Caring For Vulnerable Populations 2011 AHA Committee on Research Report January 2012

© 2011 American Hospital Association Caring for Vulnerable Populations 2 An examination into emerging and effective care coordination practices for vulnerable populations through the example of caring for dual eligibles 1.Background on dual eligibles 2.Current programs to improve coordination 3.Core elements in care coordination programs 4.Future policy developments that may help improve care coordination Report available at: AHA Committee on Research: © 2011 American Hospital Association

Who are Dual Eligibles? million Americans are dual eligibles: Medicaid beneficiaries who are also enrolled in Medicare. While 6 in 10 are 65 or older, more than 1/3 are younger individuals with disabilities.  15% more likely to have a cognitive or mental impairment  50% more likely to have diabetes  600% more likely to reside in a nursing facility  250% more likely to have Alzheimer’s disease  100% more likely to have heart disease  Much less likely to receive specific measures of preventive care, follow-up care or testing As compared to traditional Medicare beneficiaries, dual eligibles are: Sources: Kasper, Judy, Molly O’Malley, and Barbara Lyons. “Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Service Use and Spending.” Kaiser Commission on Medicaid and the Uninsured, July, Milligan, CJ et al. “Medicare Advantage Special Needs Plans for Dual Eligibles: A Primer,” The Commonwealth Fund, February Grabowski, DC. “Special Needs Plans and the Coordination of Benefits and Services for Dual Eligibles,” Health Affairs, 28 no. 1(2009): © 2011 American Hospital Association

Since Dual Eligibles Use More Health Care Services... 4 Health service utilization among dual eligibles as compared to Medicare population Source: Kasper, Judy, Molly O’Malley, and Barbara Lyons. “Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Service Use and Spending.” Kaiser Commission on Medicaid and the Uninsured, July, Accessed at: © 2011 American Hospital Association

…They Account for a Disproportionate Share of Spending 5 Source: Kaiser Family Foundation, “The Role of Medicare for the People Dually Eligible for Medicare and Medicaid,” January Dual Eligibles as a Share of 2006 Medicare Population and Spending Dual Eligibles as a Share of 2007 Medicaid Population and Spending Dual EligiblesNon Duals

© 2011 American Hospital Association Existing Service Delivery Models Lack Coordination at the Provider Level 6 ProgramFinancingPopulationCare Coordination Special Need Plans Risk-adjusted, capitated payments to cover all Medicare services (each plan determines Medicaid involvement) 298 plans serving more than 1,000,000 beneficiaries  Patient ease through one plan  Greater budget predictability  Multidisciplinary care team  No proven care improvement  Varying degree of Medicaid coordination Program of All- Inclusive Care for the Elderly Separate Medicare and Medicaid capitated benefit at an agreed-upon per member per month rate 71 sites nationally, servicing approximately 23,000 participants +Fully integrated funding stream  Established quality measures  Medical and nonmedical capabilities  Sufficient up-front capital required  High administration and workforce costs  Centered on one physical location Medicaid Managed Care Some plans maintain FFS with additional payment for coordination; others use capitated model Approximately 2.5 million beneficiaries  Incremental step toward risk sharing  Improved care coordination  FFS disincentives remain  No set design standard  Some exclusion of long-term care and behavioral health benefits Sources: (1) Milligan, C et al. “Medicare Advantage Special Needs Plans for Dual Eligibles: A Primer.” The Commonwealth Fund. February, (2) Centers for Medicare and Medicaid Services. Special Needs Plan Comprehensive Report: Medicare Advantage/ Part D Contract and Enrollment Data, Special Needs Plan Data. Accessed at: McNabney, M. “Program of All-Inclusive Care for the Elderly” (presentation, American Hospital Association Committee on Research, Chicago, IL, March 2011). (4) Petigara, T et al. “Program of All-Inclusive Care for the Elderly.” Health Policy Monitor. April, 2009.

© 2011 American Hospital Association Affordable Care Act Offers Opportunities to Improve Dual Care Coordination 7  The Federal Coordination Health Care Office will study and analyze the best methods to integrate dual benefits, improving coordination between the federal and state governments.  The Center for Medicare and Medicaid Innovation will test innovative payment and service delivery models to improve quality and reduce unnecessary costs. In April it was announced the selection of 15 states to receive financial assistance to improve care coordination across sites of care for the dual eligible population.

© 2011 American Hospital Association Hospital Strategies to Care for Duals Incorporate Several Essential Elements 8 Offer home-based care 1 Complete assessments and reassessments Align financial incentives 7 2 Incorporate person- centered care principles Develop network and community partnerships 8 3 Implement protocol- based planning Provide nonhealth care services 9 4 Conduct periodic visitsOffer home-based care 10 5 Utilize team-based care management Organize center-based day care 11 6 Facilitate data sharing and integrated information systems Incorporate cultural competency and equity of care standards 12

© 2011 American Hospital Association 1 Complete assessment and reassessment Align financial incentives 7 2 Incorporate person- centered care principles Develop network and community partnerships 8 3 Implement protocol-based planning Provide nonhealth care services 9 4 Conduct periodic visitsOffer home-based care 10 5 Utilize team-based care management Organize center-based day care 11 6 Facilitate data sharing and integrated information systems Incorporate cultural competency and equity of care standards 12 Core Element 1: Complete Comprehensive Assessments and Reassessments 9 A comprehensive assessment identifies all potential medical and psychosocial supports aids necessary for an individualized care plan. Comprehensive programs typically include annual comprehensive assessments to evaluate any change in the patient’s clinical or social needs.  Individualized care plan is designed upon admittance to the program based on a comprehensive medical and behavioral assessment.  Multidisciplinary staff (including everyone from physicians to housekeeping aids and social workers) hold quarterly intake meetings to monitor care. Example: Johns Hopkins ElderPlus Program Sources: (McNabney, M. “Program of All-Inclusive Care for the Elderly” (presentation, American Hospital Association Committee on Research, Chicago, IL, March 2011). Jaffe, S. “Federal Program Aims to Keep Seniors out of Hospitals and Nursing Homes.” The Washington Post. December 20, 2010.

© 2011 American Hospital Association Core Element 2: Incorporate Person- Centered Care Principles and Practices Incorporate person- centered care principles Place the individual and affiliated family and friends (including informal caregivers, client advocates, and peers) at the center of all planning decisions to achieve better results and promote patient self-direction.  Each patient works with a nonclinical health coach to proactively manage care, making contact once every two weeks.  New patients receive hour-long appointments, existing 30 minutes  Patients guaranteed same-day sick visits, follow-up call within 24 hours  Patients have no copayments for physician visits or prescriptions filled at on-site pharmacy Example: AtlantiCare Special Care Center Sources: Gawande, A. “The Hot Spotters: Can we Lower Medical Costs by Giving the Neediest Patients Better Care?” The New Yorker. January 24, Blash, L et al. “The Special Care Center: A Joint Venture to Address Chronic Disease.” Center for the Health Professions Research Brief. February, Page, L. “10 Ways Atlanticare’s Special Care Center Improves Outcomes and Lowers Costs.” Becker’s Hospital Review. February 4, 2011.

© 2011 American Hospital Association Core Element 3: Implement Protocol-Based Planning Implement protocol-based planning Evaluate and employ evidence- based protocols to manage common conditions affecting geriatric and other vulnerable populations, reducing unwarranted provider variation. 1.Charts flagged upon admission for eligible patients 2.Names added to a white board for provider tracking 3.Discharge process completed together by a physician and a nurse using the “teach back” technique. 4.Patient receives all discharge information on a one-page document to bring back to primary care physician. Example: BOOST Program at SSM St. Mary’s Medical Center Sources: Budnitz, Tina. “Project Boost: Reducing Unnecessary Readmissions and so much More.” Society of Hospital Medicine. Available at Wellikson, L et al. “Aligning Hospitalists & PCPs: Coordination and Transitions” (presentation, American Hospital Association Committee on Research, Chicago, IL, March 2011). BOOST = Better Outcomes for Older Adults through Safe Transitions

© 2011 American Hospital Association Core Element 4:Conduct Periodic Visits Conduct periodic visits Include periodic visits (in person, by telephone, or via internet) with the patient and his or her family/ caregivers in their own home, complementing regularly scheduled medical care. Visit frequency varies but typically includes: 1.Comprehensive in-home assessment by nurse practitioner and social worker 2.In-home visit after care plan development to discuss logistics 3.Phone contact at least once per month by GRACE coordinators 4.Home visit after each hospitalization or ED visit. Example: GRACE, Wishard Health Services Sources: Bielaszka-DuVernay, C. “The ‘GRACE’ Model: In-Home Assessments Lead to Better Care for Dual Eligibles.” Health Affairs, 30, no. 3 (2011): Counsell, SR et al. “GRACE: Geriatric Resources for Assessment and Care of Elders.” (presentation, Health Affairs, January, 2011). “IU Geriatrics.” Presentation provided by Stephen R. Counsell. GRACE = Geriatric Resources for Assessment and Care of Elders

© 2011 American Hospital Association Core Element 5: Utilize Team-Based Care Management Centered on Primary Care Utilize team-based care management Coordinate medical, behavioral, and long-term support services through the work of a multidisciplinary, accountable, and communicative care team. Integrate primary care physicians as the core of the care team, supporting and collaborating with the multidisciplinary group. Example: Commonwealth Care Alliance Sources: “Plan-Funded Team Coordinates Enhanced Primary Care and Support Services for At-Risk Seniors, Reducing Hospitalizations and Emergency Department Visits.” AHRQ Health Care Innovations Exchange. Accessed July 11, Simon, Lois. “Commonwealth Care Alliance: The Case for Primary Care Redesign and Enhancement as the Critical Strategy to Improve Care and Manage Costs” (presentation, Alliance for Health Reform Briefing, August, 2011). Multidisciplinary primary care that includes the following components: 1.Comprehensive assessments 2.Individualized care plans with integrated behavioral health 3.Team trained in social issues 4.RN, NP, behavioral health, MSW, and PCP assigned to each patient. 5.Capacity for home visits

© 2011 American Hospital Association Core Element 6: Facilitate Data Sharing and Integrated Information Systems Facilitate data sharing and integrated information systems 12 Provide mechanisms and create the necessary data-sharing arrangements to collect, store, integrate, analyze, and report data in a timely manner to promote care coordination.  Utilizes a data warehouse to measure quality of care for specific patient population.  Combines claims with clinical data to identify patients that necessitate increased care coordination.  Payer data facilitates ability to follow patients when they leave the Montefiore System.  Examine ED visits, readmissions, medication compliance. Example: Montefiore Care Management Organization Sources: Gardner, E. “Montefiore Medical Center: On the Cutting Edge of Accountable Care.” Modern Healthcare Insights Chase, D et al. “Montefiore Medical Center: Integrated Care Delivery for Vulnerable Populations.” Commonwealth Fund: High-Performing Health Care Organization. October, Czinger, P. “Aligning Health IT with Delivery System Reform: Technology Gaps in Coordinating Patient Care.” (presentation, Bipartisan Policy Center’s Health IT and Delivery System Transformation Summit, Washington, DC, June 27, 2011).

© 2011 American Hospital Association Core Element 7: Align Financial Incentives 15 1 Align financial incentives Organize financial arrangements and potential savings to encourage cooperation and alignment across the continuum of care. Fairview Partners receives a per member, per month payment to provide comprehensive care for all services. Net income is distributed to its three partnerships, and Fairview assumes full operational responsibility for the continuum of care. Example: Fairview Partners at Fairview Health Services Sources: “Conrad, J et al. “Fairview Partners” (presentation, American Hospital Association Committee on Research, March 2011).

© 2011 American Hospital Association Core Element 8: Develop Network and Community Partnerships Develop network and community partnerships Expand beyond the hospital and encourage relationships with nursing homes and long-term care providers, public health departments, community centers, and other organizations to improve care coordination and transitions Summa worked with representatives from 28 area SNFs, EMS services, and the local agency on aging to create a task force with three main objectives: 1.Standardize the SNF referral process with evidence-based guidelines 2.Create a clinical subcommittee to improve care transitions 3.Design and evaluate outcome measures to monitor network performance Example: The Care Coordination Network at Summa Health System Mc Carthy, D et al. “Case Study: Summa Health System’s Care Coordination Network.” The Commonwealth Fund. Accessed August 23, “ Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays.” AHRQ Health Care Innovations Exchange. Accessed September 9, 2011

© 2011 American Hospital Association Elements Incorporated Into The Most Integrated Programs Provide nonhealth care services 9 4 Offer home-based care 10 5 Organize center-based day care 11 6 Incorporate cultural competency and equity of care standards 12 Provide nonclinical services such as transportation to medical appointments. Incorporate timely, patient- and family-centric, home-based care options Form or partner with a program that utilizes a center-based model Develop care teams with awareness of the individual’s cultural perspective and language fluency.

© 2011 American Hospital Association Measure Progress Through Performance Metrics 18 Type of Measure Relevant Metrics to Measure Program Process Utilization  Number of ED visits  Number of hospital admissions  Number of preventable admissions  Number of surgical procedures  Number of labs and tests ordered  Number of missed appointments  Hospital length of stay  Electronic health record meaningful use Quality and Outcomes  Length of survival  Assessing Care of Vulnerable Elders (ACOVE) measures  SF-36 Questionnaire or similar scale  Medication compliance  Assisted Daily Living (ADL) improvement  Hospital Compare – process of care measures  Mortality Cost  Total cost of care  Cost per inpatient hospital stay  Cost of specialty care visits  Cost of primary care visits  Mental health care spending  Durable medical equipment costs  Nonhealth care service spending  Cost of employed care coordinators  Home health care costs Satisfaction  Patient satisfaction in all settings – inpatient (HCAHPS), ambulatory, nursing home  Affiliated partner satisfaction  Provider satisfaction  Patient satisfaction  Patient family/ caregiver satisfaction Applicable metrics will vary by program implemented

© 2011 American Hospital Association Key Take-Away: Caring for Vulnerable Populations While financial alignment may occur at a policy level, hospitals are well positioned to address the system, provider, and patient barriers impeding high-quality care for the most vulnerable populations. 19 Contact: Jill Seidman at / Report available at: AHA Committee on Research:

© 2011 American Hospital Association. All rights reserved. All materials contained in this publication are available to anyone for download on or for personal, noncommercial use only. No part of this publication may be reproduced and distributed in any form without permission of the publisher, or in the case of third party materials, the owner of that content, except in the case of brief quotations followed by the above suggested citation. To request permission to reproduce any of these materials, please