2. National Readmission Conference May 7th, 2014
Care Transitions:
Strategies that are Working
National Readmission Conference May 7th, 2014
June Simmons, CEO
Partners in Care Foundation

3. Partners in Care Foundation Who We Are
Partners in Care Foundation is a non-profit center of innovation whose mission is to change the shape of health care. We pursue our mission by developing and advancing transformational models of care that promote health, independence and quality of life

4. Health Reform: Moving From Volume to Value
Infrastructures and reimbursement are transforming; emphasis on prevention
Major consolidation – unpredictable future
The roles of hospitals, physicians and payers are blurring
The role of the community agency is growing
New broader partnerships are essential

6. Social Factors and Health Outcomes
Gallant MP. The influence of social support on chronic illness self-management: a review and directions for research. Health Educ Behav. 2003;30(2): ; DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol. 2004;23(2): ; Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health. 2002;92(5): ; American Public Health Association. The hidden health costs of transportation. Published February Accessed January 10, 2012.; Centers for Disease Control and Prevention. CDC health disparities and inequalities report – U.S Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.; Robert Wood Johnson Foundation. Overcoming obstacles to health care. Published February Accessed January 10, 2012.; Shi L, Singh D. The Nation’s Health. 8th ed. Sudbury, MA: Jones and Bartlett Learning, LLC; 2011.
Social Factors and Health Outcomes
Societal-level social determinants have individual-level impact1
Issue
Outcome
Low education, lack of social support, and social exclusion
Poor self-management2 and reduced care plan adherence3
Housing4 and
transportation5 issues
Increased health care costs
and utilization
Health disparities
and psychosocial issues
Preventable hospitalizations6
and mortality7
Many older adults or persons with chronic illnesses face challenges in these dimensions on a daily basis, such as with isolation, finances, transportation
Psychosocial challenges displace focus and energy from attending to medical conditions
Compliance with medical care may become secondary to needs perceived as more urgent for survival
So, as a result, social determinants are societal-level issues with individual-level impact, particularly for older adults2
Lack of social support and social exclusion  poor self-management3 and reduced medical care plan adherence4
Housing5 and transportation6 issues  increased health care costs and utilization
Health disparities and psychosocial issues  preventable hospitalizations7 and mortality8

7. Low Ratio of Social to Health Service Expenditures in U.S.
Bradley E H et al. BMJ Qual Saf 2011;20:
Ratio of social to health service expenditures for Organization for Economic Co-operation and Development (OECD) countries, The ratio is calculated by dividing total expenditures on social services by total expenditures on health services. *The ratio for Portugal is from 2004, owing to missing data for Source: OECD Health Data 2009 (accessed June 2009); OECD Social Expenditure Dataset (accessed December 2009); authors' calculations.
Copyright © BMJ Publishing Group Ltd and the Health Foundation. All rights reserved.

8. Health Care’s Blind Side
RWJF Survey of 1,000 PCPs:
86% said “unmet social needs are leading directly to worse health”.
80% “not confident in their capacity to address their patients’ social needs.”
76% wish the healthcare system would cover cost of connecting patients to services to meet 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,

9. Because of the Concentration of Risk and Spending, Home and Community Care Principles and Practices are Central to Improving Quality and Reducing Cost

10. CBOs as part of the healthcare system
CBOs need to play a new role connecting the home with the healthcare system
Home provides unique perspective otherwise unavailable to healthcare providers.
Quality measures for health plans and providers relate to issues such as medication use and fall prevention – HEDIS, Medicare Advantage Star Ratings
Meds are major factor in readmissions – home is key
New focus on population health – identifying and proactively addressing health for high-risk patients

11. Home and Community Based Services (HCBS) are High Value
Improves quality: Staying home is concordant with people’s goals.
Evidence-based interventions like HomeMeds, Stanford self-management programs and care transitions programs reduce ED & hospital use
Based on 25 State reports, costs of Home and Community-Based LTC Services less than 1/3 the cost of Nursing Home care.

12. Health Care + CBO/Social Services = Better Health, Lower Costs
Address social determinants of health
Personal choices in everyday life
Isolation, family structure/issues, caregiver needs
Environment – home safety, neighborhood
Economics – affordability, access
Social service agencies have advantages
Trust, time to probe, different authority
Cultural/linguistic competence
Lower cost staff & infrastructure
High impact evidence-based programs

13. Readmissions: Social Issues
“Compassionate” admissions – elder with no caregiver
Gentleman with mild cognitive impairment tries to be adherent by taking all meds – including sleepers – at breakfast – starts falling
Appointment made by hospital – but daughter can’t make it – no transportation
Can’t afford meds
No food in home – especially none that matches diet orders

14. Role of Agencies like Partners in Care
“Eyes and ears” in the home
Skilled at building trust and relationships
Gather data and information that is not shared in a medical setting or encounter
Link in medication issues with evidence based intervention
Cultural competence in local communities
Comprehensive psychosocial & environmental evaluation
Attention to caregivers – special services, support, respite

15. Major Causes of Readmissions… and what CBOs can do about them
Patient and family lack of understanding about managing patient conditions
Provide information about “red flags” and self-care
Missed post-discharge physician appointments
Transportation assistance; consider family schedules
Medication errors
Misunderstanding, language barriers, affordability, multiple prescribers – meds already in the home, OTCs
Lack of communication among providers after the discharge
Patients coached to share information with PCP
Lack of food or inappropriate diet
Arrange home-delivered meals for special diet

16. Care Transitions Coaching & Support
Evidence-based home & social services models proven to reduce readmissions
Medication Review: HomeMedsSM or HomeMeds-Plus to include comprehensive psychosocial & environmental evaluation
Coaching (Coleman Care Transitions Intervention) for those who are capable (or have caregivers)
Social services (Rush U. Med Center Bridge Program) for those who are not
Connect patients to services and supports for recuperation, rehabilitation, education

17. Partners’ HomeMedsSM-Plus Program
Description
Outcomes/Experience
Comprehensive assessment
Meds, ADL, PHQ-2/9, cognitive, sensory, social & behavioral health indicators
Comprehensive report, service plan for LTSS, self-management & behavioral health
HomeMedsSM Pharmacist review
Contact with member’s physician and other health providers
Compared to those who screened in and didn’t get the intervention:
Readmission rate 22% lower
ED use rate 12.7% lower
ROI = 53% (net)
63% post-acute had med-related problems.
77% had a home safety issue
54% had other issues (financial, caregiver, depression, etc.)
9% had depression

18. Medications & Care Transitions
72% of post-discharge adverse events are related to medications—and close to 20% of discharged patients suffer an adverse event. *
35% of Medicare patients taking 5 or more medications experience adverse drug events*
HomeMeds program – a social work solution
*Mary Andrawis, PharmD, CMMI, presentation to Drug Safety Panel, May 10, 2011 (Forster et al., Annals of Internal Medicine. 2003; 128: / CMAJ FEB 3, 2004;170-3)

19. HomeMeds℠ - Bridge between Home and Healthcare
HomeMeds℠ is designed to enable community agencies to keep people at home, out of hospital & nursing home, by addressing medication safety
Practice change with workforces that already go to the home – more cost effective use of existing effort
Targets problems for significance, accessibility to in-home staff, and likelihood of positive prescriber response.
Focuses on adverse effects (falls, confusion, dizziness, vitals) … then determines if medications may be part of the cause.
Cost-effective use of geriatric pharmacist for complex problems

20. HomeMeds-Plus Targeting Criteria
Age 65+ and
ED/hospital use in 6 months, plus 2 or more:
Hospital LOS > 6 days; or
Six or more prescribed meds; or
Warfarin/antiplatelet or insulin/diabetes meds; or
Dx CHF, COPD, depression, anxiety, bipolar, psychosis; or
DX of diabetes, dialysis, hemodialysis, renal failure, CKD, ESRD, CAD, COPD or CHF; or
Mild cognitive impairment; or
Recent treatment for fall or confusion; or
Age 80+; or
Limited caregiver support

21. Meds in the Home 101
Adherence Problem: 4 prescriptions – patient says “yes” when pharmacy calls for refill – obviously not taking meds

22. Meds in the Home 101 Spanish speaker English labels Neighbor helping
Bottles get moved
Trouble ahead!

23. Patient stored all morning meds in the same container
Meds in the Home 101
Patient stored all morning meds in the same container

24. The Role of Caregivers Family Caregivers1 Paid Caregivers
Adult children, spouses, other relatives, friends/neighbors
Older adult spouses at risk for physical & mental health issues
46% of family caregivers perform medical/nursing tasks for relative with multiple physical and cognitive conditions
78% manage medications
60% report learning how to manage medications “on their own”
47% said they NEVER received training from any source.
Paid Caregivers
60% in recent study could not fill pill box correctly
1/3 had difficulty reading and understanding health information
DF: This feels out of context w/health literacy gone and could be deleted
Home Alone: Family Caregivers Providing Complex Chronic Care. AARP. October 2012
Inadequate Health Literacy Among Paid Caregivers of Seniors. J Gen Intern Med. 2011 May; 26(5): 474–479.

25. Addressing Readmissions through a Comprehensive, Coordinated Delivery System

26. Managing Readmissions – Not Easy Alone
HSAG finds 27.5% readmitted to a different hospital
Efficiency demands coordination and a broader geographic approach
Many issues NOT in skill set of healthcare
It takes a multi-pronged approach
Hospital
Home Health
SNF
CBO
PCP, etc.

27. Bringing Local Person-Centered Services to Large Regional Systems
National movement to change the business model of the Aging & Disability Services Network
U.S. Administration for Community Living (ACL)
Add upstream value to save downstream costs
Local knowledge, trust, experience
Low-cost models
But…how do you create an efficient system with dozens of smallish agencies?

28. A Possible Solution: Led by ACL & the John A. Hartford Foundation
Initiative Overview
CBO networks to create an integrated system of non- medical care and services
Contract with healthcare organizations (Medicare Advantage, Medi-Cal managed care, duals plans, large medical groups, ACOs/Medicare Shared Savings, commercial insurance)
Measure & document value added
National dissemination & technical assistance

29. Care Transitions SoCal
Glendale Healthier Community Coalition - Glendale Hospital plus Partners in Care and 2 additional hospitals
Hollywood Area - AltaMed Health Services Corp plus 4 hospitals
Kern/Bakersfield: Partners in Care + 5 hospitals
Orange County Care Transitions Partnership - SeniorServ plus 4 hospitals
San Diego Care Transitions Partnership - AAA plus 11 hospitals
San Fernando Valley Transitions Coalition - LA Jewish Home plus 3 hospitals
Ventura County Care Transitions Community Partnership - AAA / Camarillo Health District plus 5 hospitals
Westside Care Transition Collaborative - Partners in Care+3 hosp

30. “My coach helped me make continuing health a priority – and having her support made me feel important despite my age.” Patient Lolita
Regional network covers LA, Ventura, Orange, San Diego & Kern Counties
Hospital-to-home coaching for optimal post-discharge recovery
Patient empowerment:
PCP follow-up, meds management, ER avoidance education, healthy behaviors activation
Contracted to serve 40 hospitals
Served 1,000s of patients in first year
Projected results: 20% reduction in FFS Medicare readmission rate

31. Self-Management Support
The actions that individuals living with chronic conditions must do in order to live a healthy life.
Physical Activity
Problem-Solving
Medications
Family Dynamics & Support
Planning
Managing Pain & Symptoms
Managing Fatigue
Communication
Working with Health Professionals
Understanding Emotions
Healthy Eating

32. High-Level Evidence-Based Programs Offered by CBOs
SELF-MANAGEMENT
Chronic Disease Self-Management
Tomando Control de su Salud
Chronic Pain Self-Management
Diabetes Self-Management Program
PHYSICAL ACTIVITY
EnhanceFitness & EnhanceWellness
Healthy Moves
Fit & Strong
Arthritis Foundation Exercise & Walk With Ease Programs
Active Start
Active Living Every Day
MEDICATION MANAGEMENT
HomeMeds
FALL RISK REDUCTION
A Matter of Balance
Stepping On
Tai Chi Moving for Better Balance
DEPRESSION MANAGEMENT
Healthy IDEAS
PEARLS
CAREGIVER PROGRAMS
Powerful Tools for Caregivers
Savvy Caregiver
NUTRITION
Healthy Eating

33. Diabetes Self-Management Program
Developed at Stanford by Kate Lorig, RN, Dr.PH
Patients learn to take control of their diabetes.
Peer-led workshop develops tools to:
Learn about disease & self-care & monitoring
Understand and deal with emotions
Manage medications
Work with health care providers
Make action plans for exercise and healthy eating
One year after 6-week workshop:
Improvements in stress management, self-reported health, aerobic exercise, health distress, self-efficacy, communication with physicians
Fewer hospital days; more PCP visits

34. Chronic Pain Self-Management Program
Medication isn’t the only treatment….
Developed by Stanford & Memorial Univ. of Newfoundland
Patients learn to manage & decrease chronic pain.
Outcomes:
Less Pain & Lower Dependency on Others
More Energy
Improved Mental Health
Increased satisfaction with life
More involvement in everyday activities

35. Contact Us
June Simmons, CEO Partners in Care Foundation 732 Mott St., Suite 150, San Fernando, CA Main #: