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ACTIVATE The FSL and Dignity Health Care Transition Initiative Marc M. Lato, MD Vice President of Medical Management February 12, 2015.

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Presentation on theme: "ACTIVATE The FSL and Dignity Health Care Transition Initiative Marc M. Lato, MD Vice President of Medical Management February 12, 2015."— Presentation transcript:

1 ACTIVATE The FSL and Dignity Health Care Transition Initiative Marc M. Lato, MD Vice President of Medical Management February 12, 2015

2 ACTIVATE - Advance Clients’ Transition to Independence Via Actions That Empower

3 Established: January 2012  Partners: SJHMC, FSL, Mercy Care Plan (funder) Patients:  Mercy Care Plan LTC (ALTCS) dual eligible  With multiple co-morbidities / high re-hospitalization rates Expanded to:  Chandler Regional & Mercy Gilbert in January 2013 Current Model

4  Enhanced model of Transitional Care  Draws on best practices from CMS models (Coleman, RED)  Adds an embedded RN to work with the in-hospital medical staff and coordinate post-discharge care  Discharge planning begins at admission  One visit post-hospitalization / Additional home visits if needed ACTIVATE Design Overview

5 ACTIVATE Incorporates Coleman’s Four Pillars  Medication Management – Patient has knowledge about medication and has medication management system  Use of Personal Health Record (PHR) Patient understands and uses PHR to facilitate communication and ensure continuity-of-care plan across providers  Primary Care/Specialist Follow-up: Patient schedules and completes follow-up visit with PCP or specialist and is empowered to be an active participant in these interactions  Knowledge of Red Flags: Patient recognizes the symptoms that indicate that their condition is worsening and how to respond to them

6 Key Components ( 30 Day Program)  8-10 Hours of Intervention  Transitional Care Nurse (TCN)  In-Hospital Assessment  Home Visit by the TCN  Psycho-social Assessment  Comprehensive Holistic Focus on Each Patient’s Goals and Needs  Home Safety Inspection  Telephonic Support by Transitional Care Coach (TCC)

7 Program Successes  Reduction in Mercy Care LTC Plan Readmissions 30-Day Readmission rate reduced from 28% to 8% (Cumulative Enrollees) Reduction in the number of inpatient days Improved Health Care Outcomes  Enhanced Patient Empowerment Disease Management Red Flags  Reduced Health Care Cost

8 ACTIVATE Statistics YearEnrolledCompletedPendingReadmissionReadmission Rate (%) 2011 28% 20126156010 18% 2013494603 8% 20146352112 4% Cumulative1731621115 9% Additional 44 Enrolled at Bedside but had No Home Services Closing Rate was 80% (173/217)


10 CATCH Model Clients Activated Through Community and Hospital

11 CATCH Recap Target Population  Patient of Internal Medicine Clinic (IMC)  Uninsured and Underinsured  Multi-morbidities with at least one in acute stage  38 being served; 18 completed the 12-month program Number of hours spent with client  Front-loaded in first month; 10-15 hours including home visit  Average of 5 hours per month following that

12 Components of Program  A 12-month care program  Joint home visit of IMC Resident and FSL Social Worker (S/W) Psycho-social assessment is obtained  Quarterly client visits to IMC with metrics captured  S/W coaches care plan adherence between IMC visits  Partners provide Transport, Counseling, Public Benefits Success Measures (First Six Months of Enrollment)  55% Reduction in ER visits  53% Reduction in All-Cause Admissions CATCH Recap

13  1 in 5 Fee For Service (FFS) Medicare beneficiaries had a hospital readmission within 30 days*  $15 billion lost due to readmissions - 80% of this deemed preventable with: Provision of quality care during initial hospitalization Adequate discharge planning Adequate post-discharge follow-up Improved coordination between inpatient and outpatient team of caregivers  While readmissions have been declining through 2013, the study of best practices for reducing readmissions remains an area of growth and innovationdeclining CMS Historical Perspective on Readmissions * Jencks et al, NEJM 2009; 360:1418-1428 April 2,2009

14 ACTIVATE Expansion 90-Day Program for Dignity Health

15 Where do we go from here?  Apply learnings from successful projects (ACTIVATE and CATCH)  Integrate learnings from internal hospital initiatives e.g., Readmissions / Discharge Committees, Pharmacy Concierge Program, Resource Room inquiries, etc.  Operationalize all best practices into a comprehensive Transitional Care program and expand to a much wider audience  Collaborate with other internal/external care programs

16 Target Population  Focused on Super-Utilizers: Patients that over utilize the ER (usually known to staff) or the hospital (identified by Case Management) Multi-morbidities Uninsured and Medicare FFS (ACN invited to refer their patients) Dignity Health Expansion 90 Day Program

17 Timeframe  Transitional Care period expanded from 30 to 90 days to: Ensure medication protocols Support public benefits application process Encourage / monitor patient self-management Access additional community resources Effect real behavioral changes Dignity Health Expansion 90-Day Program

18 Operational Highlights (avg. 13 hours) In-home Visits (initial, then as needed, and closure visit)  Psycho-social assessment; patient-Coach relationship deepened  Home vs. Discharge meds reconciled  PCP follow-up visits tracked; patient status shared  Caregivers engaged  Personal Health Record created Telephonic Follow-up (Transitional Care Coach)  “Red flags” reviewed Medication Protocol Compliance Assessed Community Resource Referrals Enabled Dignity Health Expansion 90-Day Program

19 WHY FSL?  40 Years experience in providing direct care services  One of the largest not-for-profit charitable entities in the State; collaborations with many community partners  Contracted with many Health Insurers  Medicare licensed/certified  Demonstrated success in implementing highly effective community based Transitional Care programs within Dignity Health Dignity Health Expansion 90 Day Program

20  Home Modifications and Safety  Low Income Senior Housing  Caregiver Training/ Support  Group Homes for SMI Adults  Senior Centers  Community Action Programs  Respite Care FSL Services  Care Management  In-home Assessments  Counseling  DME/Adaptive Equipment Demonstration  ACTIVATE  CATCH

21 21 St. Joseph’s – HSAG Program Invite highly utilized SNFs to meeting December 2013 Key SNF decision makers (Exec Director /Director of Nursing (DON) Work With HSAG to develop program and format Gain agreement to share similar data confidentially Use well known tool to aggregate the data (Advancing Excellence) Agree to make participation priority Lunch and meeting facility provided by the hospital Dignity Health/St Joseph’s –HSAG SNF Collaborative

22 22 11 Area SNFs invited 10 have come consistently 8 Meetings occurred over the first year Advancing Excellence tool training session facilitated by HSAG Requests for Additional Key topics by the SNFs HSAG and St. Joseph’s provided reference material St. Joseph’s /HSAG SNF Collaborative

23 23 Topics Resources – St. Vincent DePaul, Piper Med and Dental Clinic Circle the City – Respite- and SNF-like care for the homeless Sepsis bundle – Most expensive hospital admission, major readmission reason Blood transfusion protocols o Possibility of calling in blood transfusion and saving admission St Joe/HSAG SNF Collaborative

24 24 Topics St Joseph’s Infusion Suite – Education –Hours of Operation –Possible use for transfusion HSAG Presentation - 2 OIG Reports Medicare Nursing Home Resident Hospitalization Rates 11/2013 Adverse Events in SNFs for Medicare Beneficiaries 02/2014 St. Joseph’s/HSAG SNF Collaborative

25 25 Future Direction Monthly Meetings Continue Advancing Excellence Tool Consider INTERACT 3.0 for use in SNF Add Key Home Health providers Add the Dignity-affiliated ACO (Arizona Care Network) Consider adding Key Facility Medical Directors Determine 1 initiative for group’s participation St Joseph’s/HSAG SNF Collaborative


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