1 Together We’re Better: Extending Patient Care Outside the Hospital WallsW. June Simmons MSW, CEO, Partners in Care FoundationNancy Seck, RN, BSN, MPH, CPHQ, Director Quality ManagementGlendale Memorial Hospital and Health Center
2 Partners in Care Who We Are Partners in Care is a transforming presence, an innovator and an advocate to shape the future of health careWe address social and environmental determinants of health to broaden the impact of medicineWe have a two-fold approach, creating and using evidence-based models for: provider/system practice change and enhanced patient self-managementChanging the shape of health carethrough new community partnershipsand innovations
3 Goals of Transition Programs Engage patients (&/or caregivers) with chronic illness and activate self-care & behavior changeFollow post-discharge to ensure meds/services receivedTeach/coach regarding medications, self-care, symptom recognition and managementRemind and encourage patients to keep follow- up physician appointments – ensure transportationHow to achieve these goals differs across programs
4 Coleman Care Transition Intervention Social Worker or Health Coach (one per 40 patients)Duration-30 days post hospitalOne visit in hospitalOne Home visit post-DC or post-SNFThree follow-up calls within 30 daysBased on four pillarsMedication Reconciliation & ManagementPersonal Health Record (PHR)Primary care and specialist follow-upKnowledge of red flags re: symptom exacerbationResults*In RCT, CTI prevented 1 readmission per 17 patientsSavings $300,000 per 350 patients (cost<$170,000)*California Healthcare Foundation-”Improving Care Transitions” October 3, 2007
5 Bridge Model (Rush Medical Center) A telephonic intervention for patients who:live outside of the service area ordecline a home visit.Social work assessment in hospital visit30 days of phone support & care coordinationIdentify unmet post-discharge needsFacilitate connections to home and community-based services such as home-delivered meals and transportationIncludes clarifying discharge instructions, arranging physician follow-up and obtaining/understanding medications
6 Coleman/Bridge Commonalities Identify at-risk patientsUnit NurseCare Managers or Discharge PlannersEMR system data/risk algorithmRoom VisitIntroduce & ExplainDetermine need, coachability or appropriatenessConsentBegin assessmentLeave infoSchedule visit or callsFollow-Up at home or by phoneVerify discharge orders complete: meds, equipment, home health, etc.Ensure MD visits scheduled w/ transportation if neededConnect with resources, including mealsVerify understanding of self-careEncourage healthy behaviorsHomeMeds for medication reconciliation & safety
7 Best Practices (Coach focus group) Identify at-risk patientsCase managers who know patient & family provide fewer, but more appropriate patientsHospital-based coach who gets to know staff, schedules, how to find patients – staff trusts more and therefore refers more24 hours pre-discharge is ideal timeRoom Visit“I’m here on recommendation from”…someone patient knows – MD, case managerEfficiencyField coach & hospital coach allows everyone to see more patientsTeamwork gives us more flexibility – cover more times of day and languages
8 Issues/Challenges (Coach focus group) Identify at-risk patientsVolume (automated at-risk patient ID) vs. quality (case manager – BUSY!)Have case managers briefly review list for appropriate patientsTiming – often too late; patient already dischargedWeekends!Room VisitPatients out of room for tests & treatments, or asleep/too illHome VisitHard to reach patients – not answering phone; no voic system48-hour home visit difficult – still too ill and exhaustedFamily protects patient & blocks accessEfficiencyWe’re bugging case managers for information & they don’t have time – need direct access to face sheet & d/c summaryPatient ID & info has to be exactly right or billing won’t go throughDx codes not known until d/c summaryWe don’t know where pt d/c to (home, SNF, etc)30-40% readmitted elsewhere – how do we know?
9 Value-Added Service: HomeMedsSM The Right Meds… The Right Way! HomeMedsSM proven solution in four important problem areas affecting seniors:Unnecessary therapeutic duplicationFalls and confusion related to possible inappropriate psychoactive medication useCardiovascular problems such as continued high/low blood pressure or low pulseInappropriate use of non-steroidal anti-inflammatory drugs (NSAIDs) in those with high risk of peptic ulcer/gastrointestinal bleedingCoach & software identify medication-related problems and pharmacist works with patient and prescribers to resolve them.
10 Value-Added Service: Self-Management of Health Promising PracticeBest PracticeSupported by extensive researchMeasurable, proven outcomes to achieve specific goalsClear, structured, detailed programPeer-reviewed & endorsed by a federal agencyPeer-led, replicable in many settingsCoaches refer patients to appropriate workshops:Chronic Disease, Pain, Arthritis, & Diabetes Self-ManagementFall PreventionCaregiver SkillsEarly Memory Loss
12 The Expanded Chronic Care Model: Integrating Population Health Promotion
13 Healthcare + Community Services = Better Health & Lower Costs Social determinants of healthPersonal choices in everyday lifeSocial isolationEnvironment – home safety, neighborhoodFamily structure/issues, caregiver needsCommunity Agencies Have AdvantagesTime to ask questions, observe, probe, develop trustCultural/linguistic competenceLower cost staff & infrastructureKnowledge of resourcesHigh impact evidence-based programs
14 Providers see the need… RWJF Survey of 1,000 PCPs86% said “unmet social needs are leading directly to worse health” & it is as important to address these factors as medical conditions.80% were “not confident in their capacity to address their patients’ social needs.”76% wish that the healthcare system would cover the costs associated with connecting patients to services that meet their health-related social needs.1 of 7 prescriptions would be for social supports, e.g., fitness programs, nutritious food, and transportation assistance.Health Care’s BLIND SIDE - The Overlooked Connection between Social Needs and Good Health, Robert Wood Johnson Foundation, December 2011,
15 How Home and Community Services Improve Health Outcomes for High-Risk Patients Multiple, complex chronic conditions & self-careEvidence-based self-care programs (e.g, Chronic Disease Self-Management, Diabetes Self Management)Long-term supports and services (LTSS) to address functional & cognitive impairments – meet basic needsNursing home diversion/return to communityComplex medications/adherence (HomeMeds℠)Fill gaps in care/communication & address root causes of inappropriate ED use (e.g., insurance, meals, transportation for care, socialization)Post-hospital support to avoid readmissionsIn-home palliative care in last year of life
16 Active Patient Population Management End ofLifeComplex Chronic Illnesses w/ major impairmentChronic Condition(s) with Mild Functional &/or Cognitive ImpairmentChronic Condition with Mild SymptomsWell – No Chronic Conditions or Diagnosis without SymptomsHot Spotters!
17 Home & Community-Based Services in Active Population Health Management Examples: Hospice & home palliative careExamples: Personal assistance;Home modifications; Chore/shopping;Home-Delivered Meals, Med Mgt,Respite Care, Caregiver Classes & CounselingExamples : Coleman CTI; Rush BridgeProgram; HomeMeds; Home SafetyEvaluation & Social AssessmentExamples : Stanford Chronic Disease Self-Management; Matterof Balance; PST/IMPACTExamples: Tai Chi, Health Screenings & Education
18 Care Transitions: Buy vs. Build Decision Patients discharged to geographically disparate parts of the CountySan PedroLancasterConsiderations:Driving distances to patient homeKnowledge of local servicesTraining and experienceLanguage / CultureData collection / patient monitoringWoodland Hills
19 Individual Hospital Approach: Each hospital must hire, train, manage and pay transitions directors and health coachesRegional Model = centralized, cost- effective, efficient and experienced!
20 Single Provider – 11 Hospitals Westside (L.A.) Coalition Kern County CoalitionWestside (L.A.) CoalitionGlendale CoalitionBakersfieldHeart HospitalUCLA Ronald Reagan Medical CenterGlendale Memorial Hospital & Health CenterBakersfield Memorial HospitalUCLA Santa Monica Medical CenterGlendale Adventist Medical CenterKern Medical CenterSt. John’sHealth CenterUSC Verdugo Hills HospitalMercy HospitalSan JoaquinCommunity Hospital
21 How We Work Together Efficiently Home and Community Services NetworkBroad geographic coverage with in-home Care Coordination through a central portalCommon assessment tool and EHRMulti-lingual/cultural competence/home expertsContracted, credentialed network of trusted vendors and linked partnershipsAdministrative simplicity with full access to both arrange and purchase community care resourcesWraparound services and patient activation
22 Three-way partnership for whole person careMedicinePatients&FamiliesCommunity-BasedServices
23 Comprehensive Person-Centered Coordinated Community Care Referred ServicesAdult Day ServicesHome HealthHospice/Palliative CareHospiceDMECaregiver Support ProgramsSenior Center Exercise/Evidence-Based Health ProgramsHome-delivered mealsHousing OptionsLegal ServicesFinancial/Insurance/Legal AssistanceTransportationPurchased Services (Credentialed Vendors)Home Safety AdaptationsHome MaintenanceEmergency response systemsIn-home psychotherapyEmergency support (housing, meals, care)Assisted transportationHome maker (personal care /chore) and respite servicesHeavy cleaningHome-delivered meals – short termMedication management (HomeMeds, reminders, dispensers)Other products & services to support independenceIn-Home Assessment& Service DeliveryNurseClient & FamilySocial Worker
24 Integrated Community Care System One Call Does It All!Partnersin Care FoundationL.A. Dept. of AgingThe Jewish HomeNetwork OfficeAltaMed Health ServicesWISE & Healthy AgingSeniorServ of Orange County
25 Together – We Can Manage Population Health and Lower Costs Health Plan FunctionsEnrollment and disenrollment/UM & CMClaims and Data AnalysisTiered & comprehensive coverageHospital and Physician FunctionsIdentify patients in need of home follow-upConnect patients with coachesProvide complete discharge informationCommunity ResourcesComprehensive assessment to identify high-risk patients & target appropriate services:Patient activation & self-care coachingCare coordination/in-home supportAccess to Public benefits/IHSS/CBASCaregiver SupportTransportation, food assistance, housingEvidence-based self-management & HomeMedsFeedback/data to PCP, Hospital & Health Plan
26 For more informationContact: June Simmons, CEO Partners in Care Foundation