1. Option D ADRC Evidence Based Care Transitions Grant Program Evaluator Workgroup Call November 14, 2011 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL aoainfo@aoa.gov | WEB www.aoa.govaoainfo@aoa.gov

2. Agenda Welcome and Introductions Option D Grantee Spotlight: Florida Future Work Group Calls Resources U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

3. Question for Option D Grantees from California Are any states implementing a streamlined online data collection process? U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

4. Hawaii * Alaska * MT ID* WA † CO † WY NV CA *† NM AZ MN TX † KS * IA WI IL † KY TN † IN † OH MI ALMS AR LA FL † SC * WV VA NC* PA † VT RI † NH † OR * UT SD ND MO * OK NE NY † CT † MA † DC Care Transitions Activities DE Guam Northern Mariana Islands 35 States with ADRC program sites currently conducting care transitions through formal intervention (Total of 97 active sites with an additional 49 sites within active states currently planning to conduct care transitions) 10 States with ADRC program sites currently planning to conduct care transitions through formal intervention (Total of 13 sites currently planning care transitions activities within states with no active sites) GA 9 States not reporting current or planned care transition activities Puerto Rico * Indicates state with current CMS Hospital Discharge Planning Model grant † Indicates state with 2010 ADRC care transitions grant MD *† NJ ME †

5. Option D Grantee Spotlight: Florida Presenters – Randy Hunt, CEO Senior Resource Alliance – Steve Paquet, RN, MS, Hospital to Home Project Director/Transitions Coach – Sarah Duncan, RN Transitions Coach – Sandi Smith, Community and Support Services, Florida DOEA

6. Medicare Readmission Reduction Program Evidence-Based Care Transitions Intervention with Home and Community-Based Services A Hospital/ADRC Partnership

7. Problem Statement Arbaje AI et al. Postdischarge Environmental and Socioeconomic factors and the Likelihood of Early Hospital Readmission Among Community- Dwelling Medicare Beneficiaries. The Gerontologist. 2008;48(4):495-504.

8. Program Goals Reduce potentially preventable Medicare readmissions in patients age 60 and older Increase awareness of the ADRC core functions – To “effectively navigate their health and other long-term support options.” (Source: ADRC Program Overview) Influence health policy at the national level by: – Connecting health and community-based aging social services through the hospital discharge planning process – Post-discharge “stabilization” or health recovery

9. Program Model Intervention Combines: The Care Transitions Intervention SM Evidence-Based Program Transitions Nurse (RN) Coach– 30-day transition support program – www.caretransitions.org www.caretransitions.org SRA - Aging and Disability Resource Center (ADRC) Person-Center Transition Support and Options Counseling Connection to Home and Community-Based Services Information, Referral and Program Awareness Target Population Case Manager referred patients on Medicare, age 60 and older CHF, AMI or Diabetes (complex co-morbidities) Discharged to home in the Tri-county area.

10. Program Funding CHiC Grant - Initial Demonstration Grant Two-Year Funding period: March 2010 - March 2012 Transition Coach/Program for Florida Hospital Orlando, East Orlando, and Winter Park Campuses U.S. Administration on Aging- Option D: Evidence- Based Care Transition Expansion Grant Two-Year Funding Period: February 2010 - September 2012 Added second Transition Coach/Program for Florida Hospital Altamonte, Celebration and Kissimmee SRA was the only active Hospital/ADRC Care Transitions project in Florida eligible to apply and receive this grant

12. Measurement of Outcomes March 2010 - Sept 2011 Preliminary Analysis Intervention Program Activity CHiC (3 Hospitals)TargetTotal% CM Referrals72035950 Not Eligible45 6 Decline (Hospital Visits)63 9 Total Enrollment 360 251 70 AoA (3 Hospitals)TargetTotal% CM Referrals72023633 Not Eligible12 2 Decline (Hospital Visits)72 10 Total Enrollment 360 152 42 February 2011 - Sept 2011 Preliminary Analysis

13. Measurement of Outcomes March 2010 - Sept 2011 Preliminary Analysis Intervention Program Activity Intervention TypeTotalCHiC%AoA% CTI 2007337%12764% CTI Plus (CHiC Only) 120 100%00% ADRC (CARES/Triage) 595695%35% Other 2428%2292% Total 40325162%15238%

14. Assigning Home and Community Based Services DOEA 701A 701A Scores for IADLs at 3 or more Clients may receive more than one service

15. Measurement of Outcomes 701A Scores for IADLs at 3 or more *Clients may receive more than one service “Other” will require DOEA data analysis/evaluation CTI Plus - Funded Home and Community-Based Services March 2010 to September 2011 (CHiC Only) ServicesTotal20102011%Costs 1. Home-Delivered Meals856124 49% $ 8,147.50 2. Transportation43327 25% $ 4,732.78 3. Homemaker453811 26% $ 7,705.20 4. Other ADRC Programs Total*17313142 100% $20,585.48 Average of $120 per client for 30-day transition period

16. Measurement of Outcomes Revenue Management Analysis- 130 Hospital to Home Admissions September 2010 to March 2011 CHiC Grant Only - Readmission Rate – 5.38%

17. Lessons Learned Hospital Partnership Identifying and keeping support of hospital administrative “champions” for the project – Leadership changes – Need to communicate regularly Keeping the flow of referrals constant and time involved in acquisition and enrollment – Case management turnover and workload Need for constant education/re-education – Case management leadership support is critical – Include Nurses and Nursing departments U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

18. Lessons Learned ADRC Process Integrating with ADRC under current workload of ADRC staff “Transitions Support Network” – Importance of education – Sub-Contracting U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

19. Lessons Learned Patient-Centered Lessons Importance of home visit AND follow-up calls Lack of awareness of OAA, its programs and Aging Network Improved quality of transition – Stress reduction for patients and caregivers Intervention becomes more than only 30-day transition support Need of services after discharge vs. waiting lists Avoidable vs. unavoidable readmissions U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

20. Lessons Learned Care Transitions Process Evidence-based intervention not always “cookbook” – Patient factors – Caregiver factors – Hospital factors – Home Health factors U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

21. Questions for Florida team? U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

22. Future Work Group Calls Focus on sustainability Current schedule (monthly) Quarterly schedule? – Intermittent ad-hoc topic-specific calls Other ideas? U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

23. Question from California Are any states implementing a streamlined online data collection process? – Currently, CA’s data collection process involves an Access database Request from the sites is to move it to an online data collection process. Have other sites adopted this approach? – If so, what did you find beneficial or not? U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

24. Care Transitions Resources and Upcoming Events Innovation Advisors Program – Select and develop as many as 200 individuals from across the nation – Deadline to submit applications: November 15, 2011applications Health Literacy: New Skills for Health Professionals (IHI) – November 17, 2011, 2:00– 3:00 PM Eastern – Register Register

25. Care Transitions Resources and Upcoming Events Upcoming Work Group Call (combined with General Care Transitions Work Group) – December 12, 2011 at 1:00 PM Eastern – Register Register U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

26. Questions? Contact Caroline Ryan: caroline.ryan@aoa.hhs.gov caroline.ryan@aoa.hhs.gov U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV