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  • care transitions – MediCaring.org
    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 Shining Stars on Care Transitions Thursday at 3 ET online Posted by Janice Lynch Schuster on September 11 2013 No Responses Tagged with care transitions Medicare quality improvement Sep 11 2013 Greetings Please join us in this week s Integrating Care for Populations Communities Learning Session Webinar on Thursday September 12 2013 at 3 00 pm ET During this session we will hear from the Rhode Island Beacon Community Beacon Community Program Grantee Learning Objectives Participants will Identify how to improve the coordination and cost efficiency of care through use of inpatient and emergency department ED alerts Learn best practices from a clinical perspective to promote the adoption of admission discharge and transfer ADT alerts Learn how to use health IT to prevent hospitalizations and emergency department ED use by using lessons learned found in the Improve Hospital Transitions and Care Management Using Automated Admission Discharge and Transfer Alerts Learning Guide Presented by Gary A Christensen Chief Operating Officer and Chief Information Officer Rhode Island Quality Institute RIQI Gary A Christensen has served as Chief Operating Officer and Chief Information Officer of Rhode Island Quality Institute RIQI since 2009 He directs program and Institute operations using best practice disciplines and drives business goals through health IT innovation He has nearly two decades of IT and operations leadership experience in domestic and global financial services during which he served as divisional CIO for businesses at Capital One Financial Deutsche Bank and Bankers Trust Company Mr Christensen was named one of InformationWeek Healthcare s 25 CIOs Transforming HealthCare in May 2012 He earned both a bachelor s and master s degree from Stanford University Jonathan Leviss MD Chief Medical Officer Rhode Island Quality Institute RIQI Jonathan Leviss MD is the Chief Medical Officer for the Rhode Island Quality Institute RIQI Dr Leviss provides strategic leadership across RIQIs initiatives to transform quality and efficiency of health care in Rhode Island including the RI Beacon Communities Program and the Health Information Exchange Prior to joining RIQI Dr Leviss led HIT initiatives at large and small health systems in the US and internationally He was the Vice President Chief Medical Officer at Sentillion the market leading health care identity and access management vendor acquired by Microsoft in 2010 and then served as Director of Clinical Solutions at Microsoft Health Solutions Group Dr Leviss was the first CMIO at the NYC Health and Hospitals Corp consulted at Cerner and Deloitte and was faculty at NYU and Columbia University Dr Leviss has chaired and served on several RI state wide committees on HIT and was a founding board member of Medical Informatics NY He regularly writes and presents on health information technology health care and physician leadership and was the editor of HIT or Miss lessons learned from health information technology implementations Dr Leviss is an internist at the Thundermist Health Center RI Dr Leviss received his BA in international relations from Tufts University and MD from NYU School of Medicine Event Care Transitions Learning Session webinar Date September 12 2013 Time 3 00 PM 4 00 PM ET Teleconference 866 639 0744 No pass code needed https qualitynet webex com Meeting Password community Please join us 15 minutes prior to the presentation to ensure the automatic system set up has been properly established Attendee Instructions 1 Click or Copy and Paste this to your web browser https qualitynet webex com 2 Locate the event you wish to join 3 Click on Join Now located to the right of the event title 4 Enter your name and email address as prompted 5 Enter the password community 6 Dial in to the teleconference The number is 866 639 0744 or 678 302 3564 The access code is none If you have any questions or problems accessing the meeting please call the Buccaneer WebEx Helpline at 540 347 7400 x390 Presentation slides will be posted prior to the call at http www cfmc org integratingcare learning sessions htm These sessions will be held on the 2nd and 4th Thursdays of the month and are open to all please invite anyone who wants to learn along with us As a reminder these sessions are recorded and all previous Learning Sessions are available at http www cfmc org integratingcare learning sessions htm If you are not already receiving notifications about our upcoming Learning Sessions you may register or update your subscription preferences at http eepurl com jOFqb Reducing Readmissions From the Experts Webinar Thursday August 8 3 pm ET Posted by Janice Lynch Schuster on August 7 2013 No Responses Tagged with best practices care transitions CCTP CMS community based discharge planning eldercare frail elders hospital readmissions Medicare quality improvement Aug 07 2013 As part of its ongoing series on reducing readmissions the Integrating Care for Communities project from the Colorado Foundation for Medical Care hosts a webinar on Thursday August 8 at 3 ET Details about the program can be found here with information provided by CFMC During this session we will hear from ARC Avoiding Readmissions through Collaboration California Community Based Care Transitions Program CCTP Awardee Learning Objectives Participants will Identify the structure and tactics used by the collaborative to drive readmission reduction in participating hospitals Trace the collaborative s efforts to develop a Patient Advisory Council Examine how to develop and deploy a successful relationship between a hospital and their SNFs to optimize care transitions Presented by Cheryl Reinking RN MS Interim Chief Nursing Officer El Camino Hospital Cheryl Reinking RN MS has served 25 years at El Camino Hospital in progressive nursing leadership roles her most recent being as Interim Chief Nursing Officer which she assumed in July 2013 Cheryl has led a number of hospital wide initiatives and was key to the hospital s implementation of the nationally recognized Nurses Improving Care for Healthsystem Elders NICHE program which was designed to create increased patient centric care for hospitalized older patients She developed the hospital s site specific program Pat Teske RN MHA Cynosure Health Pat Teske RN MHA is the implementation officer for Cynosure Health In her role she strives to implement the company s vision through strategic planning and execution of projects on time and within budget that yield successful outcomes Previously she held the position of vice president of Quality Improvement and Care Management for Catholic Healthcare West Pasadena CA where she lead the regions chief nursing officers quality directors case managers and medical staff directors to accomplish their annual goals As an independent contractor Pat supported BEACON the Bay Area Patient Safety Collaborative as well as other state and local collaboratives She is currently leading the Avoid Readmissions through Collaboration ARC effort in CA and working nationally with HRET on the Partnership for Patients HEN A requested public speaker at national state and local conferences including IHI NPSF and TJC Ms Teske has developed and offered numerous educational programs designed to support performance improvement and system reliability Pat received her MHA from the University of LaVern and her BS in Nursing from the University of Virginia Lisa Ehle MPH Program Manager Cynosure Health Lisa Ehle MPH is a Program Manager at Cynosure Health and currently oversees the Avoid Readmissions Through Collaboration ARC program and the ARC Patient Advisory Council Before joining Cynosure Health Lisa served as the State Director of Program Services with the March of Dimes Massachusetts Chapter where she co founded the MA Perinatal Quality Collaborative and directed a Program Services Committee charged with addressing the perinatal needs of the state She has been an advocate for maternal and child health issues including preterm birth prevention routine HIV screening smoking cessation and improving hospital discharge practices Lisa has worked at the state level for the MA Department for Public Health creating policies and guidelines for infectious disease prevention and screening programs Lisa received her Bachelor of Science in Physical and Psychiatric Rehabilitation Counseling from Boston University Sargent College and a Masters of Public Health from Boston University School of Public Health specializing in Social and Behavioral Sciences Event Care Transitions Learning Session webinar Date August 8 2013 Time 3 00 PM 4 00 PM ET Teleconference 866 639 0744 No pass code needed https qualitynet webex com Meeting Password community Please join us 15 minutes prior to the presentation to ensure the automatic system set up has been properly established Attendee Instructions 1 Click or Copy and Paste this to your web browser https qualitynet webex com 2 Locate the event you wish to join 3 Click on Join Now located to the right of the event title 4 Enter your name and email address as prompted 5 Enter the password community 6 Dial in to the teleconference The number is 866 639 0744 or 678 302 3564 The access code is none If you have any questions or problems accessing the meeting please call the Buccaneer WebEx Helpline at 540 347 7400 x390 Presentation slides will be posted prior to the call at http www cfmc org integratingcare learning sessions htm key words readmissions rehospitalizations care transitions quality improvement organizations CMS CFMC CCTP Success Will We Know It When We See It Posted by Janice Lynch Schuster on July 3 2013 No Responses Tagged with care transitions CCTP CMS Coleman Model community based frail elders hospital readmissions Medicare quality improvement rehospitalization Section 3026 Jul 03 2013 By Carol Castillon Defining success in work that focuses on people who are very sick can be a challenge The usual metrics just aren t always applicable With that in mind how will we know success in our community based care transitions work CCTP Like everyone else involved in this endeavor San Diego faces the challenge of reaching a 20 reduction in Medicare fee for service readmissions We are avidly monitoring our progress But is that really success To some extent of course it is and it would be fabulous to get there If and when we do though I think there would still be a void Perhaps I m naïve or perhaps I have what we lovingly call a social worker s heart but my definition of success is something a little different The only way to convey this is by telling the story of patient X A day after admitting patient X to a partnering hospital our Inpatient Transition Coach assessed the patient for meeting our high risk criteria That same day the patient was assigned to the Care Transitions Intervention CTI coach The coach saw the patient and enrolled him into CTI as well as into our Care Enhancement program which could address the need for social services Throughout the hospital stay the partnering hospital provided the patient with assistance in communicating his needs to his healthcare team From this interaction the team learned that the patient could not afford his medication co pays Based on hospital regulatory charity guidelines we were able to have that fee waived After 3 days in the hospital the patient was discharged and the CCTP clock began to tick When the patient opened his apartment door our coach found herself in an all too familiar situation She found that the apartment had been hit by what looked like a tornado involving the patient s medications The patient filled with nervousness and relief at seeing the coach who is a nurse blurted I need to call 911 I need to get to the ER Every CTI coach fears hearing this Staying calm our coach assessed the patient and found that he had been suffering from a headache since the day of discharge The patient did not have any pain medications or transportation to obtain such medications Using her charismatic charm the coach was able to coach the patient to call his physician and discuss these symptoms She then helped him to identify some key issues that were quite evident with his medications The visit lasted for about 2 hours but even with that much time the coach could not complete the four pillars of the CTI model Instead she worked with the patient to set follow up medical appointment with his physician and connected him with some of our Care Enhancement services Through Care Enhancement we were able to provide a taxi prescription to get the patient to his doctor s office The Care Enhancement social worker then worked miracles The social worker connected the patient with a home health program which the patient had declined at discharge She assisted the patient in obtaining transportation through our Metropolitan Transit System Access which assists people with disabilities The long term needs assessment found that the patient had shown symptoms of depression and so the social worker addressed this problem with the patient and physician The patient was connected with in home counseling aide and attendance through the VA and housing In terms of housing she helped the patient to move from his second floor apartment floor and limited his ability to go out the patient uses a scooter to a living environment better suited to his needs Now that s success Because of our team s work and focus the patient doing better This was a direct result of our collective interventions Patient x has ongoing support from a team that is committed to improving the lives of each and every patient we meet Right now we are at 80 days post discharge and no readmission Carol Castillon works for Aging Independence services and manages the CCTP work in San Diego County key words CTI Coleman model care transitions San Diego County CMS readmissions quality improvement care enhancement Shining Stars Webinar June 27 to Learn from Leaders in Improving Care Transitions Posted by Janice Lynch Schuster on June 25 2013 No Responses Tagged with best practices care transitions CMS Medicare QIO webinar Jun 25 2013 Integrating Care for Populations Communities hosts a Learning Session Webinar on Thursday June 27 2013 at 3 00 pm ET This webinar is the twelfth presentation in the Learning Session series Shining Stars Across the Nation During the series entitled Shining Stars Across the Nation we hear from local communities that have been successful in improving healthcare through reducing hospital readmissions The webinars feature communities from different initiatives those communities that are lead by CMS Quality Improvement Organizations QIOs those that are part of Aligning Forces For Quality those that have received state funding Robert Wood Johnson awardees CCTP awardees Beacon communities ACOs and more These sessions are held on the 2nd and 4th Thursdays of the month The complete schedule is posted at http www cfmc org integratingcare learning sessions htm Call Information Shining Stars Banner Health in Phoenix AZ An Accountable Care Organization Presented by Linda Stutz RN MBA Care Coordination Senior Director Banner Health Tricia Nguyen MD MBA Chief Medical Officer Banner Health Teleconference 866 639 0744 No pass code needed https qualitynet webex com Meeting Password community Please join 15 minutes prior to the presentation to ensure the automatic system set up has been properly established Attendee Instructions 1 Click or Copy and Paste this to your web browser https qualitynet webex com 2 Locate the event you wish to join 3 Click on Join Now located to the right of the event title 4 Enter your name and email address as prompted 5 Enter the password community 6 Dial in to the teleconference The number is 866 639 0744 or 678 302 3564 The access code is none If you have any questions or problems accessing the meeting please call the Buccaneer WebEx Helpline at 540 347 7400 x390 Presentation slides will be posted prior to the call at http www cfmc org integratingcare learning sessions htm These calls are open to all please invite anyone who wants to learn along with us As a reminder these sessions are recorded and all previous Learning Sessions are available at http www cfmc org integratingcare learning sessions htm If you are not already receiving notifications about upcoming Learning Sessions you

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  • CMS – MediCaring.org
    services and CMS has allowed physicians to bill for these services now that there is a new awareness of the tasks of elderly persons living with disabilities and the conditions that come hand in hand with aging The codes begin to incentivize discussions with beneficiaries and families dealing with multiple chronic conditions and the codes recognize the need for awareness for the tasks of elderly persons living with disabilities and the conditions of aging The new codes cover at least some of the time that clinical staff needs to carry out the evaluations and discussions that are essential to better address the complex situations of the beneficiary population Incentivizing providers to coordinate care for beneficiaries living with chronic conditions is an important step for ensuring continuity and meeting personal goals of frail elders and their families We recognize that there can be many obstacles to practices for using these codes In the preliminary ruling CMS has acknowledged these obstacles and is soliciting comments about potential solutions Undoubtedly there will be ongoing improvements but first clinicians in various settings need this sort of help to take up the new codes and develop focus as to what else is needed We applaud the ongoing efforts by CMS to improve capture of the physician work and practice expense necessary to provide these important services Likewise it is also encouraging that CMS has acknowledged a need for refinements in these services to remedy the slow uptake in their use by providers In their July 15 2015 Proposed Rule https www federalregister gov articles 2015 07 15 2015 16875 medicare program revisions to payment policies under the physician fee schedule and other revisions they explicitly asked for comments from stakeholders and their response to these comments will be available in the MPFS Final Rule which will be available in November 2015 Please follow the MediCaring link to download the spreadsheet http medicaring org wp content uploads 2015 10 altarum cpt spreadsheet oct2015 xlsx Please do let us know how you found it useful and any improvements you would recommend Contact us at email protected Don t Accept Medical Errors as the Standard of Care for Frail Elders Posted by Elizabeth Rolf on September 28 2015 1 Response Tagged with advance care planning aging caregivers CMS dementia Elizabeth Eckstrom errors frail elders Marcy Cottrell Houle nursing homes quality improvement The Gift of Caring Sep 28 2015 By Joanne Lynn MD If you are hoping for a good night s sleep don t read the stories told by Marcy Cottrell Houle of her parents last years of life just before you go to bed But do read The Gift of Caring Saving Our Parents from the Perils of Modern Healthcare http www thegiftofcaring net which Houle wrote with geriatrician Elizabeth Eckstrom over a cup of coffee That will get you fired up The litany of catastrophes that occur in our poorly organized medical care system preventable avoidable suffering is overwhelming So far though no one is listening No one is reacting in horror and no one is changing the system to stop these errors We need to turn up the volume of our protests Marcy s father was once abruptly discharged from the hospital to a nursing home that lost him The nursing home put him in a room at the end of a hall and simply forgot he was there No hygiene no food nothing was provided for him In fact the staff forgot to give him water for so long that he developed renal failure He was later drugged to manage his behavior which was eventually traced to pain readily treated with acetaminophen His case spiraled on and on Marcy s mother had all the geriatric complications delirium falls anti coagulation terrible aides Worse still were her run ins with physicians who wouldn t pause to make sense of sudden changes in mental status because they just assigned every dysfunction to old age and dementia even when her mother had been functioning quite well just a day before Yes it s all there terrible and terrifying Dr Eckstrom writes a chapter after every calamity about how patients and families might prevent or cope better The book is a rare gem to help people who must navigate our care system for frail older people But it is maddening If you bought a toy that fell apart in a dangerous way you could report it to the U S Consumer Product Safety Commission and they d investigate If a person has a near miss from a safety defect in a car the National Highway Traffic Safety Administration wants to hear about it immediately If a medication causes a serious side effect the Food and Drug Administration has a consumer online reporting form Indeed any of these and more pop up when I search online But just try reporting that your dad was lost in a nursing home You have to be knowledgeable enough to find the ombudsman program or the Quality Improvement Network or know a lawyer willing to threaten to sue in order to call attention to a grave mistake The problems in care of the elderly are not just errors in the usual sense of unusual mistakes In fact they are baked right into our current delivery system The errors are not just a nurse or aide slipping up on some critical step Instead all the nurses and aides and everyone else are working in a system that is so dysfunctional that actions that cause pain or neglect are not even called out as errors Consider that I can go up to an ATM in the remote wilderness somewhere in the world and the banking system will know whether I have money in my account but if I am discharged from the hospital my community physician won t know anything about what happened to me in the hospital often even if she s been my physician for years and I told the hospital folks this Think about the profound errors that are made when medical professionals simply have no idea what matters to patients and their loved ones They never ask For example consider two men living with the same advanced degree of disability from Parkinson s disease One might want to spend anything and do whatever is necessary in order to survive long enough to finish a personal project while the other might really want not to leave his spouse impoverished The second man might feel at peace with the fact that life is coming to its end and even to feel OK with letting it end a bit early in order to have things fall into place for those he loves Today emergency room staff do not know any of this because of the way in which we have put this system together Both these men experiencing a sudden deterioration however would have to use the emergency room because we don t have 24 7 on call physicians organized to come to their homes We don t even have home delivered meals for many elderly persons in need in most of the country the waiting lists are routinely more than 6 months long because we have not chosen to fund the Older Americans Act adequately What are we doing And how can we complain effectively Each family somehow believes that its situation is bad luck or how things are There is no benchmark by which to set expectations so the families accept the errors dysfunctions suffering and impoverishment that so often come with disabilities in old age Why are the errors of our system not being debated or even mentioned in political campaigns How can we change this We can start by changing our abysmal expectations of the services that we get Let s question why the care system is so deaf to the priorities of our loved ones everywhere we can in the newspapers in the candidate debates through social media Let s reengineer current services build highly reliable care systems in our communities and see what it really costs Projections for the costs of a community anchored care system that is person centered and flexible enough to bring most services into the home are not much different from current care arrangements Let s record stories good and bad Let s figure out how family caregivers can become politically powerful Why is it for example that Medicare has no standing advisory committee speaking for the interests of its millions of beneficiaries If we are lucky we will grow old So it s our future too not just our parents We ve started an initiative to get family caregiver issues on the party platforms in all states that generate party platforms You can join the Family Caregiver Platform Project initiative It takes very little time and gets leaders talking Go to http caregivercorps org to sign up now There are some bright spots on which we can build The Centers for Medicare Medicaid Services has introduced payment for advanced care planning discussions between Medicare beneficiaries and their physicians We agree that this is a good idea and strongly support it But care planning is not just an end of life matter it needs to be comprehensive and a standard practice All health care providers and social services agencies should pursue the goals that the elder and family actually most want We invite you to read our MediCaring blog for more of our comments on this proposal http medicaring org 2015 08 25 comments on payment for advance care planning What else can you think of We need other leverage points that would focus the pent up frustration of millions of family members who have already witnessed the misery of ordinary elder care What should have been available to Marcy as she helped her parents live their last years Hers is a story that we can all absorb and tell others then we can go out and insist that our care system change Eventually Marcy and her family found some exceptional paid caregivers and together they achieved some good experiences even triumphs But this came after needless suffering She would say that she s lucky and others would say that she s especially skilled and capable Most of us need a care system that does not require exceptionally skilled and capable family members or good luck Read her book and help us push for a care system that works reliably for our old age Comments on the Comprehensive Care for Joint Replacement Payment Model Posted by Elizabeth Rolf on August 24 2015 1 Response Tagged with CMS frail elders payment model public policy Aug 24 2015 By Joanne Lynn MD CMS has issued a proposal to require all hospitals in 75 designated metropolitan areas to take on the responsibility for the related costs of hip or knee replacement surgery and 90 days after discharge from the hospital With increasing levels of responsibility the hospitals come to be at risk for refunding money to Medicare if costs are too high and also have the potential for earning part of the savings if costs decline and quality is maintained There will be major complications from this proposal including questions as to whether CMS has the authority to proceed However our comments are focused upon the implementation if the plan proceeds Many of the patients will have non elective procedures due to fractures into the hip joint but the proposal does not deal with the complications of having frail elderly people in the cohort Care planning accountability for long term care needs engagement of the family caregivers and more meaningful evaluation of quality should be required A longer description of these issues and a link to our draft comments is given below The deadline for comments is September 8 2015 The link to a PDF file of our draft comments can be found here CECAI Comments on CCJR Payment Model Identifying Communities with Potential for Pioneering MediCaring Suggest Yours Posted by Elizabeth Rolf on April 17 2015 5 Responses Tagged with caregiving CMS communities Medicare Medicaring Apr 17 2015 By Joanne Lynn The time has come to seek Medicare s cooperation so MediCaring Community programs can get underway in many parts of the country These programs are as necessary to an aging society as pediatrics and obstetrics are for children and maternal care Empowering communities to take care of their own residents who aim to age in place and eventually live with frailty is a challenge we can meet without impoverishing younger people or stalling the economy But it will take some action now Can you and your community be among the pioneers The core ideas are simple and well proven Now is the time to pull them together into a workable and affordable system of care First we have to be willing to acknowledge that becoming old and frail two or more limitations in Activities of Daily Living presence of cognitive impairment or those older than 85 is now an expectable part of life for most Americans When this period arrives we usually need a more supportive and adaptable care system The arrangements we have now for health care and supportive services are frustrating wasteful and a serious misfit for providing the comfort meaningfulness personalization and reliability that are so greatly desired at that point in our lives Critically important we become more and more individual as we grow old each of us has a unique set of relationships values resources aspirations and fears as well as a particular medical situation This demands that frail elderly people have a thoughtful care plan for the services needed across time one that fits their individual preferences and priorities Medical care for frail elderly Medicare beneficiaries also needs to fit their situation Screening to prevent illnesses that are unlikely to become a serious problem for a decade or more is a good example of low value care that should be avoided while preventing falls and delirium assumes a very high priority Going to the hospital may sometimes be essential however for frail elders this entails much more risk e g infections and falls than it did earlier in life so hospitalization decisions need to be carefully considered More medical services should be provided in the person s home once it becomes very difficult and disorienting to go to a doctor s office or clinic Here s another key point For the mainly homebound frail elderly Medicare population supportive services are critically important to daily well being and must be readily available and reliable Some frail elders need food delivered or housing adaptations Others need ongoing personal care or supervision The great majority hopes to stay in their homes and not have to move to institutions and most want to keep up relationships with neighbors family religious groups and others Family caregivers of the future will be both less available and will face more substantial challenges than in the past and we need to support them Scores of improved practices are known to achieve better care but to date all have been small projects hard to sustain and difficult to scale up and spread The current funding rules in the United States encourage overuse of medical care while providing scant supportive services and almost no tools for communities to evaluate local needs and priorities It is bizarre that any physician can write a prescription for a drug costing 100 000 that has been found to be only a little helpful for only a few potential patients but neither the doctor nor anyone else can order up a substitute caregiver when the spouse is ill or find a way to get food delivered when there is a long waiting list for Meals on Wheels Most families and elderly people find this strange as well once they experience the situation But most people are only gradually realizing that this sort of distortion is a direct result of policy choices and that we could choose differently MediCaring Communities is a way to choose differently Here s how Each community would develop a way to reflect the voice for its frail elders which we ll call a Community Board though it could have a number of names and organizational features The important thing is that it would help guide providers in the local system toward achieving and maintaining high value care For example the Community Board would work with health care public health and social services providers to monitor performance metrics that reflect the priorities of frail elders in the area including the preferences of individuals and help decide on priorities for investments and improvements Where would funding for investment and system management come from The funding would come from savings arising from much improved coordinated services that are adapted appropriately for the population of frail elderly Medicare beneficiaries follow their preferences and adhere to the principles of geriatrics and that reduce overutilized low value services in Medicare The potential for savings varies but an average of about 30 is plausible for almost any MediCaring Community program Even saving 10 would enhance the ability of communities to make supportive services that are needed by elders and which are the mainstay of long term care much more available A program could be built on a managed care platform or on an Accountable Care Organization arrangement but either strategy will require partnering with the Centers for Medicare and Medicaid Services CMS That s where your help is needed The time has come to ask CMS to take up the challenge of working with willing applicants starting by opening the door to allow pioneer MediCaring Community programs to move ahead CMS will need to adjust certain regulations and allow for more flexibility in operations to allow savings to be reinvested in long term care and support services and to enhance operational efficiency in the programs Here s what we have found likely to be important in the first set of communities enabling them to lead in building reliable sustainable services for frail elders in the MediCaring Communities model A history of cooperation in the public interest Implementation of some improvements already in frail elder care such as some experience with models like PACE GRACE INTERACT local support of nutrition and transportation services age friendly environments or similar models and programs Leaders who are concerned about the future effects of increases in the numbers of persons needing daily help in old age Enough frail elders to field a convincing project but still small enough to be able to make improvements quickly perhaps 500 10 000 is a reasonable range and frail elders are about one tenth of all persons older than 65 Reasonably self contained area with boundaries that are well known that is the health care and supportive services to people who live in the area are generally provided by services anchored in the area There will be other considerations but none are as important as commitment and leadership We invite you to think on it and talk it over with others and if building the elder care system of the future is plausible and appealing in your community city or county please let us know We are planning some webinars and perhaps some meetings to spell out details answer questions and shape up our request before we head to CMS and Congress to get approval for leadership communities to get underway Serving a far larger population of elders is a solvable problem it is only made difficult by protocols and regulations that were developed for a different younger demographic reality Let s modernize our care system for our old age and create a trustworthy set of arrangements that generate pride instead of waste and frustration Send us an email today What do you think Can you help to make this happen Write to us at email protected if you can see a good opportunity in a community that you know Also encourage support from the leadership of professional and advocacy organizations political leaders and CMS Let us know if you are doing this and what progress you are making If you contact us we ll be in touch and will aim to include your community in the list of potential pioneer communities to help persuade CMS to let us proceed Purchasing Value Not Yet Right for Medicare s Frail Elders Posted by Elizabeth Rolf on February 25 2015 1 Response Tagged with advanced care plans care plans CMS elder care eldercare measurement Medicare metrics patient goals preferences quality improvement Feb 25 2015 By Joanne Lynn In late January Department of Health and Human Services Secretary Sylvia Matthews Burwell announced that Medicare would purchase most services on the basis of value rather than volume aiming for 90 of fee for service payments by 2018 http www hhs gov blog 2015 01 26 progress towards better care smarter spending healthier people html Of course paying on the basis of value is much better than paying on the basis of volume But a moment s reflection shows that this strategy requires figuring out what people value For a child with a broken arm or a middle aged woman with a gall bladder attack desirable outcomes are obvious widely agreed upon and readily measured But this is just not the case for frail elders Consider a new heart attack affecting a 94 year old living with multiple chronic conditions self care disability and a lifetime of experiences and relationships Different 94 year olds will value very different things when it comes to treatment characteristics and quality of life goals for example some will desperately want not to go to the hospital even if doing so would likely extend their lives and others will welcome hospitalization with intensive care and every opportunity to get back to the way things were Even well established quality metrics that are important to elder care including avoiding delirium or the degree to which the person s symptoms are addressed are not yet used by Medicare and the program has done little to develop ways to identify excellent care for frail elders Rates of certain calamities and medical errors are currently measured but elderly persons and their families expect that more will be monitored than mere safety When we are old and frail and facing death we need the quality of our care to be measured by whether it offers an opportunity to attend to important relationships live comfortably and pursue what matters most to each of us Generic measures that reflect what someone else values won t suffice Consider first what Medicare has set up as measures for this population A starkly disturbing insight arises in the list of measures under consideration for implementing the Improving Medicare Post Acute Care Transformation IMPACT Act that are meant to measure outcomes and quality in after hospital care List of Ad Hoc Measures under Consideration for the Improving Medicare Post Acute Care Transformation IMPACT Act of 2014 http www qualityforum org WorkArea linkit aspx LinkIdentifier id ItemID 78784 Given the short timeline the Centers for Medicare and Medicaid Services CMS has proposed measures that have already been approved or that are in the process of approval CMS proposes four measures each applied in four care settings the rate of pressure ulcers the rate of falls with injury the existence of functional assessment and whether there is a care plan with a goal that involves function and readmissions But in setting out to talk with frail elderly people leaving the hospital for a short term stay in a nursing home before they go home what do we imagine are their highest priorities The four that Medicare proposes might make the list except that the way we measure readmissions is seriously deficient even with risk adjustment http medicaring org 2014 12 16 protecting hospitals http medicaring org 2014 12 08 lynn evidence But most people have other priorities that are equally or more important such as whether there is a workable plan to get the daily care and support needed e g housing modifications food transportation and personal care Another question elders often ask is what the effects of their disabilities on the family will be especially if family members have to provide more care Elders may also want to be sure that they will have the symptom pain control spiritual support and reliable supportive care that they will need as their conditions get worse whether they are in a care system that will maximally preserve their financial assets so that they have a lower risk of running out and whether they will have to move to a nursing home Medicare s metrics don t yet even try to address these concerns Even more troubling is the fact that Medicare does not yet have any methods to judge the match between the services given and the patient s perspective as to what matters Current metrics are all grounded in professional standards and professionals have been slow to build standards that truly take into account the very different things that individuals want in late life A high quality service delivery system must try to match the priority needs and preferences of each elder As Medicare moves toward paying its providers on the basis of value it is important to keep in mind what you value is often not what I value and this difference becomes more pronounced as we have to live with physical and financial limitations and the increasing proximity of death Here are some steps that we can take We should demand that Medicare invest in developing measures that matter for the frail phase of life before distorting the delivery system with incentives applying to everyone e g to avoid pressure ulcers falls and readmissions and to have and achieve goals concerning function CMS should be willing to be the measures steward or should fund another entity to do so since the money available for frail elder care does not spin off strong organizations that can do the developmental work and then maintain updated measures Our health information systems e g in Meaningful Use Stage 3 should at least start making room in medical records to document each patient s priorities and the care plan that is supposed to reflect those priorities Buying on value is the right idea but buying value for each elder requires knowing what each one values Initial CMS Evaluations of Readmissions Have Serious Flaws Posted by Les Morgan on January 26 2015 1 Response Tagged with CCTP CMS evaluation Partnership for Patients readmissions Jan 26 2015 by Joanne Lynn The Centers for Medicare and Medicaid Services CMS has quietly put out two evaluations of the readmissions work and both documents are remarkable for their failure to evaluate the programs fairly or to provide insights as to what works in what circumstances The Community Based Care Transitions Program CCTP pays community based organizations often Area Agencies on Aging to work with hospitals to improve transitions from hospital to home This first evaluation covering the 48 programs that started before 2012 http innovation cms gov Files reports CCTP AnnualRpt1 pdf found just four of them to have made statistically significant gains in reducing the ratio of readmissions to discharges from the participating hospitals The readmissions discharges metric that CMS and its evaluators use for categorizing success or failure is seriously flawed CMS has known this for a long time In 2009 that metric had to be changed during the Quality Improvement Organization QIO work in 14 communities because the numerator and denominator were declining together http jama jamanetwork com article aspx articleid 1558278 resultClick 3 We recently published a review of the conceptual issues http medicaring org 2014 12 16 protecting hospitals and a data driven example of the problem http medicaring org 2014 12 08 lynn evidence There is no easy switch to population based metrics in programs that were never set up to be population based Indeed much of the problem with the measures probably has roots in national leadership still conceptualizing the transitions work as being dominantly the responsibility of hospitals and their staffs while people living with serious chronic conditions need a more comprehensive community anchored population based approach Even so responsible evaluation would require at the very least a close examination of actual numerators and denominators in order to interpret the simplistic and routinely misleading ratio There are bound to be terrific success stories in the sites that did not win according to the malfunctioning readmissions discharges metric Some sites probably had reduced their denominator hospital discharges at the same rate or higher than they reduced 30 day readmissions The four sites that the CMS report considered successes might well have included some sites where a shift in the local market increased their hospital utilization with lower risk patients Moreover the 30 day limit on tallying readmissions does not mark a magical divide Nearly everything that works to help in the first 30 days will continue to have a positive effect for much longer and better support arrangements and care planning in the community will end up reducing index admissions This CCTP evaluation also observed the speed of start up and the success of efforts to achieve targeted enrollment both interesting and potentially important process components of success though neither is actually essential A delay in starting might be imposed by contracting issues business associate agreements software development or any of an array of challenges that do not affect long term success And the proposed target enrollment figures are much less important than whether the sites targeted enough high risk patients who had opportunities to reduce risk and enrolled enough of those patients to demonstrate a difference Of course the most important issue is whether the CCTP program is helping to improve transitions and keeping people who are living with fragile health in a more stable condition while living in the community thereby reducing hospitalization It would be easy for the evaluation to show that the supplemental services are desirable Evaluators could test whether enrolled patients had many fewer medication errors many more patients and families confident in their self care many more social services in place and much more medical support in the community However the current evaluation does not address these points Consider that the CCTP program pays per person served In a very important sense then the program is a winner if it reduces hospital utilization enough to cover the program s costs For example if one program reduces hospital utilization by 1 000 hospitalizations per year in an area where Medicare s average hospitalization cost is 15 000 then it saves 15 000 000 per year CMS pays community based organizations a modest fee around 300 per intervention patient The CCTP program would have to be serving 30 people to prevent one readmission in order to break even Clearly the ratio is likely to be more like 10 or 15 people to save one readmission and get a return on investment of 2 1 This suggests that the return on investment with even modest success is wildly favorable and would be so at virtually any revised estimate of cost and effectiveness which an evaluation could provide So why does the evaluation not address these central issues Further there is no reason why a 20 reduction in the now thoroughly discredited readmissions discharges ratio is the best target A more informative target would clearly focus on providing a reliable well characterized set of services that work to the advantage of patients and families and that also reduces total costs The CCTP program and other efforts to improve care transitions have already met that criterion so the question now needs to be What are the next prudent steps for health care managers and policymakers To answer that question it makes sense to look to the other recently released evaluation of readmissions work developed for the Partnership for Patients http innovation cms gov Files reports PFPEvalProgRpt pdf This report claims that readmissions reductions may have saved Medicare 2 8 billion out of 3 1 billion saved by all of the hospital acquired conditions reductions Table 3 in the report but this presentation only attributes improvement to the Partnership for Patients PfP and its Hospital Engagement Networks HENs The CCTP the hospital penalties under the Hospital Readmissions Reduction Program and the QIO s extensive work in supporting community efforts are not mentioned let alone cited as possible parts of the causal chain The metrics supporting the claim of gains pages 3 2 and 3 3 are similarly inconsistent One figure uses 30 day readmissions discharges in Medicare one uses the QIOs readmissions 1 000 beneficiaries per quarter but does not report any statistical tests and one uses the hospital reported 30 day all cause all payer readmissions discharges The report aims to have the reader believe that the PfP and the HENS generated a number of positive results including saving money On closer inspection however it becomes clear that the authors are counting the reductions in admissions as well as the reductions in readmissions in estimating the savings a tacit admission that at least some people at CMS recognize that good practices in transitions and in longer term community support reduce both the numerator and the denominator in the readmissions discharges metric There are other evaluations to come with some presumably already in the works Many site visits have been made and much data are available Let s hope that the next round of evaluation reports starts to answer serious policy questions about how to proceed Now that we have come this far what combinations of services should become standard and expected by beneficiaries and family caregivers and which ones tend to be useful only in particular settings Which specific interventions should be used for targeted patients and which should become part of the ordinary operations of high quality health care delivery What have we learned about care planning interoperability feedback loops community action and useful measures Recently the Patient Centered Outcomes Research Institute PCORI has announced a multi million dollar multiyear contract focusing on care transitions Maybe that work will start identifying better measures of quality care during transitions and leading to better support of people with fragile health in the community Perhaps that work and future evaluations could synthesize data and reports from a wide array of sites and efforts and provide guidance for future management and policy actions CMS and the Office of the National Coordinator for Health Information Technology ONC should be working toward better metrics based on information in electronic records and the IMPACT act http medicaring org 2014 10 28 impacts impact will generate better databases to work from But these first forays into evaluation of the readmissions work are quite disappointing There are contractors and participants who know much more and there are evaluation methods that would be much more revealing The work on care transitions has been a powerful catalyst toward more comprehensive care planning and service support for people living with fragile health It is time to push CMS and PCORI and any other funding agency contractor or grantee to do the work that informs managers and policymakers about what to do next given what we ve learned in the work so far Want to Know More Evaluation of the Community Based Care Transitions Program http innovation cms gov Files reports CCTP AnnualRpt1 pdf Project Evaluation Activity in Support of Partnership for Patients Task 2 Evaluation Progress Report http innovation cms gov Files reports PFPEvalProgRpt pdf For an essay by Stephen Jencks giving more of the context see http medicaring org 2014 12 16 protecting hospitals The Evidence That the Readmissions Rate Readmissions Hospital Discharges Is Malfunctioning as a Performance Measure http medicaring org 2014 12 08 lynn evidence Hartford Foundation blog Care Transitions Evaluation Is Premature and Confusing http www jhartfound

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    Based Care Transitions Program CCTP Awardee Learning Objectives Participants will Identify the structure and tactics used by the collaborative to drive readmission reduction in participating hospitals Trace the collaborative s efforts to develop a Patient Advisory Council Examine how to develop and deploy a successful relationship between a hospital and their SNFs to optimize care transitions Presented by Cheryl Reinking RN MS Interim Chief Nursing Officer El Camino Hospital Cheryl Reinking RN MS has served 25 years at El Camino Hospital in progressive nursing leadership roles her most recent being as Interim Chief Nursing Officer which she assumed in July 2013 Cheryl has led a number of hospital wide initiatives and was key to the hospital s implementation of the nationally recognized Nurses Improving Care for Healthsystem Elders NICHE program which was designed to create increased patient centric care for hospitalized older patients She developed the hospital s site specific program Pat Teske RN MHA Cynosure Health Pat Teske RN MHA is the implementation officer for Cynosure Health In her role she strives to implement the company s vision through strategic planning and execution of projects on time and within budget that yield successful outcomes Previously she held the position of vice president of Quality Improvement and Care Management for Catholic Healthcare West Pasadena CA where she lead the regions chief nursing officers quality directors case managers and medical staff directors to accomplish their annual goals As an independent contractor Pat supported BEACON the Bay Area Patient Safety Collaborative as well as other state and local collaboratives She is currently leading the Avoid Readmissions through Collaboration ARC effort in CA and working nationally with HRET on the Partnership for Patients HEN A requested public speaker at national state and local conferences including IHI NPSF and TJC Ms Teske has developed and offered numerous educational programs designed to support performance improvement and system reliability Pat received her MHA from the University of LaVern and her BS in Nursing from the University of Virginia Lisa Ehle MPH Program Manager Cynosure Health Lisa Ehle MPH is a Program Manager at Cynosure Health and currently oversees the Avoid Readmissions Through Collaboration ARC program and the ARC Patient Advisory Council Before joining Cynosure Health Lisa served as the State Director of Program Services with the March of Dimes Massachusetts Chapter where she co founded the MA Perinatal Quality Collaborative and directed a Program Services Committee charged with addressing the perinatal needs of the state She has been an advocate for maternal and child health issues including preterm birth prevention routine HIV screening smoking cessation and improving hospital discharge practices Lisa has worked at the state level for the MA Department for Public Health creating policies and guidelines for infectious disease prevention and screening programs Lisa received her Bachelor of Science in Physical and Psychiatric Rehabilitation Counseling from Boston University Sargent College and a Masters of Public Health from Boston University School of Public Health specializing in Social and Behavioral Sciences Event Care Transitions Learning Session webinar Date August 8 2013 Time 3 00 PM 4 00 PM ET Teleconference 866 639 0744 No pass code needed https qualitynet webex com Meeting Password community Please join us 15 minutes prior to the presentation to ensure the automatic system set up has been properly established Attendee Instructions 1 Click or Copy and Paste this to your web browser https qualitynet webex com 2 Locate the event you wish to join 3 Click on Join Now located to the right of the event title 4 Enter your name and email address as prompted 5 Enter the password community 6 Dial in to the teleconference The number is 866 639 0744 or 678 302 3564 The access code is none If you have any questions or problems accessing the meeting please call the Buccaneer WebEx Helpline at 540 347 7400 x390 Presentation slides will be posted prior to the call at http www cfmc org integratingcare learning sessions htm key words readmissions rehospitalizations care transitions quality improvement organizations CMS CFMC CCTP Success Will We Know It When We See It Posted by Janice Lynch Schuster on July 3 2013 No Responses Tagged with care transitions CCTP CMS Coleman Model community based frail elders hospital readmissions Medicare quality improvement rehospitalization Section 3026 Jul 03 2013 By Carol Castillon Defining success in work that focuses on people who are very sick can be a challenge The usual metrics just aren t always applicable With that in mind how will we know success in our community based care transitions work CCTP Like everyone else involved in this endeavor San Diego faces the challenge of reaching a 20 reduction in Medicare fee for service readmissions We are avidly monitoring our progress But is that really success To some extent of course it is and it would be fabulous to get there If and when we do though I think there would still be a void Perhaps I m naïve or perhaps I have what we lovingly call a social worker s heart but my definition of success is something a little different The only way to convey this is by telling the story of patient X A day after admitting patient X to a partnering hospital our Inpatient Transition Coach assessed the patient for meeting our high risk criteria That same day the patient was assigned to the Care Transitions Intervention CTI coach The coach saw the patient and enrolled him into CTI as well as into our Care Enhancement program which could address the need for social services Throughout the hospital stay the partnering hospital provided the patient with assistance in communicating his needs to his healthcare team From this interaction the team learned that the patient could not afford his medication co pays Based on hospital regulatory charity guidelines we were able to have that fee waived After 3 days in the hospital the patient was discharged and the CCTP clock began to tick When the patient opened his apartment door our coach found herself in an all too familiar situation She found that the apartment had been hit by what looked like a tornado involving the patient s medications The patient filled with nervousness and relief at seeing the coach who is a nurse blurted I need to call 911 I need to get to the ER Every CTI coach fears hearing this Staying calm our coach assessed the patient and found that he had been suffering from a headache since the day of discharge The patient did not have any pain medications or transportation to obtain such medications Using her charismatic charm the coach was able to coach the patient to call his physician and discuss these symptoms She then helped him to identify some key issues that were quite evident with his medications The visit lasted for about 2 hours but even with that much time the coach could not complete the four pillars of the CTI model Instead she worked with the patient to set follow up medical appointment with his physician and connected him with some of our Care Enhancement services Through Care Enhancement we were able to provide a taxi prescription to get the patient to his doctor s office The Care Enhancement social worker then worked miracles The social worker connected the patient with a home health program which the patient had declined at discharge She assisted the patient in obtaining transportation through our Metropolitan Transit System Access which assists people with disabilities The long term needs assessment found that the patient had shown symptoms of depression and so the social worker addressed this problem with the patient and physician The patient was connected with in home counseling aide and attendance through the VA and housing In terms of housing she helped the patient to move from his second floor apartment floor and limited his ability to go out the patient uses a scooter to a living environment better suited to his needs Now that s success Because of our team s work and focus the patient doing better This was a direct result of our collective interventions Patient x has ongoing support from a team that is committed to improving the lives of each and every patient we meet Right now we are at 80 days post discharge and no readmission Carol Castillon works for Aging Independence services and manages the CCTP work in San Diego County key words CTI Coleman model care transitions San Diego County CMS readmissions quality improvement care enhancement Solving a Puzzle Invoicing for Patient Encounters with the San Diego CCTP Posted by Janice Lynch Schuster on May 29 2013 No Responses Tagged with care transitions CCTP community based discharge planning frail elders hospital readmissions Medicare rehospitalization San Diego County May 29 2013 By Deborah Marquette It was the classic conundrum how do you fit a square peg into a round hole The County of San Diego is widely known for doing things a little differently and our model for providing community based care transitions project CCTP services is no different The San Diego Care Transitions Partnership SDCTP CCTP model includes the Care Transitions Intervention CTI However in addition to CTI the SDCTP model includes a variety of interventions that are completed prior to discharge e g High Risk Health Care Coach Inpatient Navigator Bridges and Pharmacy The model also includes additional post discharge interventions such as CTI Care Enhancement and non CTI follow up phone calls These additional interventions posed our first challenge for invoicing We quickly realized that the List Bill design CMS method for billing Medicare for CCTP wouldn t meet our internal needs for gathering monitoring and tracking invoice and intervention data For some of our interventions there is no clear mapping between our intervention and the List Bill s Care Transition Services For others the List Bill was too ambiguous For example if we select Telephone follow up as the Patient Encounter how will we know whether that patient received CTI or our non CTI follow up phone call intervention Hmm thoughtful pause we needed to find a way to meet the List Bill requirements while capturing the data in a way that would be meaningful for us as well That s how our Manual Invoicing Process was born I ll be completely honest this invoicing baby is less than attractive Alright it s downright ugly Picture this an Excel worksheet 41 columns long With no margins and at a scale of 75 the worksheet still prints out on six 6 legal size pages And that s just to capture the data we need for managing and tracking our List Bills It doesn t include the additional 32 columns that we use for capturing other data elements such as Reason for Non Enrollment or Reason for Withdrawal Now factor in the fact that at full capacity we ll be maintaining these data for 13 hospitals and roughly 21 000 patients year What fun the manual process will be then Like I said it isn t pretty But it does work and it seems to work well We may even be sad to see the manual process go not likely when it s replaced by our web based invoicing and data collection system ALEX I ll share more about ALEX in a later post The format of the List Bill led to our second invoicing challenge Considering our size there s no way we can manage all of our List Bills by entering them one by one using the List Bill template Aside from increasing the risk for data entry errors entering all of the List Bills manually would be a more than full time job for several people Since that isn t an option it was back to the drawing board Here we had some help Reaching out to our Project Officer and other CCTP sites we asked if anyone had successfully submitted a List Bill in a format other than the List Bill template Our call was answered by the Southwestern Ohio CCTP They had figured out the Excel formulas needed to convert data into the format s that would meet Gentran s requirements Gentran is the online application for submitting List Bills to CMS With a little tweaking we ve tailored those formulas and added a few of our own to convert the information collected on our Manual Invoicing worksheet With just a little copy and paste action of data and formulas we re now able to create a List Bill for all of our patients in 10 15 minutes It doesn t matter if we have 1 or 1 000 the timeframe is the same Around here we call that a success Ms Marquette is the Principal Administrative Analyst for the San Diego Care Transitions Partnership This is part of our regular series on San Diego s experiences launching its CCTP work Key words CCTP CMS Medicare care transitions quality improvement hospital readmissions frail elders San Diego County Shining Stars Webinar Highlights Care Transitions Work Posted by Janice Lynch Schuster on April 24 2013 No Responses Tagged with best practices care transitions CCTP CFMC CMS coalition building community based hospital readmissions QIO Apr 24 2013 Focused on improving care transitions A bimonthly webinar series called Shining Stars gives you a chance to hear from others working on the ground to do just the same Sponsored by The Colorado Foundation for Medical Care the next Integrating Care for Populations Communities Learning Session Webinar will air on Thursday April 25 2013 at 3 00 pm ET Participants have an opportunity to hear from local communities that have been successful in improving healthcare through reducing hospital readmissions The webinars feature communities from different initiatives those that are led by Quality Improvement Organizations QIOs as well as those that are part of Aligning Forces For Quality that have received state funding Robert Woods Johnson awardees CCTP awardees Beacon communities ACOs and more The sessions are held on the 2nd and 4th Thursdays of the month A full schedule is posted at http www cfmc org integratingcare learning sessions htm If you are interested in participating follow the steps below Call Information Shining Stars Healthy Columbia Campaign South Carolina ReThink Health Community funded by the Fannie E Ripple Foundation Presented by Kate Hilton JD MTS Director ReThink Health Richard Foster MD Senior Vice President for Quality Patient Safety South Carolina Hospital Association Event Care Transitions Learning Session webinar Date April 25 2013 Time 3 00 PM 4 00 PM ET Teleconference 866 639 0744 No pass code needed https qualitynet webex com Meeting Password community Please join us 15 minutes prior to the presentation to ensure the automatic system set up has been properly established Attendee Instructions 1 Click or Copy and Paste this to your web browser https qualitynet webex com 2 Locate the event you wish to join 3 Click on Join Now located to the right of the event title 4 Enter your name and email address as prompted 5 Enter the password community 6 Dial in to the teleconference The number is 866 639 0744 or 678 302 3564 The access code is none If you have any questions or problems accessing the meeting please call the Buccaneer WebEx Helpline at 540 347 7400 x390 Presentation slides will be posted prior to the call at http www cfmc org integratingcare learning sessions htm These calls are open to all please invite anyone who wants to learn along with us As a reminder these sessions are recorded and all previous Learning Sessions are available at http www cfmc org integratingcare learning sessions htm key words QIOs CFMC care transitions community coalition CCTP CMS Southeast Michigan CCTP Tests New Approaches to Reduce Readmissions Posted by Janice Lynch Schuster on April 23 2013 No Responses Tagged with care transitions CCTP coalition building Coleman Model community based discharge planning eldercare hospital readmissions Naylor Model rehospitalization Apr 23 2013 by Benjamin Kuder Every Community based Care Transitions Program CCTP in the country of which there are now 102 funded by the U S Centers for Medicare and Medicaid CMS aims to balance targeted evidence based interventions to patient needs CCTP teams know that every avoidable readmission has a story behind it The Area Agency on Aging 1 B AAA 1 B seeks to meet care transitions needs for elders in two of their counties Oakland and Macomb with an innovative multilayer strategy CMS directed communities applying to participate in the CCTP to conduct a root cause analysis so that they could build a CCTP that meets community needs The AAA 1 B found that it could deliver the highest priority services by dividing the population based on five clinical needs 1 Care Transitions Intervention CTI Coaching Following the self activation model developed by Dr Eric Coleman this strategy empowers participants with coaching that helps them find the strategies that enable the patient to take charge of recovery and achieve personal goals Through increased health literacy and greater confidence individuals with chronic conditions are better able to make decisions about their care and recovery and insist that clinicians provide appropriate help 2 CTI Coaching with Behavioral Intervention Many patients experience mental health issues such as depression anxiety and serious mental illnesses which contribute to frequent readmissions In this strategy a behavioral health coach works with patients to provide support and mitigate some of the problems that can hinder recovery 3 CTI Coaching with In Home Services This strategy provides coaching and referrals to in home services such as meal delivery or transportation to the doctor which help reduce risk of readmission 4 Coaching with Multiple Interventions Hospice Coaches connect with patients who have little family support and who do not want home care or hospice and try to reconnect them with supportive services and initiate longer term care planning 5 Skilled Nursing Facility SNF Transitions Coaching Skilled nursing facilities in the area had especially high readmission rates so

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  • discharge planning – MediCaring.org
    based organizations and hospitals can communicate more effectively about shared patients San Diego s Community based Care Transitions Project CCTP has opened a door for improving patient health improvement Over the past few months I have witnessed first hand the development of this crucial piece of the program In the San Diego CCTP anchored by Aging Independence Services a community based organization we offer two CCTP approved interventions the Care Transitions Intervention CTI and Care Enhancement Our partnership includes four health systems and 13 hospital campuses When I think of hospitals and medicine I think of answers Individuals seek attention from hospitals and physicians for answers as to why they are ill or why their bodies are not reacting as they should Clinicians and other professional caregivers witness health problems within the clinical environment or only hear about them from a patient or caregiver For those individuals who are in a high crisis mode accuracy can become a problem And often as soon as a patient is admitted to the hospital he or she patient expresses the desire to go home and in order to get home they will say or agree to just about anything clinicians recommend I know this from my own experience as someone who believes quite sincerely that there s no place like home At the same time patients and their loved ones often are unprepared for the functional decline that is often associated with a hospital admission often not fully appreciating how depleted they are until they actually get home To respond to this CCTP has engineered a merging of the hospital and home perspectives My organization AIS is a real partner in this process we have had the opportunity to collaborate closely with each hospital One of our approaches has been to participate in bi weekly internal meetings or huddles We use these meetings to debrief one another about patients smooth work flow processes review data to ensure that we are on target to meet performance targets present success stories and conduct a root cause analysis whenever a patient is readmitted These meetings are truly multidisciplinary and include all members of the partnership assigned to a particular hospital As we go around the table and discuss our pre and post discharge interventions we have found that our feedback circle is gaining a presence of its own The feedback circle enables us to bridge the clinical to home environment in ways we have not experienced before We are able to immediately feed information back to hospitals about successes accomplishments and challenges In some cases the feedback circle has even enabled hospitals to change internal processes The home assessments conducted by our CTI Coaches and Care Enhancement Social Workers are beginning to be incorporated into the patient s hospital medical records and even into primary care physician s records We ve had physicians contact our coaches to commend the CCTP team on a job well done One particular physician was amazed in how much a patient had changed and even commented You guys have done more for this patient with your interventions than I could ever do Such feedback is almost music to our ears Carol Castillon works with AIS to manage the San Diego CCTP key words CCTP care transitions evaluation feedback loops quality improvement community partnerships San Diego Solving a Puzzle Invoicing for Patient Encounters with the San Diego CCTP Posted by Janice Lynch Schuster on May 29 2013 No Responses Tagged with care transitions CCTP community based discharge planning frail elders hospital readmissions Medicare rehospitalization San Diego County May 29 2013 By Deborah Marquette It was the classic conundrum how do you fit a square peg into a round hole The County of San Diego is widely known for doing things a little differently and our model for providing community based care transitions project CCTP services is no different The San Diego Care Transitions Partnership SDCTP CCTP model includes the Care Transitions Intervention CTI However in addition to CTI the SDCTP model includes a variety of interventions that are completed prior to discharge e g High Risk Health Care Coach Inpatient Navigator Bridges and Pharmacy The model also includes additional post discharge interventions such as CTI Care Enhancement and non CTI follow up phone calls These additional interventions posed our first challenge for invoicing We quickly realized that the List Bill design CMS method for billing Medicare for CCTP wouldn t meet our internal needs for gathering monitoring and tracking invoice and intervention data For some of our interventions there is no clear mapping between our intervention and the List Bill s Care Transition Services For others the List Bill was too ambiguous For example if we select Telephone follow up as the Patient Encounter how will we know whether that patient received CTI or our non CTI follow up phone call intervention Hmm thoughtful pause we needed to find a way to meet the List Bill requirements while capturing the data in a way that would be meaningful for us as well That s how our Manual Invoicing Process was born I ll be completely honest this invoicing baby is less than attractive Alright it s downright ugly Picture this an Excel worksheet 41 columns long With no margins and at a scale of 75 the worksheet still prints out on six 6 legal size pages And that s just to capture the data we need for managing and tracking our List Bills It doesn t include the additional 32 columns that we use for capturing other data elements such as Reason for Non Enrollment or Reason for Withdrawal Now factor in the fact that at full capacity we ll be maintaining these data for 13 hospitals and roughly 21 000 patients year What fun the manual process will be then Like I said it isn t pretty But it does work and it seems to work well We may even be sad to see the manual process go not likely when it s replaced by our web based invoicing and data collection system ALEX I ll share more about ALEX in a later post The format of the List Bill led to our second invoicing challenge Considering our size there s no way we can manage all of our List Bills by entering them one by one using the List Bill template Aside from increasing the risk for data entry errors entering all of the List Bills manually would be a more than full time job for several people Since that isn t an option it was back to the drawing board Here we had some help Reaching out to our Project Officer and other CCTP sites we asked if anyone had successfully submitted a List Bill in a format other than the List Bill template Our call was answered by the Southwestern Ohio CCTP They had figured out the Excel formulas needed to convert data into the format s that would meet Gentran s requirements Gentran is the online application for submitting List Bills to CMS With a little tweaking we ve tailored those formulas and added a few of our own to convert the information collected on our Manual Invoicing worksheet With just a little copy and paste action of data and formulas we re now able to create a List Bill for all of our patients in 10 15 minutes It doesn t matter if we have 1 or 1 000 the timeframe is the same Around here we call that a success Ms Marquette is the Principal Administrative Analyst for the San Diego Care Transitions Partnership This is part of our regular series on San Diego s experiences launching its CCTP work Key words CCTP CMS Medicare care transitions quality improvement hospital readmissions frail elders San Diego County Southeast Michigan CCTP Tests New Approaches to Reduce Readmissions Posted by Janice Lynch Schuster on April 23 2013 No Responses Tagged with care transitions CCTP coalition building Coleman Model community based discharge planning eldercare hospital readmissions Naylor Model rehospitalization Apr 23 2013 by Benjamin Kuder Every Community based Care Transitions Program CCTP in the country of which there are now 102 funded by the U S Centers for Medicare and Medicaid CMS aims to balance targeted evidence based interventions to patient needs CCTP teams know that every avoidable readmission has a story behind it The Area Agency on Aging 1 B AAA 1 B seeks to meet care transitions needs for elders in two of their counties Oakland and Macomb with an innovative multilayer strategy CMS directed communities applying to participate in the CCTP to conduct a root cause analysis so that they could build a CCTP that meets community needs The AAA 1 B found that it could deliver the highest priority services by dividing the population based on five clinical needs 1 Care Transitions Intervention CTI Coaching Following the self activation model developed by Dr Eric Coleman this strategy empowers participants with coaching that helps them find the strategies that enable the patient to take charge of recovery and achieve personal goals Through increased health literacy and greater confidence individuals with chronic conditions are better able to make decisions about their care and recovery and insist that clinicians provide appropriate help 2 CTI Coaching with Behavioral Intervention Many patients experience mental health issues such as depression anxiety and serious mental illnesses which contribute to frequent readmissions In this strategy a behavioral health coach works with patients to provide support and mitigate some of the problems that can hinder recovery 3 CTI Coaching with In Home Services This strategy provides coaching and referrals to in home services such as meal delivery or transportation to the doctor which help reduce risk of readmission 4 Coaching with Multiple Interventions Hospice Coaches connect with patients who have little family support and who do not want home care or hospice and try to reconnect them with supportive services and initiate longer term care planning 5 Skilled Nursing Facility SNF Transitions Coaching Skilled nursing facilities in the area had especially high readmission rates so this strategy provides coaching for better transitions from the hospital to the SNF and from SNF to home Coaches meet with participants and their caregivers before hospital discharge again shortly after nursing home admission and then shortly before discharge from the SNF In addition the coach also discusses differences between the nursing home and hospital how to pursue personal goals and how to find help to achieve these goals at the nursing home The coach also works with the participant and caregiver to complete the personal health record modified for the SNF and encourages them to participate in the care plan meeting The coach also engages hospital and nursing facility partners to increase communication and improve shared processes Tailoring these strategies to the five distinctive categories of patients allows AAA 1 B to provide high value transitions coaching to virtually everyone Many of the coaches say people have been dealing with chronic conditions so long and no one has asked them their opinion on their plan of care says Barbra Link director of care transitions for AAA 1 B Coaches help them to get tools to self activate That s the most powerful thing That s the foundation of the program Participants in the program must be referred from AAA 1 B s partner hospitals have traditional Medicare and either have one of the targeted conditions chronic obstructive pulmonary disease heart attack pneumonia or congestive heart failure or any condition with a readmission within the last 90 days The AAA 1 B Care Transitions Coach assigns each beneficiary to a category using a risk assessment completed by the hospital s care management team The program also allows Strategy 1 Coaches to refer the participant to a Specialty Coach Strategy 2 Strategy 4 and Strategy 5 when appropriate All coaches provide Strategy 1 and Strategy 3 Coaching but may consult with Specialty Coaches whenever needed The AAA 1 B project is about 10 months into its initial two years with the possibility of renewal for the following three years All five strategies are operating and 650 beneficiaries have enrolled Although the first strategy has the highest volume of people 67 percent the other strategies are proving to be just as important for elders who need more support The CCTP team quickly recognized that project leaders and staff must watch for problems that call for different remedies For example when AAA 1 B leaders observed that many of the program s vulnerable elders did not understand their nutrition needs they reached out to a nutritionist at a partner hospital to develop simple accessible one page flyers for patients regarding nutrition One flyer explained how to cut back on dietary sodium and how to calculate sodium intake from a nutrition facts label Through close interactions with the patients coaches were able to identify and respond to specific nutritional problems that would not have otherwise been apparent In its CCTP AAA 1 B has a coalition with three local hospitals that had some of the highest readmissions rates in the state Creating these coalitions while ultimately quite beneficial did present some initial challenges Before implementing the program AAA 1 B leaders had to help all stakeholders understand the benefits of the program Once this had been done referrals from the hospitals took a major upswing According to Barbra Link We found that each hospital is unique and lots of relationship building was required Once we established greater trust and better understood the system things seemed to go well The future of this program involves moving toward a larger community based coalition with more community organizations Link explains We are trying to move into becoming a learning network Our focus will be information exchange and growing as a coalition Now that the program is up and running we can work on this over the next year AAA 1 B also collaborates with other CCTP organizations nationwide Through regional and national phone calls and virtual learning sessions they share best practices and solve problems together In this way AAA 1 B is spreading its innovative multilayer approach to reducing hospital readmissions and empowering patients This article originally ran on the Altarum Institute Health Policy Forum on April 18 2013 key words care transitions CCTP community based Area Agency on Aging Hear Dr Joanne Lynn Discuss Care Transitions Posted by Janice Lynch Schuster on April 2 2013 No Responses Tagged with care transitions CCTP coalition building discharge planning eldercare frail elders hospital readmissions Medicare patient activation rehospitalization Apr 02 2013 A Thursday webinar cosponsored by Illuminage com will feature Dr Joanne Lynn discussing care transitions Each year thousands of older patients are discharged from the hospital only to be later re admitted Avoiding preventable rehospitalizations has become a major cost savings goal for our health care system IlluminAge in partnership with the National Council on Aging has scheduled an online briefing to examine how older patients can play a larger role in the effort to reduce the frequency of hospital readmissions You are invited to join the webinar on Thursday April 4 beginning at 1 30 p m Eastern time Improving Care Transitions Engaging Older Patients on the Issue of Preventing Rehospitalization Joining us as presenter will be Joanne Lynn M D chair of the Center on Elder Care and Advanced Illness at the Altarum Institute Dr Lynn a geriatrician quality improvement advisor and policy advocate is a member of the Institute of Medicine and the National Academy of Social Insurance a fellow of the American Geriatrics Society and The Hastings Center and a master of the American College of Physicians The webinar aims to provide a fresh perspective on the increasingly important challenge of reducing hospital re admissions including The importance of educating and empowering older patients and caregivers The role senior care and aging service professionals can play in providing needed support services and other resources to older persons returning home following a hospital stay Resources you may find helpful in your own community practice or organization The April 4 webinar is free with registration on a first come first served basis To register follow this link https www1 gotomeeting com register 581843281 Key words Joanne Lynn care transitions quality improvement patient activation RARE Campaign Measuring Success One Pillow at a Time Posted by Janice Lynch Schuster on September 24 2012 No Responses Tagged with care transitions Coleman Model community based discharge planning frail elders hospital readmissions Sep 24 2012 The Minnesota wide RARE Reducing Avoidable Readmissions Effectively Campaign is tracking success one pillow at a time Its metric is whether or not a patient sleeps in his own bed with his own pillow The RARE website www rarereadmissions org tells the story A graphic shows individuals sleeping soundly Each face represents 250 prevented readmissions and 1 000 nights at home The RARE Campaign aims to prevent 4 000 avoidable hospital readmissions within 30 days of hospital discharge between July 1 2011 and December 31 2012 Achieving this goal would reduce Minnesota s overall hospital readmission rate by 20 as measured by the Minnesota Hospital Association s Potentially Preventable Readmissions PPR data All 82 hospitals participating in the RARE Campaign have signed on to each reduce their overall readmissions by 20 The campaign relies on three operating partners to organize collaboratives collect and analyze data and provide coaching to participating hospitals The Institute for Clinical Systems Improvement ICSI http www icsi org the Minnesota Hospital Association MHA http www mnhospitals org and Stratis Health which serves as the state s Medicare Quality Improvement Organization and can be found at http www stratishealth org index html manage operations A growing base of some 75 community partners including long term care home health professional associations and hospice are supporting the work Deb McKinley RARE communications manager for Stratis Health explains that the group began its planning process two years ago Each organization had been leading some

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  • hospital readmissions – MediCaring.org
    with hospital readmissions Medicare public policy quality improvement readmissions rehospitalization Dec 08 2014 By Joanne Lynn M D Also see companion post by Stephen F Jencks M D M P H Care transitions improvement programs have been effective in helping the health care system both become more effective in serving people living with serious chronic conditions and reduce costs However the key metric used to measure performance is seriously malfunctioning in at least some hospitals and communities leading to penalties and adverse publicity for providers and communities that are actually performing well and continuing to improve performance In this post we provide supporting data and a companion blog article provides a thoughtful discussion of the conceptual issues underlying this troubling malfunction For our earlier blog post about this problem see http medicaring org 2014 08 26 malfunctioning metrics Very simply this problem arises because the metric used is some variant of readmissions within 30 days divided by discharges from a particular hospital within a particular period Thus the usual metric is something like 20 of Medicare fee for service FFS hospitalizations are followed by a readmission within 30 days This metric works well if the denominator namely the number of hospitalizations is not affected by the improvements that reduce the risk of readmission If the denominator declines along with the numerator the metric will not reflect the degree of improvement that was actually achieved The data below show that this happens in real situations We are here showing the data from San Diego County a very large county with about 250 000 Medicare FFS beneficiaries who had about 60 000 Medicare FFS admissions to hospitals per year and about 10 000 readmissions per year in 2010 when almost all of the hospitals and the county s Aging Independence Services functioning as the Community based Care Transitions Program partner agency Area Agency on Aging Aging and Disability Resource Center started working together to improve care transitions and reduce readmissions under the San Diego Care Transitions Program one of the Community based Care Transitions Programs initiated by Section 3026 of the Patient Protection and Affordable Care Act The application year was 2012 and the start up year was 2013 The table below shows an initial summary of their results provided through their Quality Improvement Organization Exhibit 1 San Diego County Relative Improvement by Metric 30 day Readmissions Readmissions of county Medicare FFS residents fell by 15 in 2013 compared with 2010 San Diego County reduced hospitalizations by 11 However when the numerator and denominator go down at nearly the same rate the fraction moves just 4 3 which falls far short of the 20 reduction goal that Medicare has set What follows are the quarterly data from San Diego The first graph Exhibit 2 shows the quarterly rate of admissions per 1 000 Medicare FFS beneficiaries in San Diego County We have adjusted these data for the effects of seasons on admissions since there are usually more admissions in the winter The shaded portion shows the control limits an area which represents the expected range of variation demonstrated in the first 3 years of the data 2010 2012 Data that fall outside of the range or that consistently run on one side of the midline indicate that something has changed in how the system is functioning Clearly admissions are falling Exhibit 2 San Diego Seasonally Adjusted Admissions The second graph Exhibit 3 shows the readmissions rate in the same framework quarterly rate of readmissions per 1 000 Medicare FFS beneficiaries in San Diego County adjusted for seasonality The control limits again show change Readmissions are falling Exhibit 3 Seasonally Adjusted Readmissions The third graph Exhibit 4 shows the metric in the conventional form readmissions divided by discharges The graph does eventually show a decline but only a modest one The fact that the denominator was falling attenuated the impact of the falling number of readmissions Exhibit 4 Seasonally Adjusted Percent Discharges with 30 day Readmissions for San Diego County by quarter The next three exhibits show the comparison of the San Diego measures with the national rates for the same metrics Exhibit 5 shows that San Diego County is dramatically less likely to have Medicare FFS beneficiaries in the hospital than the nation as a whole 56 per 1 000 per quarter in San Diego compared with 69 per 1 000 per quarter nationwide Exhibit 6 shows that San Diego is also much lower in readmissions than the national average 10 per 1 000 per quarter in San Diego compared with 12 per 1 000 per quarter nationwide In both cases the declining use is reasonably parallel between San Diego and the nation This would imply that improvement strategies are still being effective at this lower range and thus the lower range is not yet a limit on improvement opportunities Exhibit 7 shows that San Diego County 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 22 senior alert Reducing Readmissions From the Experts Webinar Thursday August 8 3 pm ET Posted by Janice Lynch Schuster on August 7 2013 No Responses Tagged with best practices care transitions CCTP CMS community based discharge planning eldercare frail elders hospital readmissions Medicare quality improvement Aug 07 2013 As part of its ongoing series on reducing readmissions the Integrating Care for Communities project from the Colorado Foundation for Medical Care hosts a webinar on Thursday August 8 at 3 ET Details about the program can be found here with information provided by CFMC During this session we will hear from ARC Avoiding Readmissions through Collaboration California Community Based Care Transitions Program CCTP Awardee Learning Objectives Participants will Identify the structure and tactics used by the collaborative to drive readmission reduction in participating hospitals Trace the collaborative s efforts to develop a Patient Advisory Council Examine how to develop and deploy a successful relationship between a hospital and their SNFs to optimize care transitions Presented by Cheryl Reinking RN MS Interim Chief Nursing Officer El Camino Hospital Cheryl Reinking RN MS has served 25 years at El Camino Hospital in progressive nursing leadership roles her most recent being as Interim Chief Nursing Officer which she assumed in July 2013 Cheryl has led a number of hospital wide initiatives and was key to the hospital s implementation of the nationally recognized Nurses Improving Care for Healthsystem Elders NICHE program which was designed to create increased patient centric care for hospitalized older patients She developed the hospital s site specific program Pat Teske RN MHA Cynosure Health Pat Teske RN MHA is the implementation officer for Cynosure Health In her role she strives to implement the company s vision through strategic planning and execution of projects on time and within budget that yield successful outcomes Previously she held the position of vice president of Quality Improvement and Care Management for Catholic Healthcare West Pasadena CA where she lead the regions chief nursing officers quality directors case managers and medical staff directors to accomplish their annual goals As an independent contractor Pat supported BEACON the Bay Area Patient Safety Collaborative as well as other state and local collaboratives She is currently leading the Avoid Readmissions through Collaboration ARC effort in CA and working nationally with HRET on the Partnership for Patients HEN A requested public speaker at national state and local conferences including IHI NPSF and TJC Ms Teske has developed and offered numerous educational programs designed to support performance improvement and system reliability Pat received her MHA from the University of LaVern and her BS in Nursing from the University of Virginia Lisa Ehle MPH Program Manager Cynosure Health Lisa Ehle MPH is a Program Manager at Cynosure Health and currently oversees the Avoid Readmissions Through Collaboration ARC program and the ARC Patient Advisory Council Before joining Cynosure Health Lisa served as the State Director of Program Services with the March of Dimes Massachusetts Chapter where she co founded the MA Perinatal Quality Collaborative and directed a Program Services Committee charged with addressing the perinatal needs of the state She has been an advocate for maternal and child health issues including preterm birth prevention routine HIV screening smoking cessation and improving hospital discharge practices Lisa has worked at the state level for the MA Department for Public Health creating policies and guidelines for infectious disease prevention and screening programs Lisa received her Bachelor of Science in Physical and Psychiatric Rehabilitation Counseling from Boston University Sargent College and a Masters of Public Health from Boston University School of Public Health specializing in Social and Behavioral Sciences Event Care Transitions Learning Session webinar Date August 8 2013 Time 3 00 PM 4 00 PM ET Teleconference 866 639 0744 No pass code needed https qualitynet webex com Meeting Password community Please join us 15 minutes prior to the presentation to ensure the automatic system set up has been properly established Attendee Instructions 1 Click or Copy and Paste this to your web browser https qualitynet webex com 2 Locate the event you wish to join 3 Click on Join Now located to the right of the event title 4 Enter your name and email address as prompted 5 Enter the password community 6 Dial in to the teleconference The number is 866 639 0744 or 678 302 3564 The access code is none If you have any questions or problems accessing the meeting please call the Buccaneer WebEx Helpline at 540 347 7400 x390 Presentation slides will be posted prior to the call at http www cfmc org integratingcare learning sessions htm key words readmissions rehospitalizations care transitions quality improvement organizations CMS CFMC CCTP Success Will We Know It When We See It Posted by Janice Lynch Schuster on July 3 2013 No Responses Tagged with care transitions CCTP CMS Coleman Model community based frail elders hospital readmissions Medicare quality improvement rehospitalization Section 3026 Jul 03 2013 By Carol Castillon Defining success in work that focuses on people who are very sick can be a challenge The usual metrics just aren t always applicable With that in mind how will we know success in our community based care transitions work CCTP Like everyone else involved in this endeavor San Diego faces the challenge of reaching a 20 reduction in Medicare fee for service readmissions We are avidly monitoring our progress But is that really success To some extent of course it is and it would be fabulous to get there If and when we do though I think there would still be a void Perhaps I m naïve or perhaps I have what we lovingly call a social worker s heart but my definition of success is something a little different The only way to convey this is by telling the story of patient X A day after admitting patient X to a partnering hospital our Inpatient Transition Coach assessed the patient for meeting our high risk criteria That same day the patient was assigned to the Care Transitions Intervention CTI coach The coach saw the patient and enrolled him into CTI as well as into our Care Enhancement program which could address the need for social services Throughout the hospital stay the partnering hospital provided the patient with assistance in communicating his needs to his healthcare team From this interaction the team learned that the patient could not afford his medication co pays Based on hospital regulatory charity guidelines we were able to have that fee waived After 3 days in the hospital the patient was discharged and the CCTP clock began to tick When the patient opened his apartment door our coach found herself in an all too familiar situation She found that the apartment had been hit by what looked like a tornado involving the patient s medications The patient filled with nervousness and relief at seeing the coach who is a nurse blurted I need to call 911 I need to get to the ER Every CTI coach fears hearing this Staying calm our coach assessed the patient and found that he had been suffering from a headache since the day of discharge The patient did not have any pain medications or transportation to obtain such medications Using her charismatic charm the coach was able to coach the patient to call his physician and discuss these symptoms She then helped him to identify some key issues that were quite evident with his medications The visit lasted for about 2 hours but even with that much time the coach could not complete the four pillars of the CTI model Instead she worked with the patient to set follow up medical appointment with his physician and connected him with some of our Care Enhancement services Through Care Enhancement we were able to provide a taxi prescription to get the patient to his doctor s office The Care Enhancement social worker then worked miracles The social worker connected the patient with a home health program which the patient had declined at discharge She assisted the patient in obtaining transportation through our Metropolitan Transit System Access which assists people with disabilities The long term needs assessment found that the patient had shown symptoms of depression and so the social worker addressed this problem with the patient and physician The patient was connected with in home counseling aide and attendance through the VA and housing In terms of housing she helped the patient to move from his second floor apartment floor and limited his ability to go out the patient uses a scooter to a living environment better suited to his needs Now that s success Because of our team s work and focus the patient doing better This was a direct result of our collective interventions Patient x has ongoing support from a team that is committed to improving the lives of each and every patient we meet Right now we are at 80 days post discharge and no readmission Carol Castillon works for Aging Independence services and manages the CCTP work in San Diego County key words CTI Coleman model care transitions San Diego County CMS readmissions quality improvement care enhancement The Feedback Circle San Diego CCTP Listens to All Perspectives to Improve Care Transitions Posted by Janice Lynch Schuster on June 21 2013 No Responses Tagged with care transitions CCTP CMS coalition building community partnerships discharge planning hospital readmissions Medicare quality improvement rehospitalization San Diego Section 3026 Jun 21 2013 By Carol Castillon By developing a feedback loop so that community based organizations and hospitals can communicate more effectively about shared patients San Diego s Community based Care Transitions Project CCTP has opened a door for improving patient health improvement Over the past few months I have witnessed first hand the development of this crucial piece of the program In the San Diego CCTP anchored by Aging Independence Services a community based organization we offer two CCTP approved interventions the Care Transitions Intervention CTI and Care Enhancement Our partnership includes four health systems and 13 hospital campuses When I think of hospitals and medicine I think of

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  • From Hospital to Home: The Missing Element in Discharge Planning – MediCaring.org
    providers In the case of home health agencies for example discharge and transfer summaries must include demographic information contact information for the physician an advance directive if available the course of the illness treatment procedures diagnoses lab tests and other diagnostic testing consultation results a functional status assessment a psychosocial assessment including cognitive status social supports behavioral health issues reconciliation of discharge medications all known allergies immunizations smoking or nonsmoking status vital signs unique device identifiers for implantable devices recommendations for ongoing care patient goals and treatment preferences the current plan of care including goals instructions and the latest physician orders and any other information necessary to ensure a safe and effective transition of care that supports the post discharge goals for the patient In contrast there is a much shorter list for critical access hospitals to consider in the context of areas where the patient or caregiver support person s would need assistance It includes admitting diagnosis or reason for registration relevant co morbidities and past medical and surgical history anticipated ongoing care needs post discharge readmission risk relevant psychosocial history communication needs e g language barriers diminished eyesight and hearing patients access to non health care services and community based care providers and patients goals and preferences Yet another list of criteria pertains to discharge to home situations which requires instruction on post discharge care to be used by the patient or the caregiver support person written information on warning signs and symptoms prescriptions including the name indication dosage and significant risks and side effects medication reconciliation and written instructions for patient follow up care including appointments diagnostic tests and pertinent contact information Logically there should be a list of core elements that could also be the foundation for a common care plan and which could then be readily shared across providers working in different settings Requiring a list of core elements would simplify care coordination and basic communication between providers and decrease confusion and chaos for families who are often confronted suddenly with very difficult tasks when taking a seriously ill or disabled person home Perhaps the list of required elements outlined for home health agencies could be the basis for crafting standardized core elements for all covered health care providers along with a person s likely future course strengths treatment preferences and goals Concerning the critical role played by family caregivers the rule recognizes and acknowledges the importance of families in many places yet does not clearly establish the voluntary nature of this support In other words the primary consideration in discharge planning with regard to family caregivers should be to determine their willingness to provide services To address this we hope that CMS will consider requiring health care providers to engage in a conversation and subsequently document that a family caregiver has been asked about specific supports that he or she may need taking into account the family s economic resources The regulation features thoughtful discussion medication reconciliation and health information technology HIT For beneficiaries

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  • Moving a Medicare Reform Agenda for Frail Beneficiaries: Let’s Do It – MediCaring.org
    time to test such a straightforward approach is now before per capita Medicare reimbursements decline as they inevitably will with the rise in the numbers of eligible persons Developing such a model which we call MediCaring Communities might seem to be a daunting challenge at first glance But in fact it can be accomplished by motivated providers and community leaders by using existing financial and delivery structures such as Accountable Care Organizations and Programs of All inclusive Care for the Elderly Today millions of Medicare beneficiaries often experience recurring costly crises late in life that result in continued high cost overutilization of hospitals and premature long stay placement in nursing homes A principal reason for this is that the program offers no access to social services and supports needed by beneficiaries many of whom live with both chronic conditions and accompanying functional limitations Persons not yet poor enough for Medicaid often scrimp on services because they are expensive and unfamiliar ending up with complications that escalate their Medicare costs and accelerate their spending down to poverty and Medicaid coverage Medicaid which does offer such services though often not in an optimal and well organized way is available only to those who have spent their lifetime savings and agree to forfeit all but a few assets From a national policy and economic planning perspective this makes no sense In contrast investing modest sums today in anticipation of the full impact of the age wave 15 years from now in order to test and field APMs designed to offer medical care and social supports is a smart sensible investment that would do a great deal to help sensibly bend Medicare s cost curve It would also accelerate development of measures that are capable of tracking and evaluating a mix of health care and long term services and supports that could be included as part of public information websites MediCaring Community programs serving primarily frail beneficiaries in defined geographic areas could develop data dashboards to monitor local service availability thereby contributing to a planning infrastructure that aims to optimize the experience of the last years of life for everyone What does it take to live well in the last years of life Good medical care counts and Medicare could do more to improve it But there s more Elders want to be as comfortable and functional as possible It matters if you can take care of your feet and keep hearing eyesight and teeth as intact as possible Older adults want to be presentable just like everyone else Safety matters but for most people not at the cost of losing one s independence While people should feel the need to save for old age an elderly person should not have to become destitute before the community helps out with the basics of food housing hygiene social interactions and transportation Family help may be essential but no one wants to cripple their spouse or the next generation with years of being tied to continual

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  • Medicare – MediCaring.org
    to proceed Meanwhile a recent research brief prepared by the HHS Assistant Secretary for Planning and Evaluation Long Term Services and Supports for Older Americans Risks and Financing stated that about half 52 of Americans turning 65 today will develop a disability serious enough to require long term services and supports LTSS with about one in seven adults needing assistance for more than 5 years Americans turning 65 today will incur 138 000 in future LTSS costs about half of which families will pay out of pocket http aspe hhs gov daltcp reports 2015 ElderLTCrb cfm A final report will be issued under the auspices of the Sixth WHCOA later this year With the number of frail elderly Americans set to double over the next few decades much more needs to be done to meet the needs of our aging population Raise aging issues in the upcoming campaigns ask the politicians for their thoughts ideas and what concrete actions they would take if re elected If you want to present specific ideas and join a gradually building movement send friends and neighbors to the Family Caregiver Platform Project http caregivercorps org where they can find ways to take action and planks that they can suggest in local caucus meetings or in letters to state convention delegates Push officials to raise funding for local services and to support elders in their communities in other ways The time for congratulations and commemorations on past successes is nearly behind us it is now time for new action Just How Dysfunctional is Frail Elder Care in the U S Posted by Elizabeth Rolf on May 19 2015 No Responses Tagged with frail elders hospice Meals on Wheels Medicare older americans act May 19 2015 By Joanne Lynn Very very dysfunctional You need evidence Try these two tales First a remarkably illuminating piece of research was released on March 2 concerning the Meals on Wheels program http www mealsonwheelsamerica org docs default source News Assets mtam full report march 2 2015 pdf sfvrsn 6 The title was More than a Meal and it showed that people who got warm meals home delivered by volunteers 5 days per week did better in many ways than people who got frozen food delivered once a week and much better than those who were on a wait list for Meals on Wheels That finding was not surprising Our mothers could and did tell us enough to expect that finding though it is good to have it properly documented What is so profoundly dysfunctional is that there were eight U S cities participating that each had waiting lists for Meals on Wheels of more than 6 months That s right The program to provide food so that elderly people could stay at home live with dignity and count on a friendly face coming by on most days has a waiting list longer than many needy people s life spans What happens when cities build up 6 month waits for food Most on the waiting list can t shop most can t cook Some neighbors help out Some find enough money to get fast food Many get sick or dizzy and end up in the emergency room the hospital and then a nursing home All are hungry and none thrive The cost of home delivered meals for a year is less than just the ambulance trip to the emergency room The cost of one hospitalization would pay for a hundred people for a month Yet we are primed to provide the ambulance and the hospital but not lunch The funding for Older Americans Act services has increased less than 5 in a decade while the funding going to Medicare has doubled These priorities were not set by 88 year old women living alone in poverty but by much younger men scared of heart attacks and wanting assurance of rescue But wait there s another story This one is about my mother now in her 94th year She caught a cold which progressed to pneumonia and she was quickly in a precarious state The craziness started when her primary care physician making a home visit yes a home visit noted that my mother could not get a good broad spectrum antibiotic except by going to the emergency room because all pharmacies near her small county seat in western Pennsylvania were closed on Saturday night and all day Sunday Feeling like a participant in a modern day Iditarod I got the antibiotic and drove 4 hours to deliver it and it actually did the trick My mother turned the corner within 12 hours and was breathing much easier by Sunday afternoon But then she was very weak and severely dehydrated which causes nausea and therefore she required some way to accomplish hydration other than just by drinking fluids I asked about home health care getting her some intravenous fluids The answer That would take 48 hours to set up I asked whether I could buy or slip away with the fluids and an IV setup after all I m a physician That would break too many rules I stumbled onward asking what would happen if my mother were in hospice Miracle delivered In hospice she could have an IV at home that day Her primary care physician agreed that without something changing her prognosis fit the hospice requirements and having an IV could hardly count as curative medicine except of course that it did put her back into her usual state of health and then she left hospice care Now let s think about this The usual course would have been an ambulance to the hospital an emergency room visit and a hospitalization perhaps followed by a few days of skilled nursing facility care to get her back on her feet And that course assumes no serious complications like a fall or an infection Hospice cost about 1 10 as much But why did her doctor and I have to figure out an end run around the rules that seemed to connive to ensure that she would have to go to the hospital if not to get the antibiotic then to get the fluids This time the priorities were set by service providers seeking their convenience and perhaps their incomes not by 93 year old women very much wanting to live out their lives at home Most of us will be relatively healthy for most of our lives We will end up spending about half our lifetime health care costs in the last years of life when we are frail needing food delivered by a friendly volunteer needing that antibiotic to be available without going to the hospital and needing some IV fluids at home today not after a lot of paperwork gets done We ll need that remarkable primary care doctor who visits at home But I sure hope that not everyone needs a physician daughter who can find one more question to ask to evade the ruthlessness of a seriously dysfunctional system and we must all insist that no elderly person will ever need to wait 6 months without being able to count on food not now not ever not in the United States If you agree talk with your Congressional representatives today about reauthorizing the Older Americans Act and call on them to actually increase the funding to account for the increasing numbers and the current shortfalls Tell them to take Older Americans Act funding out of the pool that is at risk of sequestration Join us in pushing for some leadership communities to focus on building a care system constructed around the hopes and fears of frail elderly people themselves Join the campaign by writing to us at email protected See more at http altarum org health policy blog just how dysfunctional is frail elder care in the u s sthash wH8LQgsy dpuf Identifying Communities with Potential for Pioneering MediCaring Suggest Yours Posted by Elizabeth Rolf on April 17 2015 5 Responses Tagged with caregiving CMS communities Medicare Medicaring Apr 17 2015 By Joanne Lynn The time has come to seek Medicare s cooperation so MediCaring Community programs can get underway in many parts of the country These programs are as necessary to an aging society as pediatrics and obstetrics are for children and maternal care Empowering communities to take care of their own residents who aim to age in place and eventually live with frailty is a challenge we can meet without impoverishing younger people or stalling the economy But it will take some action now Can you and your community be among the pioneers The core ideas are simple and well proven Now is the time to pull them together into a workable and affordable system of care First we have to be willing to acknowledge that becoming old and frail two or more limitations in Activities of Daily Living presence of cognitive impairment or those older than 85 is now an expectable part of life for most Americans When this period arrives we usually need a more supportive and adaptable care system The arrangements we have now for health care and supportive services are frustrating wasteful and a serious misfit for providing the comfort meaningfulness personalization and reliability that are so greatly desired at that point in our lives Critically important we become more and more individual as we grow old each of us has a unique set of relationships values resources aspirations and fears as well as a particular medical situation This demands that frail elderly people have a thoughtful care plan for the services needed across time one that fits their individual preferences and priorities Medical care for frail elderly Medicare beneficiaries also needs to fit their situation Screening to prevent illnesses that are unlikely to become a serious problem for a decade or more is a good example of low value care that should be avoided while preventing falls and delirium assumes a very high priority Going to the hospital may sometimes be essential however for frail elders this entails much more risk e g infections and falls than it did earlier in life so hospitalization decisions need to be carefully considered More medical services should be provided in the person s home once it becomes very difficult and disorienting to go to a doctor s office or clinic Here s another key point For the mainly homebound frail elderly Medicare population supportive services are critically important to daily well being and must be readily available and reliable Some frail elders need food delivered or housing adaptations Others need ongoing personal care or supervision The great majority hopes to stay in their homes and not have to move to institutions and most want to keep up relationships with neighbors family religious groups and others Family caregivers of the future will be both less available and will face more substantial challenges than in the past and we need to support them Scores of improved practices are known to achieve better care but to date all have been small projects hard to sustain and difficult to scale up and spread The current funding rules in the United States encourage overuse of medical care while providing scant supportive services and almost no tools for communities to evaluate local needs and priorities It is bizarre that any physician can write a prescription for a drug costing 100 000 that has been found to be only a little helpful for only a few potential patients but neither the doctor nor anyone else can order up a substitute caregiver when the spouse is ill or find a way to get food delivered when there is a long waiting list for Meals on Wheels Most families and elderly people find this strange as well once they experience the situation But most people are only gradually realizing that this sort of distortion is a direct result of policy choices and that we could choose differently MediCaring Communities is a way to choose differently Here s how Each community would develop a way to reflect the voice for its frail elders which we ll call a Community Board though it could have a number of names and organizational features The important thing is that it would help guide providers in the local system toward achieving and maintaining high value care For example the Community Board would work with health care public health and social services providers to monitor performance metrics that reflect the priorities of frail elders in the area including the preferences of individuals and help decide on priorities for investments and improvements Where would funding for investment and system management come from The funding would come from savings arising from much improved coordinated services that are adapted appropriately for the population of frail elderly Medicare beneficiaries follow their preferences and adhere to the principles of geriatrics and that reduce overutilized low value services in Medicare The potential for savings varies but an average of about 30 is plausible for almost any MediCaring Community program Even saving 10 would enhance the ability of communities to make supportive services that are needed by elders and which are the mainstay of long term care much more available A program could be built on a managed care platform or on an Accountable Care Organization arrangement but either strategy will require partnering with the Centers for Medicare and Medicaid Services CMS That s where your help is needed The time has come to ask CMS to take up the challenge of working with willing applicants starting by opening the door to allow pioneer MediCaring Community programs to move ahead CMS will need to adjust certain regulations and allow for more flexibility in operations to allow savings to be reinvested in long term care and support services and to enhance operational efficiency in the programs Here s what we have found likely to be important in the first set of communities enabling them to lead in building reliable sustainable services for frail elders in the MediCaring Communities model A history of cooperation in the public interest Implementation of some improvements already in frail elder care such as some experience with models like PACE GRACE INTERACT local support of nutrition and transportation services age friendly environments or similar models and programs Leaders who are concerned about the future effects of increases in the numbers of persons needing daily help in old age Enough frail elders to field a convincing project but still small enough to be able to make improvements quickly perhaps 500 10 000 is a reasonable range and frail elders are about one tenth of all persons older than 65 Reasonably self contained area with boundaries that are well known that is the health care and supportive services to people who live in the area are generally provided by services anchored in the area There will be other considerations but none are as important as commitment and leadership We invite you to think on it and talk it over with others and if building the elder care system of the future is plausible and appealing in your community city or county please let us know We are planning some webinars and perhaps some meetings to spell out details answer questions and shape up our request before we head to CMS and Congress to get approval for leadership communities to get underway Serving a far larger population of elders is a solvable problem it is only made difficult by protocols and regulations that were developed for a different younger demographic reality Let s modernize our care system for our old age and create a trustworthy set of arrangements that generate pride instead of waste and frustration Send us an email today What do you think Can you help to make this happen Write to us at email protected if you can see a good opportunity in a community that you know Also encourage support from the leadership of professional and advocacy organizations political leaders and CMS Let us know if you are doing this and what progress you are making If you contact us we ll be in touch and will aim to include your community in the list of potential pioneer communities to help persuade CMS to let us proceed Purchasing Value Not Yet Right for Medicare s Frail Elders Posted by Elizabeth Rolf on February 25 2015 1 Response Tagged with advanced care plans care plans CMS elder care eldercare measurement Medicare metrics patient goals preferences quality improvement Feb 25 2015 By Joanne Lynn In late January Department of Health and Human Services Secretary Sylvia Matthews Burwell announced that Medicare would purchase most services on the basis of value rather than volume aiming for 90 of fee for service payments by 2018 http www hhs gov blog 2015 01 26 progress towards better care smarter spending healthier people html Of course paying on the basis of value is much better than paying on the basis of volume But a moment s reflection shows that this strategy requires figuring out what people value For a child with a broken arm or a middle aged woman with a gall bladder attack desirable outcomes are obvious widely agreed upon and readily measured But this is just not the case for frail elders Consider a new heart attack affecting a 94 year old living with multiple chronic conditions self care disability and a lifetime of experiences and relationships Different 94 year olds will value very different things when it comes to treatment characteristics and quality of life goals for example some will desperately want not to go to the hospital even if doing so would likely extend their lives and others will welcome hospitalization with intensive care and every opportunity to get back to the way things were Even well established quality metrics that are important to elder care including avoiding delirium or the degree to which the person s symptoms are addressed are not yet used by Medicare and the program has done little to develop ways to identify excellent care for frail elders Rates of certain calamities and medical errors are currently measured but elderly persons and their families expect that more will be monitored than mere safety When we are old and frail and facing death we need the quality of our care to be measured by whether it offers an opportunity to attend to important relationships live comfortably and pursue what matters most to each of us Generic measures that reflect what someone else values won t suffice Consider first what Medicare has set up as measures for this population A starkly disturbing insight arises in the list of measures under consideration for implementing the Improving Medicare Post Acute Care Transformation IMPACT Act that are meant to measure outcomes and quality in after hospital care List of Ad Hoc Measures under Consideration for the Improving Medicare Post Acute Care Transformation IMPACT Act of 2014 http www qualityforum org WorkArea linkit aspx LinkIdentifier id ItemID 78784 Given the short timeline the Centers for Medicare and Medicaid Services CMS has proposed measures that have already been approved or that are in the process of approval CMS proposes four measures each applied in four care settings the rate of pressure ulcers the rate of falls with injury the existence of functional assessment and whether there is a care plan with a goal that involves function and readmissions But in setting out to talk with frail elderly people leaving the hospital for a short term stay in a nursing home before they go home what do we imagine are their highest priorities The four that Medicare proposes might make the list except that the way we measure readmissions is seriously deficient even with risk adjustment http medicaring org 2014 12 16 protecting hospitals http medicaring org 2014 12 08 lynn evidence But most people have other priorities that are equally or more important such as whether there is a workable plan to get the daily care and support needed e g housing modifications food transportation and personal care Another question elders often ask is what the effects of their disabilities on the family will be especially if family members have to provide more care Elders may also want to be sure that they will have the symptom pain control spiritual support and reliable supportive care that they will need as their conditions get worse whether they are in a care system that will maximally preserve their financial assets so that they have a lower risk of running out and whether they will have to move to a nursing home Medicare s metrics don t yet even try to address these concerns Even more troubling is the fact that Medicare does not yet have any methods to judge the match between the services given and the patient s perspective as to what matters Current metrics are all grounded in professional standards and professionals have been slow to build standards that truly take into account the very different things that individuals want in late life A high quality service delivery system must try to match the priority needs and preferences of each elder As Medicare moves toward paying its providers on the basis of value it is important to keep in mind what you value is often not what I value and this difference becomes more pronounced as we have to live with physical and financial limitations and the increasing proximity of death Here are some steps that we can take We should demand that Medicare invest in developing measures that matter for the frail phase of life before distorting the delivery system with incentives applying to everyone e g to avoid pressure ulcers falls and readmissions and to have and achieve goals concerning function CMS should be willing to be the measures steward or should fund another entity to do so since the money available for frail elder care does not spin off strong organizations that can do the developmental work and then maintain updated measures Our health information systems e g in Meaningful Use Stage 3 should at least start making room in medical records to document each patient s priorities and the care plan that is supposed to reflect those priorities Buying on value is the right idea but buying value for each elder requires knowing what each one values Protecting Hospitals That Improve Population Health Posted by Les Morgan on December 16 2014 No Responses Tagged with best practices hospital readmissions Medicare Medicare Readmission Reduction Program MRRP public policy quality improvement readmissions rehospitalization Dec 16 2014 by Stephen F Jencks M D M P H Also see companion post by Joanne Lynn M D Issue The Medicare Readmission Reduction Program MRRP encourages hospitals to reduce readmissions within 30 days of discharge by imposing substantial financial penalties on hospitals with more readmissions than would be expected if the same patients were discharged from an average hospital 1 But some hospitals and communities have succeeded too well and reduced discharges even more than readmissions so that their readmission rates as currently calculated do not improve much which puts them at higher risk for penalties There are two underlying problems First there are two ways of thinking about and therefore measuring the rate of readmissions and they often lead to quite different results and quite different decisions on penalties One is discharge based the other population based The relationship between the two is simple Relationship between two formulas for measuring the rate of hospital readmissions Plain text equivalent of formula picture readmissions discharges X discharges beneficiary population 1 000s readmissions beneficiary population 1 000s Patients who are admitted but die during hospitalization or are transferred to another hospital are not counted as discharges from the first hospital Second effective interventions to reduce 30 day readmissions have an effect on admissions that extends far beyond 30 days after discharge and they reduce a lot of other admissions especially if implemented in partnership with community providers and services When Congress created the MRRP many stakeholders had become aware and dismayed that 20 of people enrolled in Medicare fee for service and discharged from a hospital were readmitted within 30 days of hospital discharge Clinical trials had shown that improved processes around hospital discharges could prevent many of these readmissions The aim of establishing accountability also made a hospital focus desirable In this view readmission is a burden resulting from poor hospital discharge processes whether clinically premature or poorly executed With that emphasis on discharge processes as cause and cure for readmissions it was natural for the Centers for Medicare Medicaid Services CMS to choose to estimate each hospital s expected readmissions as the number of patients whom the hospital discharged and who would be expected to be readmitted after discharge from an average hospital Most readmission reduction initiatives use this discharge based readmission rate to measure performance This discharge based perspective effectively defines the readmission rate as the percentage of discharges that are followed by a readmission In this way of thinking the number of hospital discharges is simply a fact of life much like the fact that a year has 365 24 days This view does not see that hospital actions might reduce the number of patients they discharge and this blind spot causes trouble Hospitals actually have a great deal of influence on how many patients they admit and discharge because so many of their discharges are admitted through their emergency department or by hospital affiliated physicians and because they can collaborate with community services and providers who can forestall patients even coming to the hospital Population based hospital discharge rates vary substantially across regions and they can change over time Some policy makers worried that the discharge based rate could behave in unexpected ways if hospitals took steps that reduced total discharges by more than the reduction in 30 day readmissions As a result several programs such as the Partnership for Patients and the Quality Improvement Organizations QIOs Care Transitions Program were designed using a population based readmission rate or converted to such a rate after evaluating early findings The population based rate is the number of readmissions for every 1 000 fee for service Medicare beneficiaries in the hospital s service area This view sees readmissions as a community health problem a burden on a population of beneficiaries and the Medicare trust funds that is associated with that population s use of hospitals just as hospital acquired infections are associated with use of hospitals From this perspective preventing hospitalizations improving discharge transitions and improving post discharge care are equally valid ways to reduce readmissions Whether the hospital reduced hospitalizations in order to reduce readmissions is less important than being sure that we do not penalize hospitals for taking such steps Population based rates are closely aligned with the three part aim of the National Quality Strategy individual care population health and affordability not only because they are population based but also because they reflect the close relationship between care in the community and a hospital s apparent performance Thus a program can reduce burdens on beneficiaries and Medicare through significant reductions in the population based discharge and readmission rates but see much smaller reductions in the discharge based readmission rate In a companion blog to this piece Joanne Lynn presents evidence that this attenuation of changes in discharge based rates has happened repeatedly in community based readmissions programs We do not know at this point whether attenuation of changes translate into financial penalties but it seems very likely to increase a hospital s risk We also do yet fully understand what specific changes produce these decreases in the population based discharge rate but the most parsimonious explanation is that the causes are pretty much the causes of reduced readmissions Provide urgent care with support for keeping the patient in the community and you are likely to reduce all admissions not just readmissions Enroll more patients in medical homes and the benefits will not disappear 30 days after hospital discharge Improve nursing home communications with emergency rooms and the benefits will not be limited to patients within 30 days after hospital discharge What we can foresee is that hospitals already wary of readmissions reduction because it directly reduces revenue will become doubly wary if they conclude that reducing discharges may also cause or increase the MRRP penalty If CMS is penalizing hospitals and communities for succeeding at improving care and reducing costs the reaction may threaten a very successful set of initiatives The examples we report are for community based efforts to reduce readmissions Hospital level calculations are generally beyond our capability CMS can however easily determine whether all else being equal penalties are more likely or larger in areas where the population based hospital discharge rate is declining substantially than elsewhere That information is urgently needed What to do The purpose of the MRRP is to reduce the burden of readmissions on Medicare beneficiaries and the Medicare trust funds so the important indicator of progress is the number of readmissions not the percentage of discharged patients that are readmitted Healthcare quality measurement needs to catch up with the National Quality Strategy and add measures of the impact of care on the health of the population that will complement measures of the quality of individual episodes of care such as hospitalizations In the case of readmission measurement for the MRRP this need is substantially more urgent because there is good reason to fear that a hospital that engages with its community and does exactly what the MRRP hopes for is more liable to financial penalties under the current discharge based measure than it would be under a population based measure The first step is to assess the degree of urgency by examining national evidence on actual penalties If unreasonable penalties are at all frequent then the problem is far more urgent This will be complex because Epstein has already shown in cross sectional studies that population based hospitalization rates and readmission rates are positively correlated 2 At the same time it will be important to develop population based measures of readmissions and compare their impact on penalties with the impact of discharge based measures The obstacles are bureaucratic technical and political Bureaucratically the most important obstacle has been a widespread belief that the Patient Protection and Affordable Care Act requires calculating discharge based rates In fact the Act says only that penalties are to be determined from the ratio of observed to expected numbers of readmissions and is silent on how the expected number is to be calculated The other bureaucratic problem is less tractable Under current procedures the steps laid out for implementing a new measure both at CMS and at the National Quality Forum NQF would likely take several years The process should be expedited if the analysis of current penalties indicates that hospitals are being penalized for success in reducing admissions The technical challenges of creating a population based readmission measure for hospitals are substantial First the procedure must find a way to measure each hospital s population based hospitalization rate Second a method of risk adjustment must be developed and applied so that population based readmission rates for each hospital and community can be compared Although these methods are still evolving adjustments for factors such as neighborhood deprivation 3 are actually easier at the population level These are difficult tasks but a first step good enough to improve on the existing model should be possible within a year Politically hospitals will be concerned about accountability for the community hospitalization rate They will recognize that if hospitals in areas with low hospitalization rates are protected then hospitals in areas with high hospitalization rates will be more vulnerable Some have hoped that traditional risk adjustment could solve this problem because the most likely scenario is that average risk of readmission increases as the number of discharges decreases That prospect is not promising because the most assiduous work on risk adjustment has produced tools of only moderate power The prospects for solving this problem with improved risk adjustment are not promising 4 5 When you find yourself in a hole you should stop digging It seems prudent for NQF to suspend endorsement of the pending discharge based readmission measures and for CMS to delay implementing discharge based measures if NQF endorses them until CMS has studied and reported the extent to which readmission penalties punish hospitals that are actually reducing both admissions and readmissions and has laid out an approach to any problems found Finally the problem identified here underlines the importance of placing a population based foundation under at least some measures of health care system performance Footnotes References 1 Centers for Medicare and Medicaid Services Readmission reduction program Retrieved from http www cms gov Medicare Medicare Fee for Service Payment AcuteInpatientPPS Readmissions Reduction Program html 2 Epstein A M Jha A K Orav J E 2011 December 15 The relationship between hospital admission rates and rehospitalizations New England Journal of Medicine 365 24 3 Kind A J H Jencks S Brock J Yu M Bartels C Ehlenbach W Smith M 2014 December 2 Neighborhood socioeconomic disadvantage and 30 day rehospitalization a retrospective cohort study Annals of Internal Medicine 161 11 765 775 4 Yale New Haven Health Services Corporation Center for Outcomes Research Evaluation 2014 July 2014 measure updates and specifications Hospital wide all cause unplanned readmission version 3 0 Retrieved from https staging qualitynet org dcs BlobServer blobkey id blobnocache true blobwhere 1228774408425 blobheader multipart 2Foctet stream blobheadername1 Content Disposition blobheadervalue1 attachment 3Bfilename 3DRdmsn Msr Updts HWR 0714 pdf blobcol urldata blobtable MungoBlobs 5 Kansagara D Englander H Salanitro A Kagen D Theobald C Freeman M Kripalani S 2011 October 19 Risk prediction models for hospital readmission A systematic review Journal of the American Medical Association 306 15 1688 1698 The Evidence That the Readmissions Rate Readmissions Hospital Discharges Is Malfunctioning as a Performance Measure Posted by Les Morgan on December 8 2014 3 Responses Tagged with hospital readmissions Medicare public policy quality improvement readmissions rehospitalization Dec 08 2014 By Joanne Lynn M D Also see companion post by Stephen F Jencks M D M P H Care transitions improvement programs have been effective in helping the health care system both become more effective in serving people living with serious chronic conditions and reduce costs However the key metric used to measure performance is seriously malfunctioning in at least some hospitals and communities leading to penalties and adverse publicity for providers and communities that are actually performing well and continuing to improve performance In this post we provide supporting data and a companion blog article provides a thoughtful discussion of the conceptual issues underlying this troubling malfunction For our earlier blog post about this problem see http medicaring org 2014 08 26 malfunctioning metrics Very simply this problem arises because the metric used is some variant of readmissions within 30 days divided by discharges from a particular hospital within a particular period Thus the usual metric is something like 20 of Medicare fee for service FFS hospitalizations are followed by a readmission within 30 days This metric works well if the denominator namely the number of hospitalizations is not affected by the improvements that reduce the risk of readmission If the denominator declines along with the numerator the metric will not reflect the degree of improvement that was actually achieved The data below show that this happens in real situations We are here showing the data from San Diego County a very large county with about 250 000 Medicare FFS beneficiaries who had about 60 000 Medicare FFS admissions to hospitals per year and about 10 000 readmissions per year in 2010 when almost all of the hospitals and the county s Aging Independence Services functioning as the Community based Care Transitions Program partner agency Area Agency on Aging Aging and Disability Resource Center

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