1. Barriers to Care Transitions Each health plan has different forms and different requirements for authorizations Multiple health plan formularies Providers (Hospitals, Physicians) aren’t incentivized to reduce readmissions No/low funding for services such as telehealth, medication dispensing, nurse visits Patients don’t want to pay co-pays to see a Physician after leaving the hospital Enrollees unable to access transportation quick enough to see physician

2. Barriers to Care Transitions con’t Access issues – not enough Medicaid providers –Low reimbursement rate is a disincentive to see patients Reimbursement and coverage provides disincentives –Hospital activity to reduce rehospitalizations (ex: f/u phone calls) –Palliative Care and Hospice programs –LTACH level of care Patient compliance Transient population Enrollees move in and out of eligibility Patient can’t afford medications

3. Barriers to Care Transitions con’t Inadequate handover communication from hospitals Medication lists not complete or accurate Patient education materials not patient-centered Patient’s caregivers aren’t included in the education and discharge process Hospital discharge planning fragmented Misaligned transition processes between hospitals and health plans

4. How to address the Barriers? PCPs incentivized to keep appointments open for follow-up visits; see patients in the hospital Case Management for all high-risk patients Coverage for patient advocates and coaches Cover first home visit regardless of qualifying criteria (need for medication reconciliation) Transportation for patients; must be timely Standardization of forms and benefit design and formularies Coverage for off-formulary medications Shared-savings program with hospitals Provide hospitals with lists of which providers will accept patients – home health, skilled nursing, etc.

5. How to address the Barriers? con’t Redesign patient education materials and process –Teach-back –Include the learner/caregivers Discharge planning upon admission Multi-disciplinary discharge teams/process Standardize handover information and establish real-time communication Medication Reconciliation Improved communication between hospital and health plan case managers Promote patient self-management

6. The Care Transitions Intervention Use of Transition Coaches – RNs, Socials Workers & Community Health Works Coaches help newly discharged patients and their caregivers learn skills to keep them out of the hospital –Medication self-management –Use of a personal health record –Timely primary and specialty care follow-up –How to recognize red flags and how to respond Transition Coach visits the patient in the hospital before discharge and visits in the home over 4 weeks One community reduced readmission by 14% * http://www.caretransitions.org/ Butcher, Lola. How to Save a Bundle on Hospital Readmissions. Managed Care, July 2009 *The Hospitalist, February 2011. http://www.the-hospitalist.org

7. Transitional Care Model Targets adults 65+ with 2 or more risk factors –Poor self-health ratings –Multiple chronic conditions –Recent hospitalizations Transition Care Nurse coordinates the patient’s discharge plan with the family and hospital staff Transitional nurse helps patient manage post-discharge care and facilitates communication with outpatient providers and community services Home visits and phone calls for up to 3 months after discharge Helps patient/family understand condition, how to care for themselves, recognize problems,, and how to take medications correctly Aetna: Reduced readmissions in the 3 months after discharge by 25% –Cost saving of $439 pmpm was achieved http://www.transitionalcare.info/ Butcher, Lola. How to Save a Bundle on Hospital Readmissions. Managed Care, July 2009

8. Other Innovations According to research conducted by America’s Health Insurance Plan’s Center for Policy and Research, there are three important trends: –Health Plans are rebuilding primary care by placing nurses, social workers an case managers in settings such as hospitals, skilled nursing facilities and patient homes –Health Plans are building patient relationships by helping members understand their care plans, checking their symptoms, arranging for services and enabling them to have follow-up visits –Health Plans are connecting patients with pharmacists directly, by phone or in person, to review medications. Innovations in Reducing Preventable Hospital Admissions, Readmissions and Emergency Room Use: An Update on Health Plan Initiatives to Address National Health Care Priorities. AHIP, Center for Policy and Research, June 2010