1. IMPROVING TRANSITIONS: A COMMUNITY APPROACH Cheri Lattimer Executive Director Case Management Society of America (CMSA) Executive Director National Transitions of Care Coalition (NTOCC) Tennessee Hospital Association

2. TODAY’S HEALTHCARE ENVIRONMENT “It's about better care: care that is safe, timely, effective, efficient, equitable and patient-centered.” O’Reilly, K. Health Reform Law Will Boost Care Quality. Amednews.com.

3. Critical Business Issues Current Approaches Are Not Working Needs Access to Care Options (24x7) Collaborative Practice Whole Person Care Approach Rising Costs of Drugs Premium Increases, MLRs and Work Force Shortages Transitions of Care Facilitation Inconsistent Approach Fragmentation of Care Growing Cost of Chronic Care Regulatory/Gov’t Imperatives Gaps Providing health care services to all Americans including health prevention, care coordination, and appropriate resource coordination. To promote quality of care to improve quality of life for our citizens. A commitment to processes that focus on education, consumer advocacy, clinical optimization of resources, patient safety, and technology to achieve superior clinical and financial outcomes with positive consumer and provider satisfaction. Optimum Health Problem Identification, Education and Logistical Support

4. National Health Expenditures as a % of GDP National Health Expenditures (NHE) are unsustainable - Individually, insurance premiums as a % of employee income By 2016, estimated that half of U.S. households will need to spend more than 45%b of their income on premiums NHE20102019 As a % of GDP 17.5%19.3% Source : https://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_sheet.asp, Permission of Larson Allen, LLPhttps://www.cms.gov/NationalHealthExpendData/25_NHE_Fact_sheet.asp

5. PPACA Care Management Provision SEC. 2717. ENSURING THE QUALITY OF CARE "(1) IN GENERAL.--Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary, in consultation with experts in health care quality and stakeholders, shall develop reporting requirements for use by a group health plan, and a health insurance issuer offering group or individual health insurance coverage….. "(A) improve health outcomes through the implementation of activities such as quality reporting, effective Case Management, Care Coordination, chronic Disease Management, and medication and care compliance initiatives, including through the use of the medical homes model ……. "(B) implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; "(C) implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; and "(D) implement Wellness and health promotion activities.

6. HEATH CARE REFORM IMPLEMENTATION TIMELINE Kaiser Foundation http://healthreform.kff.org/timeline.aspx Use the Health Care Reform Source which is a interactive Tool

7. Establishing the Goals On March 22, 2011, the U.S. Department of Health and Human Services released its National Strategy for Quality Improvement in Health Care (National Quality Strategy). The Affordable Care Act required the Secretary of HHS to establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health. This strategy is designed to guide federal, state, and local health initiatives. Source: http://www.healthcare.gov/center/reports/nationalqualitystrategy032011.pdf

8. Three Broad Aims of the National Quality Strategy: Page  8 www.NTOCC.org Prevention and Treatment of Leading Causes of Mortality Supporting Better Health in Communities Making Care More Affordable Making care safer by reducing harm caused in the delivery of care Ensuring that each person and family members are engaged as partners in their care 1 2 3 4 5 Promoting effective communication and coordination of care 6 Better Care, Healthy People/Healthy Communities, and Affordable Care. Six Strategies to Advance these Aims include:

9. The Future Under Health Care Reform How We Pay for Care Payment Reductions Bundled payments Shared Savings Value-based payment Independent Payment Advisory Board How Care Is Organized Accountable care organizations Medical Homes Episodes of care Health information exchange Hospital Engagement Networks How Care is Delivered Center for Medicare and Medicaid Innovation Comparative effectiveness (evidence-based best practices) Multidisciplinary care teams across sites of service Electronic Health Records Care Transitions Improved coordination of care for dual eligible's Larsen Allen LLP

10. Emerging Models Across the Healthcare Landscape New Models of Healthcare Delivery and Reimbursement Patient-Centered Medical Home (PCMH) Primary Care PracticesAccountable Care Organizations (ACOs)Integrated Health Delivery SystemsPopulation Health ManagementOutcomes-Based Reimbursement With Shared RiskValue Based Purchasing of Health Care Services

11. Goals Of These New Models Minimize fragmentation & improve transitions of care Focus on patient safety and quality of careImprove the patient’s experience with careExpand access to careReduce the cost of effective care Payment that recognizes value of patient-centered care

12. Some Words from Secretary Kathleen Sebelius Soue:http://www.hhs.gov/news/press/2011pres/04/20110412a.html www.tha.comwww.tha.com, December 15, 2011 “At some point in our lives, many of us are going to need hospital care and we need to be confident that no matter where we live, we’re going to get the best care in the world. The Partnership for Patients is helping the nation’s finest health systems share their knowledge and resources to make sure every hospital knows how to provide all of its patients with the highest quality care ”

13. Partnership for Patients A Nationwide public-private collaboration to improve quality, safety and affordability of health care for all Americans Development of hospital engagement networks (HEN’s) Reducing hospital-acquired conditions Decreasing 30-day readmissions Launched April 2011, the Partnership of Patients now consists of more than 6500 partners, including over 3,167 hospitals along with employers, health plans, physicians, nurses, patient advocates, and state and federal government officials that have pledged to work together to reduce the number of hospital-acquired conditions by 40% and reduce hospital readmissions by 20% by the end of 2013 13 www.tha.comwww.tha.com December 15 th 2011

14. Spectrum of Services Skilled Nursing Care Respite Care Palliative Care Hospice Doctor's Office Case/Disease Management Long Term Acute Hospital Sub-acute Rehab Home Health Skilled & LTC Specialist Health & Wellness Health Health Enrollment OP Therapies Acute Hospitalization Diagnostic & Treatment Center How will you coordinate care beyond your service?

15. The movement of patients from one health care practitioner or setting to another as their condition and care needs change Occurs at multiple levels Within Settings Primary Care Specialty Care ICU Ward Between Settings Hospital Sub-acute facility Ambulatory clinic Senior center Hospital Skilled nursing Home Care Hospital Across Health States Curative care Palliative care/Hospice Personal residence Assisted living What Is “Transition of Care”? Coleman, EA, Boult C, The American Geriatric Society Health Care Systems Committee.. American Geriatrics Soc 2003;51:556-7

16. Patient & Caregiver Caregiver ERERICUICU In-PatientIn-Patient Patient & Caregiver OUTPATIENT: Home Home Home Care Home Care PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Caregiver Caregiver Hospice HospiceOUTPATIENT: Home Home Home Care Home Care PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Caregiver Caregiver Hospice HospiceSNFSNFALFALF Transition Issues Dramatically Impact Patients & Their Caregivers

17. OUTPATIENT: Home Home Care PCP Specialty Pharmacy Case Mgr. Caregiver Hospice Patient & Caregiver ERICU In-Patient Patient & Caregiver SNFALF NO Medication Reconciliation NO Personal Medicine List NO Coordinated Care Plan NO Discharge Care Plan NO Care Plan NO Medication Reconciliation NO Personal Medicine List NO Care Plan NO Medication Reconciliation NO Personal Medicine List Transition Issues Dramatically Impact Patients & Their Caregivers & Providers

18. Medication Reconciliation Elements Comprehensive Care Plan Health or Clinical Status Transition Summary Patient & Caregiver Tools & Resources Consistent Performance Measures That Apply to All Health Care Settings Accountability for Sending & Receiving Information To Date We Have Not Had Consistent and Accepted Transition Tools

19. Analysis of Medicare Claims data from 2003-2004 11,855,702 Medicare beneficiaries DC from the hospital –19.6% nearly 1/5 were rehospitalized within 30 days –34% were rehospitalized within 90 days –50.2% of those rehospitalized within 30 days after a medical discharge there was no bill for a visit to a physician office Rehospitalization among Patients in the Medicare Fee-For-Service Program, Stephen F. Jencks, M.D., M.P.H., Mark V. Williams, M.D., and Eric A. Coleman, M.D., M.P.H. Rehospitalization – Medicare Fee-For-Service

20. Jenks NEJM 2009 SOURCE: Jencks, SF, Williams MV, EA Coleman, EA. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine, 360 (14): 1418-1428 Hospital Readmissions

21. NTOCC is a 501c4 non-profit Coalition www.NTOCC.org 32 Advisory Council Members, 3276 Subscribers, 503 Associate Members, 83 Countries Collaborative Models of Care & Resources to Improve Transitions of Care

22. The Care Transitions Intervention Does encouraging older patients and their caregivers to assert a more active role in their care transition reduce rates of rehospitalization? 17. Coleman EA et al. Arch Intern Med 2006

23. Dr. Eric Coleman – Transition Coaching - http://www.caretransitions.orghttp://www.caretransitions.org Dr. Mary Naylor – Advanced Nurse Practitioners - http://www.nursing.upenn.edu/media/transitionalcare/Pages/default.aspx http://www.nursing.upenn.edu/media/transitionalcare/Pages/default.aspx Guided Care - Dr. Chad Boult - Guided Care Nurse -http://www.guidedcare.orghttp://www.guidedcare.org Boston University Medical Center - Project RED – Re-engineering Discharges – http://www.bu.edu/fammed/projectred/http://www.bu.edu/fammed/projectred/ Society of Hospital Medicine – Project BOOST- http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransition s/CT_Home.cfm http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransition s/CT_Home.cfm Transition Models

24. Transition of Care Clinic - Tallahassee Memorial Hospital – Dr. Dean Watson, Chief Medical Officer http://www.tmh.org/TMHTransitionCenter Rush Enhanced Discharge Planning Program – Rush University Medical Center - Robyn Golden, MA, Director of Older Adult Programs. robyn_golden@rush.edu. Emerging Models

25. Transition Coaching (CTI) - The anticipated cost savings of one “Transitions Coach” (responsible for 350 chronically ill adults), after an initial hospitalization, over a period of twelve months, is $330,000. The total annual intervention costs averages $196 per patient. Eric Coleman, “Person-Centered Models for Assuring Quality and Safety Transitions Across Care Settings,” Written Testimony to the US Senate Special Committee on Aging Transitional Care Model (TCM) - TCM’s impact on total healthcare costs within the University of Pennsylvania healthcare system at 24 weeks, per patient was $3,630, and at 52 weeks was $7,636, compared to $6,661 and $12,481 respectively for those not using the tools provided with the program. Mary Naylor. “Transitional Care Model,” Guided Care Model - Guided Care patients experienced, on average, 24% fewer days in hospital, 37% fewer skilled nursing facility days, 15% fewer emergency department visits, and 29% fewer home health care episodes, as well as 9% more specialist visits. This translated into an annual savings annual savings of $75,000 or $1,364 per patient. Leff B, Reider L, Frick KD, Scharfstein DO, Boyd CM, Frey K, Karm L, Boult C. “Guided Care and the Cost of Complex Healthcare: A Preliminary Report.” AM J Manage Care, 2009; 15 (8): 555-559. Tangible Savings

26. Project Re-engineered Discharge (RED) - In 2008, a randomized controlled trial study found that patients who utilized Project RED experienced a 30% lower rate of hospital utilization 30 days post discharge and that readmission or emergency department visit was prevented for every 7.3 subjects receiving the intervention. Additionally, patients who received intervention had a 33.9% lower cost than those who did not receive intervention, translating into a savings of $412 per person. Boston University School of Medicine. “The Re-Engineered Hospital Discharge Program to Decrease Rehospitalization.” http://www.bu.edu/fammed/projectred/publications/RED%20Fact%20Sheet%202-7- 09%20v2.pdf http://www.bu.edu/fammed/projectred/publications/RED%20Fact%20Sheet%202-7- 09%20v2.pdf Rush University Medical Center’s Enhanced Discharge Planning Program (EDPP) - In 2010, a randomized controlled trial at Rush University Medical Center showed readmission decreases at 30, 60, 90, 120, 150 and 180 days. Additionally, mortality rates in the intervention group were 2.2% vs. 5.3% in the control group. Cost analysis within Rush’s fee-for-service environment showed a $1,293 savings per patient. Rush University Medical Center, Older Adult Programs, Enhance Discharge Planning Programs: Early Findings, 2011 Tangible Savings

27. Patient and Family Caregiver Tool Development

28. NTOCC Provides Tool and Resource Development for Patient and Family Caregivers www.ntocc.org Guidelines for a Hospital Stay with Helpful Definitions -- For Patient, Family, & Caregiver Taking Care of MY Health Care – français & español My Medicine List --español, français Provider Tools and Resources

29. Improve communication during transitions with providers, patients and caregivers Support the implementation of electronic medical records that include standardized data elements Establish points of accountability for sending & receiving Increase the use of case management and professional care coordination Expand the role of the pharmacist in transitions of care Implement a payment system that align incentives Development performance measures to encourage better transitions of care Considerations for Change

30. Provider Tools and Resources

31. www.NTOCC.org TOC Compendium The TOC Compendium is a collection of resources such as white papers, journal articles, and websites that a "Transitions of Care" professional or interested consumer might find useful in their practice or medical situation. Explore the TOC Compendium at: www.NTOCC.org/Compendium www.NTOCC.org/Compendium

32. Seven Essential Intervention Categories Source: http://www.NTOCC.org/com pendium (2011) Medications Management Transition Planning Patient and Family Engagement / Education Information Transfer Follow-Up Care 1 2 3 4 5 Healthcare Providers Engagement Shared Accountability across Providers and Organizations 6 7 http://www.ntocc.org/Toolbox/browse/

33. Transition of Care Evaluation Software Tool

34. TOC Evaluation Software Tool

35. Tracking & Monitoring the Intervention

36. Reporting on the Outcomes

37. Promoting Effective Communication and Care Coordination: Building the Team and Improving the Handovers

38. NTOCC Measures Work Group, 2008 Improving Communication

39. Stable for transfer Patient/caregiver understand and are prepared Transfer information is complete Contact person’s name and number Sending health care team Review transfer information promptly and clarify Incorporate patient’s goals/preferences in care plan Document contact information Receiving health care team (c) Eric A. Coleman, MD, MPH Responsibilities of Health Professionals for Patients in Transition

40. Pharmacy Employer PCP/Medical Home Specialist Patient TOC CM Hospital Community Health Center Health Plan Adherence Assessment & Support Health Promotion Motivational Advocacy Prescription Assessment & Care Plan Motivational Interventions Advocate Assessment Medication Reconciliation Care Plan Adherence Assessment & Support Coordination & Care Plan Non-Adherence Behavior Health Change Facilitation Increase Productivity LTC Home Care Hospice Transitioning the Continuum of Care with Bi-Directional Communication

41. SNFSNFALFALF ERERICUICU In- Patient OUTPATIENT: Home Home Home Care Home Care PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Care Giver Care Giver Hospice HospiceOUTPATIENT: Home Home Home Care Home Care PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Care Giver Care Giver Hospice Hospice Patient & Care Partner & Care PartnerPatient My Med List Medication Reconciliation Data Elements + Care / Case Transition Process Improving Communication Will Improve Transition Issues

42. NFCA - National Family Caregiver Association - Family Caregiving Resources – www.thefamilycaregiver.org CAPS - Consumers Advancing Patient Safety – Toolkits www.patientsafety.org www.patientsafety.org NTOCC - National Transitions of Care Coalition – Provider & Consumer Tools www.ntocc.orgwww.ntocc.org CMSA - Case Management Society of America – CM Medication Adherence Guidelines & Disease Specific Adherence Guidelines - www.cmsa.org www.cmsa.org AMDA’s (Dedicated to Long Term Care Medicine TM ) Transitions of Care in the Long Term Care Continuum practice guideline - http://www.amda.com/tools/clinical/TOCCPG/index.html http://www.amda.com/tools/clinical/TOCCPG/index.html ACC and IHI – Hospital to Home – Reducing Readmissions, Improving Transitions - http://www.h2hquality.org/http://www.h2hquality.org/ AHRQ – Questions Are The Answers – www.ahrq.orgwww.ahrq.org Additional Resources for TOC

43. QUESTIONS 43