HEALTH CARE AND HUMAN SERVICES POLICY, RESEARCH, AND CONSULTING - WITH REAL-WORLD PERSPECTIVE. ADRC September 2009 Monthly Call ADRCs Potential Role in Care Transitions

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

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 RED (Re-engineered discharge) Care Transitions Resources and Technical Assistance BOOST (Better Outcomes for Older Adults through Safe Transitions)

Shared Characteristics of Care Transitions Models (Coleman, Boult and Naylor) Nurse in care coordinator role Focus on patient empowerment Involvement of primary care physician Medication reconciliation Home-visit and follow-up phone calls Use of centralized medical record Emphasis on patient understanding Screen for cognitive ability Use of customized, individual care-plan Involvement of family and/or informal caregivers

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”

In 2008/2009 awarded grants for states to develop ADRCs as well as person-centered hospital discharge programs 1 st round - Alaska, Missouri, South Carolina, Kansas, Oregon 2 nd round - Maryland, North Carolina, Hawaii, California Consumer Discharge Planning Checklist Continuity Assessment Record and Evaluation (CARE) QIOs 9 th Statement of Work (SOW) included care transitions

CMS contracts (3 years) with one in every state to provide Beneficiary Protection Patient Safety, Prevention, and “Care Transitions” “Improve quality of care for Medicare beneficiaries through a comprehensive community effort Goal to reduce hospital re-admissions

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 a care transitions model

CMS Fact Sheet – QIOs and Care Transitions - tions_0807.pdf tions_0807.pdf CMS list of state QIOs df Oregon’s Hospital Discharge Feedback Questionnaire ( Kansas Person Centered Discharge Fact Sheet ( tae.org/tikidownload_file.php?fileId=28302) CMS Consumer Discharge Planning Checklist

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 a care transitions model

CMS Person centered hospital discharge grantee Currently in planning phase (three county pilots) Will target Medicaid eligible individuals with PD or chronic illness Identified Measurable Outcomes Discharge of Medicaid patients to nursing facilities will be reduced by 35% (estimated $5.2 million savings). Home care services will be started within 24 hours of referral for 90% of patients discharged home. Customer satisfaction rating will be 90% or higher related to discharge planning process and caregiver education.

CMS Person Centered Hospital Discharge Planning Grantee Care Transitions Task Force established Lane Council of Governments (AAA), Lane Independent Living Alliance (CIL), Sacred Heart Medical Center, Lane Individual Practice Association (Medicaid managed care plan Two year planning process “Hospital Discharge Feedback” survey Health navigator model

Care Transitions page on Issue Brief – Hospital-based Diversion Strategies Peer to Peer Exchange Care transitions workgroup (Fall 2009) Matrix of major care transition models (coming soon) Additional monthly calls on related topics Potential trainings in 2010 Other ideas?