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  • The Evidence That the Readmissions Rate (Readmissions/Hospital Discharges) Is Malfunctioning as a Performance Measure – MediCaring.org
    s conventional metric of readmissions divided by discharges simply tracks the national average Clearly the metric is not functioning in a way that reliably separates good practices from wasteful ones That readmissions over discharges metric does not convey the fact that San Diego is much less likely to hospitalize and to rehospitalize Indeed 10 of the 14 San Diego hospitals eligible for penalties for high readmission rates are being penalized next year Since the calculations that go into determining the hospital penalty focus on particular diagnoses in three past years it is possible that these hospitals manage to do badly with those diagnoses in those years but it seems quite unlikely More plausibly the metric used is of the readmission divided by discharge form so the shrinking denominator will affect this calculation Exhibit 5 Seasonally Adjusted Quarterly Admissions National and San Diego County Exhibit 6 Seasonally Adjusted Quarterly Readmissions National and San Diego County Exhibit 7 Percentage of Quarterly Discharges Readmitted National and San Diego County Without access to and analysis of much more data one cannot know how widespread this problem is We do know that San Francisco had an admission rate of just 50 per 1 000 per quarter in 2013 and a readmission rate of just 8 per 1 000 per quarter which are rates much lower than San Diego Yet 8 of San Francisco s 10 eligible hospitals will be penalized for excessive readmissions in 2015 Furthermore we know that the initial Medicare foray into this work published in the Journal of the American Medical Association in January 2013 link http jama jamanetwork com article aspx articleid 1558278 resultClick 3 Association Between Quality Improvement for Care Transitions in Communities and Rehospitalizations Among Medicare Beneficiaries see Outcome Measures involved 14 smaller communities and that project had to change from using the discharge based metric to using the population based metric when it became clear that the shrinking denominator was making the project monitoring unreliable Hospitals other providers and communities that believe they may be adversely affected by the malfunctioning metrics should have access to the data needed to investigate and CMS should welcome reconsideration of those situations NQF should suspend endorsement of new readmission discharge metrics and re examing existing ones CMS has multiple contractors working on readmissions and some have substantial experience and skills in the technical details of these metrics CMS should quickly modify their contracts to require them to investigate the extent of this problem to identify steps to ameliorate adverse impacts of the current readmissions discharges metrics and to build the metrics that can guide care transitions work into the future Certainly the time has come to sort this out and develop metrics that reliably separate exemplary from persistently inefficient practices Want to know more Protecting Hospitals that Improve Population Health by Stephen F Jencks http medicaring org 2014 12 16 protecting hospitals Senior Alert A Swedish National Dashboard for Preventitive Care for the Elderly by Elizabeth Rolf http medicaring org 2014 12

    Original URL path: http://medicaring.org/2014/12/08/lynn-evidence/ (2016-04-30)
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  • IOM Supports Strengthening Social Services near EOL – MediCaring.org
    of life remaining in their homes or community if that is their preference The IOM report addresses challenges in advance care planning health care costs financing reimbursement structures and communication among patients family members and providers The report offers a series of specific recommendations for changes in policy financing mechanisms payment practices workforce developments research and clinical and supportive care Key recommendations include the following All insurers should cover comprehensive care for individuals with advanced serious illness who are near the end of life Professional societies and others should develop quality standards for clinician patient communication and advance care planning Educational institutions and credentialing accrediting and regulatory organizations should act to strengthen palliative care knowledge and skills of all clinicians All insurers should integrate the financing of medical and social services to support quality care consistent with patients values and preferences A wide variety of stakeholder organizations should provide fact based public education that encourages advance care planning and shared informed medical decision making The report s challenge to redesign the care system to explicitly incorporate social services is centrally important to improving how we die Integrating medical and social services e g transportation home delivered meals caregiver training in a seamless care system may help eliminate incentives to shift the cost of services from one setting to another and will improve the likelihood that more people receive care in the setting of their choice at the right time and in accordance with their informed preferences and values At the Altarum Institute Center for Elder Care and Advanced Illness our efforts to develop a model for frail elders that we call MediCaring Accountable Care Communities directly aims to accomplish the IOM s recommendations for integrating social and supportive services alongside medical care at least with regard to frail elderly people Individuals with needs for long term services and supports often need services that Medicare does not cover notably assistance with obtaining adequate housing food transportation and support with the basics of daily living If we can muster the creativity and the will to establish a service delivery system that tailors care to the needs of frail elders before the age boom takes hold in communities across the country we will be able to generate the necessary savings to eliminate overuse of medical care and establish a much more cost effective delivery system essentially what Dying in America is suggesting Want to know more The full IOM report Dying in America is at http www iom edu Activities Aging TransformingEndOfLife 2014 SEP 17 aspx More about MediCaring is at http medicaring org 2013 08 20 medicaring4life Tweet Pin It Leave a Reply Cancel reply Your Comment You may use these HTML tags and attributes a href title abbr title acronym title b blockquote cite cite code del datetime em i q cite s strike strong Name required E mail required URI A Dangerous Malfunction in the Measure of Readmission Reduction IMPACT s Impact on Quality Measurement for Frail Elders MediCaring is

    Original URL path: http://medicaring.org/2014/09/23/iom-dying-in-america-report/ (2016-04-30)
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  • A Dangerous Malfunction in the Measure of Readmission Reduction – MediCaring.org
    high rate of readmissions This is not a new observation The first sizable pilot project that CMS sponsored involved 14 communities and the readmissions discharges metric functioned so poorly that the outcome measure was changed during the project to a population based measure readmissions per 1 000 Medicare FFS beneficiaries in the geographic community See http jama jamanetwork com article aspx articleid 1558278 That measure works to track changes in the experience of those living in a community but it does not help in assigning credit or blame to particular providers unless there is only one provider in the area It is intrinsically community anchored The rub is that while good care of frail chronically ill persons is at heart a community endeavor Medicare has few tools to incentivize or penalize communities Furthermore it is not clear what the right rate of readmissions should be Very little work has been published on how well the various metrics perform in various circumstances though NQF has a score of new ones under consideration See http www qualityforum org ProjectDescription aspx projectID 73619 The hospital penalty measure has a very complicated risk adjustment but should the population based measure also be risk adjusted perhaps at least for the population age structure and whether the person is in Medicare due to disability or age The problem here is more urgent than other controversies regarding the Medicare readmission measure such as higher readmission rates in disadvantaged populations and whether communities with low total hospital utilization should be expected to have higher readmission rates In the case of measuring change the measurement flaw directly punishes hospitals and communities for doing what the Affordable Care Act and the Medicare Readmissions Reduction Program otherwise encourage them to do reduce preventable hospitalizations What should a responsible system manager like Medicare do Below are some suggestions In the short term Quickly sort out how to exclude certain contexts perhaps as part of risk adjustment e g whether CMS is authorized to limit application of the readmissions discharges metric through regulation or whether the issue has to go back to Congress For safety net hospitals don t penalize hospitals primarily serving poor beneficiaries For reducing admissions see which of these approaches works best or combine them Hospitals with declining admissions and the same bed size when the decline is at roughly the same rate or more than declining readmissions Hospitals with 50 of their Medicare FFS utilization in counties with admission rates in the lowest quartile in the nation Allow hospitals in a particular geographic area to propose accountability for a population jointly or singly so long as they together supply more than for example 70 of the hospital use for that population Then measure their success on a population basis readmissions 1 000 relevant people living in the area quarter and admissions 1 000 quarter In the longer term Develop useful metrics for continuity and quality of care especially for Reliability patient family sense of trustworthiness preparation and Patient family

    Original URL path: http://medicaring.org/2014/08/26/malfunctioning-metrics/ (2016-04-30)
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  • Support the Caregiver Corps Act of 2014! – MediCaring.org
    volunteer experience at the community level in a way that serves a collective good is central to forging a future that we can all live with happily and comfortably Finding ways to engage and support people of all generations who have the skills resources and motivation to help is in everyone s self interest The challenge before us is how we can accomplish this goal and the Caregiver Corps Act of 2014 is an important part of the answer As soon as the bill is introduced or the Senator s office posts the summary or the bill we will put a link here Make a note to check back in a few days Sen Casey announced the bill at a Senate Special Committee field hearing in Pittsburgh on June 30 2014 Titled Sandwich Generation Squeeze Confronting the Middle Class Struggle to Raise Kids Care for Aging Parents and Scrape Together Enough for Retirement in Today s Economy the hearing was held from 1 to 3 p m in the Allegheny County Courthouse Want to learn more Sen Casey press release on the Caregiver Corps concept http www casey senate gov newsroom releases casey hearing examines challenges that regions sandwich generation faces caring for older parents raising children and preparing for retirement U S Senator Robert P Casey D PA http www casey senate gov Keywords Caregiver Corps Senator Casey Caregiver Corps Act of 2014 caregivers volunteers family caregiving Tweet Pin It 5 Responses to Support the Caregiver Corps Act of 2014 Joe Angelelli says July 1 2014 at 4 55 am Historic Thank you Senator Casey for your leadership on this critical issue Reply Cheryl E Woodson MD FACP AGSF says July 20 2014 at 11 57 am This piece of legislation is a good start to relieving the load for family caregivers but we also need an aggressive attack on the financial burdens The value of unpaid caregivers work exceeds the combined spending of Medicare and Medicaid for eldercare in many care settings but not only are these warriors unpaid their personal finances also suffer The average caregiver pays for medications transportation hired caregivers and other resources out of pocket without even a tax deduction They lose time from work and suffer what eldercare professionals call presenteeism their bodies are at their work stations but their minds are at home with Mom I have not seen the data on the impact on performance evaluations promotions and lifetime income but I do know many caregivers retire early Since 60 of caregivers are women who earn less than men and spend less time in the workforce their senior years are at risk of poverty because of paltry pensions I thought we passed legislation in the 1990s allowing states to use Medicaid funds to care for eligible clients at home at a considerably lower cost than nursing homes What happened to that idea My mother s functional status did not require nursing home care but the effect of dementia on her memory

    Original URL path: http://medicaring.org/2014/06/30/casey-caregiver-corps-act/ (2016-04-30)
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  • Innovation Requires Shedding Established Patterns – MediCaring.org
    long term care Really A frail elder who needs long term care is likely to need that care during the first 90 days after hospitalization and planning for the time beyond that People needing long term supports need a service delivery system that works with a comprehensive care plan for a good life not just for a few months of rehabilitation services A modern folk song by David Mallet has the wonderful line We are made of dreams and bones Indeed each unique individual comes to old age not only with a medical history but often more importantly with a lifetime of connections to others personal and family histories and aspirations and an array of resources Our bodies are not like cars which can go to the repair shop just for tires Perhaps a person can sometimes see a doctor for preventive maintenance or repairs to just one body part But once someone is living with serious illnesses or disabilities the central challenge is how to live well with those conditions and their treatments Still whole sectors of the health care industry continue to operate like repair shops addressing one treatment diagnosis or setting and therefore regularly falling short in providing good care for frail elders Comprehensive Care for Frail Elders Imagine a service delivery system that really worked for frail elders A key member of a multidisciplinary team would know each person well and understand the particulars of each situation including strengths fears and priorities The frail elderly person his or her family and the care team would develop and agree to a plan of services that optimally helps attain important and achievable goals At the same time an organization representing the community would be continually working toward making available an optimal array of services Making such an arrangement a reality will require developing new rules and procedures that enable the community to improve service supply and quality We will have to learn how to evolve from the currently dysfunctional structure a legacy developed for a different time and a different population with a different set of challenges MediCaring Communities CECAI is now working with several communities whose visionary leaders are moving toward our comprehensive MediCaring model learning how to work within current limitations without accepting them MediCaring offers a strategy that spans settings and time through to the end of life and even beyond to support the bereaved This model goes beyond our traditional focus on medical services by including important services such as housing nutrition transportation social connections and caregiver support One idea behind MediCaring is to balance the resources available for medical services with those needed for social supports within each community We know that many other communities and organizations are working to similar ends and we would enjoy hearing more about just what you are doing Share some compelling stories of how you are using the flexibility of Center for Medicare Medicaid Innovation waivers or the adaptability granted by capitation or local funding to make

    Original URL path: http://medicaring.org/2014/05/28/innovation-requires-shedding-established-patterns/ (2016-04-30)
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  • Care Planning: Promising Practices in Minnesota – MediCaring.org
    the responsible clinician documents the care plan and ensures continuity of care across time and setting by always being available to the on call physician or nurse practitioner NP Dr Nick Schneeman the project s lead physician says Physicians the NPs and the entire clinical team are trained to think about and access the patient s goals of care for every interaction and before any prescriptions testing or referrals are even contemplated Sounds simple and in a way it is but it is transformational The LifeCourse project at Allina Health System takes a different path to a similar end That project builds a deep understanding of the patient s life story and provides trained lay persons community health workers known as Care Guides who help inform and guide clients and their families through the experience of living with serious illness and progressive disability They work with a team that includes nurses pharmacists and behavioral therapists They have contact with the patient s primary care physician and although the team includes a physician its primary focus is to provide support for physical emotional spiritual and social issues along with a practical plan for daily needs LifeCourse has enhanced its EPIC medical records system with a What Matters Most feature to record goals as the patient or family member says them You can learn more about the LifeCourse project at LifeCourseMN org These are two very different approaches but they share some important strategies They ensure that the care team knows enough about the patient and family and the likely future course to help make workable plans that suit the situation and their priorities They effectively integrate and implement the plans across time and settings They are engaged with their community s resources and are clever and thoughtful about creating a workable plan Of course they are quite different from one another in emphasizing a physician coordinator or a layperson guide and it will be very interesting to see how they affect the experience of elders and their families and the costs of care Where are the good models for care planning Do you know of a program that is doing a good job of care planning for frail elders Who is working on these issues What do you think and what do you see happening How could we measure the quality of care plans and care planning What could encourage caregivers to demand good care plans We are eager to hear from you Post a comment below or send email to email protected Tweet Pin It Leave a Reply Cancel reply Your Comment You may use these HTML tags and attributes a href title abbr title acronym title b blockquote cite cite code del datetime em i q cite s strike strong Name required E mail required URI Shining Stars on Care Transitions Thursday at 3 ET online A Dangerous Malfunction in the Measure of Readmission Reduction MediCaring is a service of the Center for Elder Care and Advanced Illness at

    Original URL path: http://medicaring.org/2014/03/24/care-planning-minnesota/ (2016-04-30)
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  • IHI Training Seminar on Frail Older Adults: Building a Care System – MediCaring.org
    work with communities on the MediCaring model There will be substantial opportunity for one on one coaching and group problem solving The aim is to bring interested and committed service providers clinicians and managers to a strong level of understanding Every day the population continues to age This means that every day a higher proportion of the population require reliable and appropriate services for disabilities and illnesses associated with aging in a health care system that is often inefficient fragmented and expensive Now is the time to change how we provide care for our frail older adults If you are looking to get a good start in your setting this is a good way to get underway Tweet Pin It Leave a Reply Cancel reply Your Comment You may use these HTML tags and attributes a href title abbr title acronym title b blockquote cite cite code del datetime em i q cite s strike strong Name required E mail required URI Advanced Old Age in America What Can We Count On Senate Works to Advance Care Plans Listen to Senator Mark Warner s Take MediCaring is a service of the Center for Elder Care and Advanced Illness at Altarum Institute Follow Us To receive our email newsletter send a request to email protected Tweets by medicaring Care Transitions News Ringling Bros circus elephants set for final act Sunday USA TODAY April 29 2016 PMH announces Annette Schnabel as president CEO Bureau County Republican April 29 2016 College baseball Weekend Preview April 29 May 1 NCAA com April 29 2016 AbbVie Doubles Down on M A Bloomberg April 29 2016 Aspen Valley Hospital reaps awards for patient experience Aspen Times April 29 2016 Optimizing care transitions the role of the community pharmacist Dove Medical Press April 26 2016 3 lessons

    Original URL path: http://medicaring.org/2014/02/25/ihi-frail-older-adults/ (2016-04-30)
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  • JAMA Theme Issue features MediCaring article by Dr. Joanne Lynn – MediCaring.org
    including millions of Boomers now on their way face a health care system not designed or equipped to meet the essential needs of very old people for continuity of care community based services access to nutrition and transportation and help for family caregivers Lynn writes that requiring a comprehensive realistic assessment of each frail elderly person s situation and development of a shared plan of care is the keystone of highly reliable effective and affordable care These care plans would inform and direct a person s care and build the delivery system we need in advanced old age Anchoring the effort in the communities where people live will make them more effective and will allow savings from more efficient medical care to be used to support social services a plan that Dr Lynn calls MediCaring ACOs Lynn concluded today s remarks with a sense of urgency and a call to action It s not a hotshot pill anymore it s how people are going to live with these conditions she said We have about a decade to get it right In earlier posts for Altarum s Health Policy Forum Lynn has written about her vision for creating and testing the MediCaring model And in a recorded session she highlights just how that vision might play out viaa proposal to demonstrate MediCaring4LIFE in 4 communities around the country That proposal is now under review at the Centers for Medicare and Medicaid Innovation key words Joanne Lynn JAMA MediCaring Medicaring4LIFE Tweet Pin It Leave a Reply Cancel reply Your Comment You may use these HTML tags and attributes a href title abbr title acronym title b blockquote cite cite code del datetime em i q cite s strike strong Name required E mail required URI Touch Talk Listen Why EMRs are Dangerous

    Original URL path: http://medicaring.org/2013/11/12/jama-special-issue-features-medicaring-article-by-dr-joanne-lynn/ (2016-04-30)
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