1. May 10, 2012 1 Person-Centered Hospital Discharge Planning Workgroup

2. Agenda Welcome and Introductions Short review of workgroup goals Review evaluation of ADRC Care Transitions Project Discuss ADRC Care Transitions pilot site lessons learned Understand opportunities for collaboration with other NH care transitions projects Brainstorm options for the ongoing role of ServiceLink’s in discharge planning throughout the state Finalize “recommendations” document outline 2

3. Person Centered Hospital Discharge Planning Model 2010: Establish workgroup, evaluate models, develop model for NH, develop tools and resources 2011: Develop implementation plan for two pilots, develop evaluation, training in model and tools. Implementation in two pilot areas late in year 2 2012: Engage hospitals in statewide roll out, evaluate and modify, develop sustainability plan, roll out statewide late in year 3 3 Timeline established in grant application

4. The focus of a person-centered system is on the individual, their strengths, and their network of family and community support in developing a flexible and cost effective plan to allow the individual maximum choice and control over the supports they need to live in the community. 4 Person-Centered System Source: Sue Fox “Person-Centered Services Hosp Disch Webinar_suefox

5. A person-centered system respects and responds to individual needs, goals and values. Within a person-centered system, individuals and providers work in full partnership to guarantee that each person’s values, experiences, and knowledge drive the creation of an individualized plan as well as the delivery of services. 5 Person-Centered System Source: Sue Fox “Person-Centered Services Hosp Disch Webinar_suefox

6. A clear structure for shifting the focus of planning and problem solving from program menus and human service solutions to the broader perspective of individual’s and family’s lives and informal and community resources. 6 Process Design in PCP Source: Sue Fox “Person-Centered Services Hosp Disch Webinar_suefox

7. Person-Centered Hospital Discharge Planning Project: Vision and Mission Vision: A coordinated, person-centered long term care system that supports individuals as they transition back into the community. Project Mission: Partner hospitals & community providers will identify persons 65+ who are at-risk of institutionalization or re-hospitalization and utilize person-centered transition planning to help maintain their ability to live & age in the community. 7

8. GOAL 1: Persons who may trigger for use of the Emergency Department or re-admission to the hospital will be identified and appropriate interventions developed and implemented. Activities: Select person-centered criteria for identifying the target population. Define and document the current and potential role(s) for an SLRC in hospital care coordination activities.-Done Offer technical assistance for county-wide inventory of medical and community care coordination & care transition activities.-Ongoing Develop person-centered discharge planning tool for the individual and caregiver(s) to use when communicating with primary care and other community care providers.- Done Use follow-up phone call after discharge to check on how person is doing, and refer if further support needed.-Done (part of each pilot) 8

9. GOAL 2: A person-centered planning approach is incorporated into the hospitals' discharge planning (transition) processes and communicated with care providers, including SLRC's, caregivers, community providers and nursing facilities. Activities: Not Done  Develop a “readiness tool” to assess current person-centered planning practices within an organization to use as a baseline before participating in the training.  Develop a person-centered planning training customized for discharge planners/transitions coaches and offer to all community partners. 9

10. GOAL 3: Perform ongoing project evaluation, which will include (as a minimum) Activities:  Assessment of project accomplishments, gathering input from communities and integrating as appropriate. On-going  Assessment of barriers to implementing person- centered planning from hospitals to community care. On-going  Data collection of Nursing Facility v. Home & Community-Based Care of participants. Not started  Define data elements needed for evaluation- Done 10

11. GOAL 4: Develop a plan for state-wide roll out. Activities:  Offer technical assistance for county-wide inventory of medical and community care coordination and care transition activities. On-going  Develop an ongoing mechanism for medical and community organizations to share transition models in order to facilitate coordination and learning of best practices. In process  Design a roll out plan. In process. 11

12. Design a roll out plan = “Recommendations Document” “Recommendations Document” will help guide BEAS and the SLRC Network as they formalize their hospital care transitions work and will serve as sustainability/funding tool. What have we learned about SLRC’s and acute hospital stays? What have we learned from other care transitions/coordination projects? What are the key components of the document? 12

13. Evaluation Evaluation metrics used for three purposes: 1. Reporting to AoA 2. Guide “recommendations” document for SLRC resource statewide 3. Used by local SLRC’s for sustainability conversations 13

14. SLRC Care Transitions Pilot Refer7 Preliminary Data- Year 1 March 1, 2011 - February 29, 2012 Belknap CarrollMonadnockTotal Unduplicated pilot participants 166* 3238236 Referrals to SLRC 150 2925204 Referrals outside SLRC 51 23285 Hospital # visits pilot only 44 31663 # people pilot only 43 31662 # visits total 166 4162269 # people total 75** 3058163 Consults 84 49135268 Follow-ups home 0 202 hospital 3 5311 call 1 10011 14 *Does not include 18 whose names were not recorded, one pharmacy dept., and one duplicate. **Does not include 32 whose names were not recorded, 4 case mgt dept., 2 nursing staff, 2 social work dept.

15. Outcome 2: Participants feeling prepared for discharge (CTM 3 questions by phone in Monadnock & Carroll, by written survey in Belknap) 15 Evaluation TemplateMonadnockCarrollBelknap Number of consumer surveys sent/received ( as of Jan 5, 2012) n/a* 141/12 % of responses on satisfaction survey feeling prepared for discharge n=11n=4n=12 CTM question 1: staff took my preferences into account (% strongly agree and agree) 82%100%74% CTM question 2: Left hospital with good understanding (% strongly agree/agree) 91%75%74% CTM quesiton3: Left hospital understood purpose of taking meds (% strongly agree/agree) 81%75%69% *phone survey for these questions

16. Outcome 3: Medical and Social Providers report good communication and coordination of medical and social services 16 Hospital provider survey: Belknap- completed (see next slide) Monadnock- in the field Carroll- waiting till Aug/Sept

17. Care Transitions Survey - Lakes Region General Healthcare What is your role? Answer Options Response Percent Response Count Hospital Administrator 20.0%4 Social Worker 15.0%3 Nurse 5.0%1 Nurse Care manager 30.0%6 Physician 10.0%2 Other 20.0%4 answered question20 17

18. Are you familiar with the Care Transition Specialist from the ServiceLink Resource Center, Nancy Bacon, who works part time within your hospital? Answer Options Response Percent Response Count yes 100.0%20 no 0.0%0 18 Please choose the most appropriate response. Answer OptionsNeverRarelySometimesOftenAlways Response Count How frequently do you interact with the Care Transition Specialist? 04610020 I trust the Care Transition Specialist to make appropriate referrals with community based services for patients. Answer Options Response Percent Response Count yes 94.7%18 no 5.3%1 answered question19 skipped question1 Care Transitions Survey - Lakes Region General Healthcare

19. Please indicate if you Disagree or Agree with the following statement: Answer OptionsDisagree Somewhat disagree Somewhat agree Agree Not Applicable % respondents who agree or somewhat agree The on-site Care Transition Specialist has made a difference in the level of care received by patients. 02215089% The Care Transition Specialist communicates with me or my organization, appropriately. 01215094% The Care Transition Specialist calls me or my organization when appropriate. 02411280% The Care Transition Specialist is an integral part of the discharge planning process at our hospital. 02512089% The Care Transition Specialist is an integral part of coordinating social services for patients as they transition back to the community settings. 02314089% answered question19 skipped question1 19 Care Transitions Survey - Lakes Region General Healthcare

20. If there were a full-time Care Transition Specialist available, care transitions would be improved at my facility. Answer OptionsResponse PercentResponse Count yes 94.7%18 no 5.3%1 answered question19 skipped question1 20 Please answer Disagree or Agree to the following statement: Answer OptionsDisagree Somewhat disagree Somewhat agree Agree Not Applicable % responden ts who agree or somewhat agree Overall, as a result of the ServiceLink Resource Center Care Transition Specialist on site at the hospital, I feel there is improved communication between ServiceLink staff and hospital staff. 01314189% Overall, the ServiceLink Resource Center Care Transition Specialist on site at the hospital improved the level of care received by patients. 01513095% answered question19 skipped question1 Care Transitions Survey - Lakes Region General Healthcare

21. Outcome 4: The referral process to link patients to community resources is improved 21 Metrics: 1.referrals to community resources (recall from slide 14 we are still working on cleaning data) 2.Consumer Survey Questions- have results from Belknap for year 1 (see next slide) Outcome 5: participants report confidence in their ability to navigate the medical and social systems. Metric: 1. Survey questions- results from Belknap for year 1 (see next slide)

22. 22 Belknap SLRC n=12 Strongly Disagree Disagree Agree Strongly Agree DK / NA % of Respondents who Agree and strongly agree I know how to find the help I need.3 09 00 75% I know what services and supports are available in my community. 3 072 075% I have the tools and skills I need to manage my care at home. 3 053167% I am well informed and capable of making choices about my care. 3 063 075% I can find the correct service provider(s) for my needs. 2 062267% I am able to clearly describe my needs to service providers. 2 033 050% I am able to follow through with recommendations about my care. 2 073 083% I am able to get answers and solutions even if a service provider staff is not helpful. 3 043258% Consumer Satisfaction Survey- Care Transitions- Belknap SLRC

23. 23 Very Confident Somewhat Confident Not Very Confident Not Confident At All Don’t Know / Not Applicable % of respondents who are very or somewhat confident Overall, how confident do you feel that you have the skills and resources to manage your recovery at home? 82 02 083% Consumer Satisfaction Survey- Care Transitions- Belknap SLRC

24. Belknap SLRC Lessons learned, challenges, surprises Lesson Learned: We needed a better understanding of the Human Resource practices at the hospital. As a result, this delayed 'start up' date. Lesson Learned: Our success came when we utilized existing SL staff. The Counselor is a natural fit for this type of work. Surprise: We didn't need to 'sell' the importance of this pilot to the hospital staff. We had almost immediate buy-in. Surprise: Unintended benefit to our other core services, i.e. value added, increased referrals for Caregiver Support and Medicare Counseling. Challenge: We continue to struggle with discharge to facilities outside of our catchment area. 24

25. Carroll SLRC Lessons learned, challenges, surprises Not every person is going to be receptive to having a non-medical /non- hospital staff person visit them. Need to look more broadly at the CTI Coleman model criteria for health conditions and age and not restrict our program from the beginning. We learned not to rule out participation by the Skilled Nursing facility (SNF) in the project, but to have conversations with the SNF for relationship building and to develop the project to its fullest, especially for the rural areas. We learned that we should have developed and used the client tracking sheet from the beginning of the project. We learned that it was easy early on to have community meetings with hospital, VNS, nursing facility and SNF in order to educate about the project. One challenge we have had is keeping those participants interested in the project and adding additional community members. 25

26. Monadnock SLRC Lessons learned, challenges, surprises Utilization of E-discharge made it easy to receive discharge information and connect with the hospital. The Medical Home clinic care coordinators don’t use e-discharge and effective communication was not established with them during the first year. Data collection was and continues to be (although much less so) confusing. Care Transitions Specialist models are very helpful for training and shifting traditional ways of thinking about providing services but can limit opportunities. There needs to be a constant focus on the original goals In an ideal scenario we would work with project partners locally and potentially elsewhere to establish buy-in for the model, tools for documenting and evaluating early in the process. 26

27. Things every SLRC should know/consider when working with acute care hospital discharges (1 of 3) Know the HR practices at the hospital. Consider forming an advisory team specific to Care Transitions; include hospital, VNA and NF staff. Reach out to community providers to explain pilot goals in order to reduce feelings of threat and 'duplication' accusations. 27

28. Things every SLRC should know/consider when working with acute care hospital discharges (2 of 3) Create relationships across the hospital early on and work to maintain communications: – Not only with the head of the social services department, but with the social workers themselves. – Meet with the hospitalist, covering physicians and nursing staff of the hospital. – Meet with or include the hospital CEO in the process. – Meet regularly with the social services department to reiterate the program, re-evaluate the CTI criteria & review the referral process. 28

29. Things every SLRC should know/consider when working with acute care hospital discharges (3 of 3) For the first year, a lot of work is needed at the management level to establish a successful project (ServiceLink Director level). It is important to work with the hospital’s HR department very early in the process to obtain ‘privileges’ for SLRC staff. It is important to have a good, simple PR document that your SLRC staff and your Care Transitions staff can distribute and refer to when appropriate so that other providers in the community are all getting the same message about the role ServiceLink is “suddenly” playing in a new arena-- what many have considered to be VNA/Nursing Home territory. 29

30. Barriers within the current SLRC Network model that need to be addressed for formal care transitions models or formal partnerships to be implemented/expanded (1 of 3) Sustainable Funding- included (and viewed) as a core service of delivery. Catchment (territorial) limitations. Educate SLRC regarding medical systems. Shared respect for and understanding of work. 30

31. Barriers within the current SLRC Network model that need to be addressed for formal care transitions models or formal partnerships to be implemented/expanded (2 of 3) Time to attend meetings and processes need to be developed for good communication among Care Transition Specialists. Another barrier may be the larger catchment areas of the SLRC network- travel time/cost, more then one hospital with different models, FTE needs. The resources (like meeting time) it takes to start a pilot is significant and not currently reimbursed. Good database skills for Refer7, so data is captured correctly from the start of the project. Funding for on-going training of the Care Transition Specialist. 31

32. Barriers within the current SLRC Network model that need to be addressed for formal care transitions models or formal partnerships to be implemented/expanded (3 of 3) SLRC Network needs to continue on current path toward becoming an independent group with the capacity to represent itself, make decisions as group, speak with one voice. Need agreement for a common approach to collecting data and pulling report information. Network should identify care transitions as initiative it would like to pursue and then identify what care transitions would typically look like for the Network so that we can promote as a group. Network should meet with the hospital association and others to discuss potential roles. 32

33. Person-Centered (P-C) Hospital Discharge Planning: Flowchart of possible project options-DRAFT Non-CFI waiver Has multiple needs No case manager “Trigger” Tool utilized in hosp Hosp discharge utilizes modified P-C tools Direct referral to SLRC Options Counseling: utilizes P-C tools & visits in hospital before discharge P-C transition packet given SLRC VNA, Home Care Other supports Referral to “Choices For Independence” case manager Non-Medicaid Has supports Not “high need” NF, AL, Rehab Discharged to the community with P-C info shared with community providers for continued planning and follow-up ED or Hosp Admit triggers ….. Follow-up calls made every ….. Primary Care Medical Home Case Management Has Medicaid On CFI waiver Has case manager P-C transition packet given

34. KEY to Abbreviations: P-C means “person-centered” CFI stands for “Choices for Independence,” a NH Medicaid waiver program SLRC is “ServiceLink Resource Center” NF is “nursing facility” AL is “assisted living” ED is “emergency department”

35. Some Possible Components of Specific “Boxes”: “Trigger Tool” is a type of screening form that will be used to identify the target population “Transition Packet” contains person-centered tools and resources, possibly including: Personal Resource Guide, Meds “Day Planner,” few weeks of planning calendars, other P-C tools “Choices for Independence” (CFI) case manager is one example, there are other care coordinators that should also be includes as appropriate

36. A clear structure for shifting the focus of planning and problem solving from program menus and human service solutions to the broader perspective of individual’s and family’s lives and informal and community resources. 36 Process Design in PCP Source: Sue Fox “Person-Centered Services Hosp Disch Webinar_suefox

37. Outline for Recommendations Document 37

38. Work group name Remain statewide with representation from both medical and community system providers. Goal - have a forum for programs occurring around Care Coordination and Care Transitions can share projects, learn from each other, collaborative when appropriate, etc. We spend a good hour of every meeting on project updates and people seem to get a lot out of this time. Goal - enhance the level of involvement of community based organizations with CC and CT projects across the state. The forum would allow us to identify opportunities and strengthen the approach. MA= Safe Passages Collaboration 38

39. Work group Name Partnership to Promote Effective Care Transitions Community Care Transitions Partnership Partnership on Care Transitions and Coordination (PCTC) Partnership on Community Care Transitions Care Transitions/Coordination Partnership Partnership on Community Care Coordination Partnership to Improve Care Transitions Partnership to Improve Community Transitions Care Transitions Resource Group Care Transitions Collaborative NH’s Care Transitions Network Care Transitions Collaborative (the CTC) Transitional Care Collaborative (TCC) Pathways Collaborative Passageways Paths Navigating Transitions 39