1. Home and Community Innovative Strategies for Safe Transitions and Care W. June Simmons, CEO Partners in Care Foundation April, 2013 Care Coordination for your Older Patient Symposium 1

2. Partners in Care Who We Are… Partners in Care is a transforming presence, an innovator and an advocate to shape the future of health care We address social and environmental determinants of health to broaden the impact of medicine We have a two-fold approach: evidence-based models for practice change and for enhanced self-management Changing the shape of health care through new community partnerships and innovations

3. Active Patient Population Management “System” Support: EHR, Data aggregation, Population Registries, Predictive Modeling, Decision Support, Practice Standards, Quality Measurement and Reporting, Accountability, Tele-Medicine, Tele-Health Patient- Centered Shared Decision Making Traditional Benefit-Based Home Health Hospital & Hospitalist- Extensivist Programs  Communication  Care Transitions  ER interventions  Efficient hospital use SNFist and SNF Program Ensuring Care Implementation in the Community & at Home Home Social/Environmental Factors Patient Coaching Transitions of Care Use of Community Resources Comprehensive Care Centers Optimal Discharge (Hospital, ER, SNF, other)

4. Caring for the whole person – Non-medical services Health results come from both medical interventions and non-medical drivers Much truth is found in the home The non-medical drivers are powerful: – Environmental factors – Social Factors – Self-Management Factors

5. Stratify Services for Increasing Needs

6. Community Agencies = crucial partners

7. Networks for Integrating Healthcare with Community- based Organizations

8. Evidence-based programs Stanford Chronic Disease Self-Management (including online, Spanish, Arthritis, Pain, Diabetes, HIV versions) Fall Prevention – Matter of Balance & Healthy Moves Depression/Mental Health – Healthy IDEAS & PEARLS Physical Activity – EnhanceFitness, Fit & Strong Medication Safety – HomeMeds

9. New Self Management Priorities New Medicare Peer Led Diabetes Program Chronic Pain Management New Target Populations for Spread – Veterans – UniteHere

10. Westside Care Transitions Collaborative Partners in Care Foundation and the UCLA Health System and Faculty Practice Group, including Ronald Reagan UCLA and Santa Monica UCLA Medical Centers, and St. John’s Health Center

11. Westside Care Transitions Collaborative Major Initiatives  Identify patients at high readmission risk  Redesign patient flow/discharge planning functions from hospitals  Create new gap-filling resources to smooth patient transfers (e.g. Care transitions, new UCLA urgent care center for post-discharge; in-home medical care program; home palliative care)  Expand offerings of evidence-based models for self-care (e.g., Stanford University’s Chronic Disease Self-Management Program)  Develop standardized transfer tools, processes and quality monitoring for SNFs  Adopt home care best practices, including piloting and spreading a standard of one-hour response time 24/7 for home health and hospice admissions, whether discharged from hospital or ER

12. Westside Care Transitions Collaborative A Root-Cause Analysis (RCA) found the following areas in need of improvement : Coordination and communication among providers Medication management Timely support for patients discharged home Communication with patients and families about post-hospitalization care needs and alternatives Patient activation to improve self-care skills Late life care and decision support services including advance care planning for life-limiting illness

13. In-Home Assessment and Care Coordination Care Transitions Interventions Coaching vs. Care Coordination Identification of what is needed Determination of best location to obtain what is needed Natural supports Purchased services and supports

14. A Key Problem – Medications at Home Medication Errors at home are: – Serious: They cause approximately 7,000 deaths per year in the US – Costly: Annual cost of drug-related illness and death exceeds $170 billion – Common: Up to 48% of community-dwelling elders have medication-related problems – Preventable: At least 25% of all harmful adverse drug events are preventable

15. A Solution – HomeMeds In-home collection of comprehensive medication list, how each drug is being taken, plus vital signs, falls, symptoms, and other indicators of adverse effects Use of evidence-based protocols and processes to screen for risks and deploy consultant pharmacist services appropriately – chosen for physician response Computerized medication risk assessment and alert process with comprehensive report system Consultant pharmacist addresses problems with prescribers

16. Care Transitions: Buy vs. Build Hypothetical Los Angeles County Scenario Patients discharged to geographically disparate parts of the County Lancaster San Pedro Woodland Hills Considerations:  Driving distances to visit patients in home setting following discharge  Arranging for local services (transportation, meals, medical supplies, etc.)  Training and experience hospital (clinical) staff vs. community-based care  Language / Culture  Data collection / patient monitoring becomes more complex

17. Regional Model = centralized, cost- effective, efficient and experienced! Individual Hospital Approach Each hospitals must hire, train, manage and pay transitions directors and health coaches

18. Challenges in Providing End-of-Life Care Fragmentation of care Aging population Costs of medical care – 25% of Medicare revenue is spent on 5% who die each year – Average cost of care in last year of life is $26,000 (1996 costs) – Average cost of care in last 2 years $ 58,000

19. 19 Home Based Palliative Care Model Bridge traditional medical care and Hospice care In home end-of-life care for patients with one year life expectancy Blended model of care Shift focus of care from hospital to home Honor patient choices for own care

20. 20 Pain & other symptom management – comprehensive primary care to manage underlying conditions – aggressive treatment of acute exacerbation per patient and family request 24 hour phone support, visits if necessary Volunteer & bereavement services Transfer to hospice if appropriate Core Components of Palliative Care

21. Unadjusted Medical Service Use (n=297) * P<.01

22. 22 Total Service Costs Adjusted costs of care for those in PC were 32.6% less than those receiving UC Saves $7,551 p<.001 F=16.66 n=292

23. Acute Care Service Use (n=297) * P<.01

24. Other Causes of Readmissions Discharge processes must be realigned Skilled Nursing Facilities and Home health caused 30% of readmits in our targeted hospitals Gaps in care must be identified and remedied – Innovations are emerging

25. SNF Transitions Innovation: Results 25 Discharged to SNF Home with Home Health Baseline 30-day readmission rate 25%14% Pilot Period 30-day readmission rate 11%7% By engaging in robust performance improvement, Cedars-Sinai Health System identified interventions that reduced 30-day readmissions for SNF & Home Health patients by more than 50%.

26. Root Causes for SNF Readmissions 26 Infrequent visits by a physician or advanced practice nurse Patient not seen by physician within first week of discharge SNF nursing staff unable to communicate with physician when needed Patient/Family not communicating Red Flags to SNF staff Lack of clinical oversight on weekends Medication Management/Reconciliation between hospital and SNF Patients at end of life without an Advance Directive/POLST completed A chart review of 150 SNF patients revealed recurring factors that likely contributed to preventable readmission within 30 days.

27. SNF Intervention: Enhanced Care Program 27 Pilot 1: October/November 2011 Pilot 2: January/February 2012 A Nurse Practitioner followed 115 CSMC patients in the SNF. They saw the patient in the hospital They saw the patient in the SNF 24 hours after discharge They saw the patient 1-2 times per week in the SNF When they saw something, they said something… (to the patient’s MD, the SNF staff & to the family)

28. Cycle I: October/November 2011 28 The first pilot demonstrated a 60% reduction in 30-day readmissions. During these two months, readmissions occurred mostly on weekends, when Nurse Practitioners were not working. Readmissions from SNF

29. Cycle II: January/February 2012 29 The second pilot, in which NP coverage was extended to include weekends, yielded a 50% reduction in 30-day readmissions. During this iteration, the NPs prevented 13 likely readmissions. 13 Potential readmissions averted by Nurse Practitioner Duplicate Medication Administration averted (Warfarin) Patient’s family’s concerns alleviated (2 different patients) Patient’s medication concerns addressed Weekend contact with MD with lab results & Rx dosage issues Patient code status changed to DNR/DNI, patient expired in SNF POLST form completed in SNF- patient expired in SNF

30. Cycle I: Enhanced Home Health 30 WHO All CSMC Discharges to a high volume Home Health agency WHAT In-hospital visit by nurse + 6 touch-points after discharge Home visit within 48 hours of discharge Friday “Tuck-in” Phone call Weekend Visits Medication Reconciliation 24-hour call number staffed by a nurse WHEN November 1 – 30, 2011 WHY To determine if more rigorous home health services can prevent readmissions. (Baseline = 19% readmit rate)

31. Root Causes for Home Health Readmissions 31 Patients & families often turn away Home Health agencies after hospital discharge Inconsistency in frequency of home visits post-discharge 45% of readmissions occurred on a Saturday or Sunday Patient/Family not communicating Red Flags to Home Health agency Medication Management/Reconciliation Physicians not responsive when Home Health Agencies have questions/concerns A chart review of 45 Home Health patients revealed recurring factors that likely contributed to preventable readmission within 30 days.

32. Enhanced Home Health 32 Only 6.8% of the 59 TOC patients were readmitted within 30 days of discharge. This rate is less than 50% of the baseline rate observed during FY 2011. Patient PopulationTime Frame % Readmitted (All-Cause) CSMC discharges home with Home Health (any agency) Jul 2010 -Jun 2011 19% CSMC discharges home with TOC Home Health Agency* Jul 2010 -Jun 2011 14% Test of Change (n=59 patients) November 2011 6.8% * The agency selected for the Test of Change had the highest proportion of Home Health referrals from Cedars-Sinai Medical Center.

33. Conclusions 33 Readmissions can be prevented when hospitals take the lead to collaborate with partner agencies in the community. Intervening during the 14 days following hospital discharge is crucial for preventing avoidable readmissions. Clinical resources in the community (SNF, Home Health) need to be bolstered on weekends. Involvement & leadership from Primary MD are key in executing improvements related to readmissions.

34. The Time is Now – drive the change For more information contact: -June Simmons, Partners in Care Foundation -jsimmons@picf.org (818) 837-3775