1. Healthy Aging and the Importance of Transitions of Care
Rob Schreiber MD
Chief Medical Officer, HSL
American College of Health Care Administrators
March 17, 2011

2. Objectives
Environmental Scan: review the prevalence, cost and impact of chronic Illness in our health system.
Discuss importance of prevention and health promotion to reduce risk of chronic illness impact
Discuss the opportunities for the Aging Service Provider network to partner with medical system through the ACA act to reinvent healthcare
Discuss present and future innovative opportunities that can redefine health care delivery and improve health outcomes while lowering costs

3. The New Reality
Healthcare consumes now 18% of GDP and will increase to 34% by 2040
79% of US healthcare $ spent on chronic care
Medicaid expenditures are growing so rapidly that states can not meet demand
Nursing home beds are decreasing in the communities
Health care reform is going to result in payment for outcomes and not service

4. We Face an Epidemic of Unparalleled Proportions
More than 1.7 million Americans die of a chronic disease each year.
One-third of the years of potential life lost before age 65 is due to chronic disease.
Four chronic diseases—heart disease, cancer, stroke, and diabetes—cause almost two-thirds of all deaths each year.
Mensah:

5. Number of Chronic Conditions per Medicare Beneficiary
Number of Conditions
Percent of Beneficiaries
Percent of Expenditures 18 1 19 4 2 21 11 3 12 5 7 6 13 7+ 14
Too often we organize our care around a certain chronic condition, like diabetes, or asthma. But the data show a different story. Well over half of those over age 65 have more than one chronic condition and they account for 95% of all health care expenditures.
Source same as prior slide
63%
95%

6. NCOA Survey of Chronic Conditions: Findings 2009
The survey examines the attitudes of Americans with chronic conditions and explores their quality of life, health needs and experiences with the health care system
A bleak and broken health care system for millions of Americans suffering from a variety of chronic conditions.
The survey also identifies barriers to self-care and what is needed to better manage overall health.
Points to need for cost-effective self-management programs and support as part of comprehensive health reform

7. Themes from People with Chronic Conditions
Diversity in who is affected and how.
Hurting, tired, depressed and stressed
Reliance on healthcare system that’s not working
Need help learning how to take better care of my health in a way that works for me and my life
Have multiple health problems and conditions make it difficult for them to take better care of myself
Struggles
Delaying medical care
Barriers to self-care
Seeking realistic, practical, customized help

8. Life Expectancy by Health Care Spending
Mensah:

9. The IOM Quality report: A New Health System for the 21st Century
“The current care systems cannot do the job.”
“Trying harder will not work.”
“Changing care systems will.”

10. IOM Report: Six Aims for Improving Health Systems
Safe - avoids injuries
Effective - relies on scientific knowledge
Patient-centered - responsive to patient needs, values and preferences
Timely - avoids delays
Efficient - avoids waste
Equitable - quality unrelated to personal characteristics
Here are the aims from the report.
They kind of system change we need in chronic illness care and the care model I will describe addresses all of these aims.

11. Retooling for an Aging America:Building the HealthCare Workforce
IOM 2008
Report Calls for a fundamental reform in the way we care for older adults

12. IOM Retooling Taskforce Three Prong Approach
Enhance the competence of all individuals in the delivery of geriatric care
Increase the recruitment and retention of geriatric specialists and caregivers; and
 Redesign models of care and broaden provider and patient roles to achieve greater flexibility.

13. What Impacts Health Most?
Weelock
Source: McGinnis and Foege, JAMA 1996 & the CDC

14. “Actual Causes of Death” Behavioral Risk Factors
Behavior % of deaths, 2000
Smoking 19%
Poor diet & nutrition/ 14% Physical inactivity
Alcohol %
Infections, pneumonia %
Racial, ethnic, economic ? Disparities
McGinnis & Foege, JAMA, 1993; Mokdad et al, JAMA, 2004

15. U.S Preventative Services Task Forces Principal Findings
Most effective interventions address personal health practices: smoking diet, safety, physical activity, substance abuse
Need more selectivity guided by individual risk factors
Counseling and patient education are most important criteria than certain diagnostic tests
Preventative services could be incorporated into visits for illness
Patients need to assume greater responsibility for their health

16. Healthy Aging ……More than a program
Healthy aging is a systems change strategy, not simply a program or service.
We need systems change to address all the forms and consequences of chronic conditions.
Chronic conditions are unlikely to disappear – but we can influence their impact on our lives.

17. Briefly Describe Model
How many have seen this Model in a presentation before?
Let me rephrase – how many have seen this model in the COMMUNITY before? (JRR: This will help you gauge level of knowledge of audience. Likely to be many have seen model in presentation, practice before but few in paractice.)

18. Challenges Facing Medical Care Providers and Health Systems
Payment for Quality, prevention and outcomes
Penalized for bad outcomes
Freezing of payments and/or cuts in Medicare payments
Public Report Cards show a significant gap in best practice and the care delivered
Being asked to restructure and redesign process of care
Dong more with less

19. , Volume 361
Estimated Cumulative Percentage Changes in National Health Care Expenditures, 2010 through 2019, Given Implementation of Possible Approaches to Spending Reform. HIT denotes health information technology, NP nurse practitioner, and PA physician assistant
Estimated Cumulative Percentage Changes in National Health Care Expenditures, 2010 through 2019, Given Implementation of Possible Approaches to Spending Reform.
HIT denotes health information technology, NP nurse practitioner, and PA physician assistant
NEJM, November 26, 2009, Volume 361: , Hussey et al.

20. “Patient Protection and Affordable Care Act”
Focus on 4 issues relevant to healthcare reform
Providers
Self-Management
Care Coordination
requires three “I”s: information, infrastructure, and incentives
Research
Patient-Centered Outcomes Research Institute (PCORI)
Integration of the PCORI’s research findings with decision supports, guidelines, and other aspects of EHR
The integration of the PCORI’s research findings with decision supports, guidelines, and other aspects of electronic health records

21. “Patient Protection and Affordable Act”
Lays groundwork for wide-ranging continuum of care reform
Establishes framework for care coordination
CLASS –Community Living Assistance Services and Supports
Office of Dual Eligible
CMS Innovation Center

22. ACA Promoting Innovation
Testing of programs that will lead to improvements in care coordination
Expand beyond a narrow medicalized scope of practice toward connecting older adults in need of long-term care to supportive service in the community
Transformation of payment and delivery system models of care such as ACO, medical health homes
Bundling of payments for acute and post-acute services
Funding to expand provider base to deliver long-term care services through direct workforce investments

23. A Different Health System Evolving
Self-management, self-determination, self-advocacy
Community-based, collaborative solutions
Prevention in delay of sickness and impairment
Evidenced based outcomes, comparative effectiveness
Development of Health Aging Communities
Challenge ageism, health disparities

24. Value Proposition Quality/Cost
“Outcomes not service” is the new mantra for community based providers
Jim Firman CEO of NCOA
Health system is transforming-what will be your role in it???
Will you act or react?
Goal is to be relevant, add value

25. Opportunities For Aging Service Providers: Preventing Hospitalizations
Preventing Readmissions-improving transitions from Hospital to Home
Care Transitions Program
STARR Program
MA QIO Homecare Intervention
Project RED
Project BOOST
Avoidable hospitalizations through community interventions

26. National Perpective
17.6% of Medicare beneficiaries are re-hospitalized within 30 days of discharge, accounting for $15 billion in spending
Estimates show that 76% of these readmissions may be preventable
Of Medicare beneficiaries re-admitted within 30 days, 64% receive no post-acute care between discharge and re-admission
Source: MedPAC:June 2007 Report To Congress: Promoting Greater Efficiency in Medicare

27. Hospitals are Dangerous Places for Elderly Patients
A frail, demented 81 yo woman with frequent falls and previous bleeding in her brain is incidentally found to have AF on a routine cardiologist visit and is admitted to the hospital for anticoagulation.
A delirious 85 yo woman brought to the ED for blood in her urine is restrained and given large doses of antipsychotics for a head CT scan.
A dying 90 yo woman with AD is given atenolol, lisinopril, lipitor, and aspirin for heart disease.

28. Danger Also Lurks in Transitions to and from the Acute Hospital
Thyroid medication is never resumed upon discharge. Patient is severely hypothyroid 6 months later.
Hospital decision not to treat future pneumonias in a 90 yo woman with end-stage Parkinson’s Disease is never transmitted to the NH and she is readmitted for pneumonia 1 week later.
Family is angry about early discharge to a skilled nursing facility, unaware of a rehabilitation plan.

29. Adverse Events Common Coming and Going
46% of hospitalized patients have 1 or more regularly taken medications omitted without explanation. Potential for harm estimated at 39%.
Cornish Arch Int Med 2005; 165: 424-9
Transfers from NH to hospital have an average of 3 med changes. 20% lead to adverse drug events.
Boockvar Arch Int Med 2004 (164)
19 % have 1+ adverse events within 3 weeks of d/chg. 66% are adverse drug events.
Forster et al. Annals of Internal Med 2003;138:161-7

30. Provider Issues
Cookbook medicine and the fear of litigation, demerits, or income penalties.
Poor communication of patient meds, history, and preferences.
Losing the forest for the trees: No quarterback, fragmentation of care by subspecialties
Lack of geriatric knowledge and perspective
Failure to involve patients and caregivers

31. Why try to Reduce Hospitalizations in the Nursing Home?
Hospitalization is often bad for frail nursing home patients
Many hospitalizations can be avoided by improving care in the NH setting
Financial and regulatory incentives are likely to change over the next few year
We can improve care and avoid unnecessary expenditures
Savings can be re-invested to further improve care
Impact on quality MDS indicators

32. 1 in 5 Medicare fee-for-service Hospitalized patients are re-admitted within 30 days
N Engl J Med 2009; 360:

35. Clinical Causes of Rehospitalizations
70% of post-surgical hospitalizations are for medical reasons such as pneumonia, heart failure and sepsis
Roughly 90% of hospitalization with in 3 days appear to be unplanned and a result of clinical deterioration

38. EB Interventions to Prevent Rehospitalizations
STARR Initiative (IHI)
Medicare 9th Scope of Work
Care Transitions Program
Project RED
Project Boost
Interact II Tool
MOLST/POLST

39. STARR Initiative (State Action on Avoidable Re-hospitalizations)
IHI led Commonwealth Funded
3 states-MA, MI, WA
Goals
Reduce Statewide 30-day rehospitalization rates by 30%
Increase patient and family satisfaction with transitions in care and with coordination of care
20 hospitals in Commonwealth have project teams

40. Medicare 9th Scope of Work Care Transitions Initiative
Fourteen state QIOs
Goal:
Prevent rehospitalizations and improve care transitions
Identify and work with one defined cohesive cross-setting community with common referral patterns for health care
10/14 Using the Care Transitions Program

41. Care Transitions ProgramTM
4 week process involving
Care Transitions CoachesTM
Implementation of the CARE (Continuity Assessment Record & Evaluation) Tool
 Focus on medication self management, red flags, followup, PHR 
 RCT showing significant decrease in rehospitalization rates at 30 and 90 days
Coleman et al., Arch Int Med, 2006,

44. Project RED (Re-engineered Discharge) http://www. bu
Goal: Reduce rehospitalizations by using
In hospital nurse discharge
After Hospital Care Plan
After Discharge Clinical Pharmacist Call
AHRQ Funded RCT Results
improved readiness for discharge
improved PCP follow-up
30% decrease in overall hospital use (ER, inpatient)
A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial, Jack et al., Ann Intern Med. 2009;150:

45. MOLST/POLST
Medical/Physician Orders for Life Sustaining Treatment(MOLST)
POLST paradigm exists in 20 states
Goal: establish a standardized process for communicating patient’s end of life care wishes across the continuum
Part of an advanced caring process
Being piloted In MA ,

46. Nursing Home Hospitalizations and Readmissions: A Particular Problem

47. Hospitalization of Nursing Home Residents
Common
Expensive
Often traumatic to the resident and family
Fraught with many complications of hospitalization
(e.g. deconditioning, delirium, incontinence/catheter use, pressure ulcers, polypharmacy)
Sometimes an inappropriate use of the emergency room and acute hospital

48. Saliba et al, J Amer Geriatr Soc Grabowski et al, Health Affairs
As many as 45% of admissions of nursing home residents to acute hospitals may be inappropriate
Saliba et al, J Amer Geriatr Soc
48: , 2000
In 2004 in NY, Medicare spent close to $200 million on hospitalization of long-stay NH residents for “ambulatory care sensitive diagnoses”
Grabowski et al, Health Affairs
26: , 2007

49. Hospital Readmissions within 30 days from SNFs are common
Of ~1.8 million SNF admissions in the U.S. in 2006, 23.5% were re-admitted to an acute hospital within 30 days
In Massachusetts the rate is 26%
Cost of these readmissions = $4.3 billion
Mor et al. Health Affairs 29 (No. 1): 57-64, 2010

50. Common Reasons for Transfers
Medical instability
Availability of:
On-site primary care providers
Stat tests, IVs
Inadequate assessments to identify early changes
Communication gaps
Family issues/preferences
Lack of advance directives (DNR, DNH)

51. The Challenge of Decreasing Hospitalizations
Reducing hospitalizations from NHs will be challenging due to lack of infrastructure, on-site clinical support, and incentives to manage residents without transfer
Current incentives all favor hospitalization

52. What are the Incentives for Providers?
Hospital reimbursement
Physician reimbursement
Qualification for skilled nursing facility stay
Liability

53. Value Proposition for Reducing Avoidable Hospitalizations
HIGH
Improved Quality,
Reduced Costs
Reduced Avoidable
Acute Care Transfers
Quality
$ Incentives for
Providers
(Value Based
Purchasing or “P4P”)
Costs Avoided $
LOW
$ Costs
LOW
HIGH

54. = $10,000 per hospitalization
How Much Can Be Saved to Reinvest in Quality ?
Assume:
Among 1.5 million NH residents in the U.S., ~1/3 will be hospitalized in one year
= 450,000 hospitalizations
The cost of each hospitalization is ~ $6,500 for a hospital DRG payment, plus a 30 day SNF stay for 1/3 of those hospitalized at $350/day
= $10,000 per hospitalization
Total cost: $ 4.5 billion

55. How Much Can Be Saved to Reinvest in Quality?
% of hospitalizations avoidable
Estimated Medicare savings on avoidable hospitalizations
30%
$ 1.4 billion
40%
$ 1.8 billion
50%
$ 2.3 billion

56. Two Tools to Decrease Hospitalizations and Rehospitalizations
Interact Toolkit
Rehospitalization Avoidance Program

57. Interact II Toolkit Goal: Major focus
Improve quality of care in nursing homes
Reduce patients transfers form nursing homes to hospitals
Major focus
Improve clinical assessment skills by nurses
Improve communication tools
Increase advance care planning

58. Advance Care Planning Tools
A Toolkit to Improve Nursing Home Care by
Reducing Avoidable Acute Care Transfers and Hospitalizations
Developed based on interviews and ratings of avoidability, and Expert Panel ratings of importance and feasibility
Care Paths
Communication Tools
Advance Care Planning Tools

59. A Rehospitalization Reduction Program on a Geriatric Skilled Nursing Unit
Randi Berkowitz MD –lead physician
Funded by Practice Change fellowship

60. Target Population All admissions to the RSU subacute unit
1000 admissions a year
Multiple academic institution referral sources
Medical/Surgical patients
Predominant geriatric patients
3NP/3MD- geriatric and palliative care certified
Where are the md’s in improvement plans and qa herding cats

61. Why decrease readmissions?
Excellence in care
Decrease errors
patient satisfaction
staff satisfaction
Financial
Increased referrals
subacute beds long-term care
census
reimbursement/patient
Bad for patients, families, nursing homes, costly to health care system and society
Only entity might not be bad for are hospitals but that might be changing- we ‘ve seen a focus and becoming concerned about rehospitalizations- terry o’malley- bundled payment- it’s coming

62. Reducing AVOIDABLE hospital transfers

63. Reduce AVOIDABLE hospital transfers Approach to the Problem: Admission
MD standardized discussions
Communication family and PCP
High risk patients
Automatic Palliative Care consult
Flag for entire team
including “Do Not Hospitalize” or “Treat Here” orders by MD/NP; Framing conversation in patient’s goals of care.

64. Reduce AVOIDABLE hospital transfers Approach to the Problem: Stay on the Unit
Team Improvement for the Patient and Safety (TIPS) conference
Call to hospital
Root cause analysis
Case studies- ekg box; value and sanctity of each life
Family members; ovy vey moments
Chair didn’t fit- went home w/o ostomy bags;- call to hospital- name industry doesn’t check after prodcution belt the imperfect ones and learn from them

65. Reduce AVOIDABLE hospital transfers Approach to the Problem: Home Discharge
Project RED
Written home care plan from electronic medical record
Making specific for geriatric use
E.g. advance directives, diet, VNA, assistive devices
Standardized discharge summaries

66. Process and Outcome Measures
Admission
90% patients have discussion with MD
prognosis
rehospitalizations past 6 months
Communication family and PCP
Patient/ family satisfaction survey

67. Y is %unplanned trasnfers/total discharges back to hospital
X number months

68. Preliminary Data Unplanned Transfers
January June 2009 compared with post TIPS July 2009-November 2009
Massachusetts 30 day 22-28% Pre-intervention 16.9% Post-intervention 12.7% Rate Reduction -24.7%

69. Opportunities For Aging Service Providers and LTC Organizations: Care Coordination
Care Coordination/Integration
Referral to EBP Community Prevention Programs
Patient Centered Medical Homes

70. Evidenced based Programs Disseminated in MA
Healthy Eating for Successful Living in Older Adults
Stanford University’s Chronic Disease Self-Management Program (My Life, My Health)
A Matter of Balance (Falls Prevention)
Fit For your Life (Physical Activity)
Arthritis Foundation Exercise Program
Diabetes Self-Management Program

71. National Initiative Surgeon General
“Americans will be more likely to change their behavior if they have a meaningful reward--something more than just reaching a certain weight or dress size. The real reward is invigorating, energizing, joyous health. It is a level of health that allows people to embrace each day and live their lives to the fullest without disease or disability.”
- VADM Regina M. Benjamin, M.D., M.B.A., Surgeon General

72. National Initiative: Endorsement
AoA
CDC
AHRQ (Agency for Healthcare Research and Quality)
ASA/ NCOA
CMS
ARRA Funds

73. A Chronic Disease Self-Management Program In Massachusetts
Massachusetts Department of Public Health & The Executive Office of Elder Affairs
My Life My Health
A Chronic Disease Self-Management Program
In Massachusetts

74. My Life My Health: EBP In Practice
Massachusetts Department of Public Health & The Executive Office of Elder Affairs
My Life My Health: EBP In Practice
Participant Benefits
Six Months Later
Increased exercise
Better coping strategies and symptom management
Improvement in self-rated health, disability, social
and role activities and health distress
Increased energy
Decreased fatigue
Decreased disability
Fewer visits to the doctor and hospitalizations
My Life My Health: Chronic Disease Self-Management Program

75. My Life My Health: EBP In Practice
Massachusetts Department of Public Health & The Executive Office of Elder Affairs
My Life My Health: EBP In Practice
Participant Benefits
Two Years Later
No further increase in disability
Decreased health distress
Decreased visits to the doctor and emergency room
Increased self-efficacy
Saved from $390 to $520 per patient over the two year study (1999)
My Life My Health: Chronic Disease Self-Management Program

76. EB Programs by the numbers …
More than 400 community-based program leaders and trainers through Massachusetts
More than 90 community sites, including Senior Centers and Councils on Aging, Residential Settings, Neighborhood Health Centers, outpatient clinics, Family Service Centers currently offer programs
More than 3200 older adult participants throughout the Commonwealth

77. For participant referrals or to learn more about program opportunities
Contact Information
For participant referrals or to learn more about program opportunities
Jennifer Raymond
Director of Evidence-based Programs
Hebrew SeniorLife / Elder Services of the Merrimack Valley, Inc.
1200 Centre Street
Boston, MA 02113
Joan Hatem-Roy, LICSW
Assistant Executive Director
Elder Services of the Merrimack Valley, Inc.
360 Merrimack Street, Bldg. 5
Lawrence, MA 01843

78. Opportunities For Aging Service Providers: Building Healthy Aging Communities
Involvement with dissemination of Evidenced-based Programs
Building healthy communities through chronic care coordination, prevention and self-empowerment and efficacy
Being part of the leadership solution for implementing a chronic care model in communities
Getting best outcomes for populations involved with caring for no matter what the setting

79. Conclusion ACA has changed the playing field
Rehospitalizations are going to be a prime focus of health care in the coming years
New system paradigm will be needed to meet the demand for prevention of readmissions
Critical role of Community Providers of Aging Network and LTC organizations for care coordination and self-management
Healthy Aging Communities need to be a goal and bringing the hospital into the community will be one significant approach