7, Note: This shows overall readmission and are not specific to the top 3 diagnoses; clients were admitted for one diagnosis and readmitted for another. Information for the 7.5% represents 4 out of 53 (# who completed CTI). 9

Our Initial Results: Sources: CMS readmission report, and Council on Aging of Southwestern Ohio 6/7/11 Note: Information is based on clients who completed CTI (n=53) and were readmitted with the same diagnosis as their original admission (AMI=8, CHF=7, PNU=4). AMI, CHF & Pneumonia 30 Day Readmission at University Hospital 10

Our Initial Results: 60.9% were discharged directly to a community setting Source: Council on Aging of Southwestern Ohio, 6/7/11: n=69 Note: N/A: includes individuals discharged from CTI and individuals who are still in the hospital. 11 Of those who were discharged to a short term nursing facility or in- patient rehab, 17 (77%) were discharged back to the community for a total of 59 (85.5%) of CTI participants successfully transitioning back to their homes and communities. Overall, roughly 50% of CTI participants have had their home- based services increased (at least temporarily) following their discharge.

12 Feedback from Participants “CTS was extremely helpful, my husband had a liver and kidney transplant and was having difficulty with his medication management. The Personal Health Record that (CTI specialist) gave us to use was extremely helpful. No one has ever asked my husband what his goals were…It was refreshing for someone to actually talk with us about things instead of talking to us.” J.D., wife of consumer “ I was very happy to have the extra information that (CTI specialist) brought out. I typically keep all my medications in a bowl or a bag if I have to go to the doctor or the hospital. The Personal Health Record was a nice way to keep all my information in one place and a great place to write things down for my doctor that I normally would have forgotten.” G.G., PSP consumer “I was very thankful for (CTI Specialist’s) help at the hospital. I am blind and the hospital social worker and doctor were insisting that I go to a Nursing facility. I told them I wanted to go home because I felt more comfortable there and did not want to go to some strange place where I didn’t know anyone. The CTS talked with the social worker and my case manager at Passport to make sure I had what I needed to go home.” W.T., PSP consumer

13 Feedback from Participants “ We loved working with (CTS) and the Care Transitions program. (CTS) took the time to go over my husband’s medications with me and to reassure me that it was a good thing to pay attention to some of the changes/redflags that I noticed in my husband that let to his hospitalization. (CTS) talked with my husband about his goal, which was to drive. I was very worried about him driving, but I knew that it would make him feel better to be able to do some things for himself again. Since working with (CTS), my husband is now driving short distances, to the store and back. My husband said he feels like a new man. I also liked the booklet (CTS) brought in that has places for questions for our doctor. (CTS) gave me an extra one so that I could use one for myself. We were very thankful we had the opportunity to meet and work with (CTS).” D.G., PSP consumer “(CTS) helped assist in getting the things she needed,” J.R., caregiver for PSP consumer.

14 Abbe Lackmeyer Business Intelligence Department Council on Aging of Southwestern Ohio (513)