1. Hospital Readmissions Expensive – Putting the Patient First Priceless Cheri Lattimer, R.N., BSN Executive Director Case Management Society of America (CMSA) and National Transitions of Care Coalition (NTOCC)

2. Objectives  1) Define the care barriers and gaps in delivery impactful case management and care coordination  2) Review various models of care and their impact on improving patient engagement and care  3) Understand the value of the professional case manager and the need of workforce development  4) Examine public policies effecting case management, new measures and reimbursement codes

3. Critical Business Issues ? Health Care Needed A Transformation Access to Care Options (24x7) Collaborative Team Practice Whole Person Care Approach Technology Advancements Premium Increases, MLRs and Provider Payment Transitions of Care Facilitation Inconsistent Approaches Fragmentation & Silo’s of Care Growing Cost of Chronic Care Regulatory/Gov’t Imperatives Gaps Needs “To provide health care services and support to all consumers including health prevention, care coordination, and appropriate resource utilization. To promote quality of care to improve quality of life for our citizens. A commitment to processes that focus on education, consumer advocacy, clinical optimization of resources, patient safety, and technology to achieve superior clinical and financial outcomes with positive member and provider satisfaction” Optimum Health The Vision The Current Process Is Not Working

4. Six Years Ago – March 2010 Congress Passed & President Obama Signed the Health Care Reform Bill – The Patient Protection and Affordable Care Act – Known as PPACA, ACA and ObamaCare Increases access to health coverage Aims to reduce costs via payment reductions and focus on wellness and prevention Seeks to reward “value-based” care delivery

5. Prevention and Treatment of Leading Causes of Mortality Supporting Better Health in Communities Making Care More Affordable Making care safer by reducing harm caused in the delivery of care Ensuring that each person and family members are engaged as partners in their care Promoting effective communication and coordination of care Three Broad Aims of the National Quality Strategy Page  5 www. NTOC C.org 1 2 3 4 5 6 Better Care, Healthy People/Healthy Communities and Affordable Care Six Strategies to Advance these Aims include:

6. Health Care Policy Shaping Our Strategy Courtesy: www.hhs.gov/healthcare /facts/timel ine/index.html

7. Readmissions Expensive ConditionReadmission $ Initial Admission $ % of Readmission Rate CHF$13,000$11,00025.1% All Cause Readmissions $11,20021.2% Heart Attack$13,000$7600- $23,400 17.1% Pneumonia$13,000$9,60015.3% COPD$8,400$7,00017.3% Joint Replacement$12,300$18,5008.2% http://www.beckershospitalreview.com/quality/6-stats-on-the-cost-of-readmission-for-cms-tracked-conditions.html http://www.modernhealthcare.com/article/20150803/NEWS/150809981 Most U.S. hospitals will get less money from Medicare in fiscal 2016 because too many patients return within 30 days of discharge.

8. Most hospitals face 30-day readmissions penalty in fiscal 2016  Only 799 out of more than 3,400 hospitals subject to the Hospital Readmissions Reduction Program performed well enough on the CMS' 30-day readmission program to face no penalty. Thirty-eight hospitals will be subject to the maximum 3% reduction, according to a Modern Healthcare analysis of newly posted CMS data.newly posted CMS data  For fiscal 2015 the CMS added treatment for two conditions— chronic obstructive pulmonary disease and total hip and total knee replacements—and the penalty rose to 3%. The majority of hospitals faced fines during that reporting year. The number subject to penalties in fiscal 2016 rose by 55 facilities, to 2,665. http://www.modernhealthcare.com/article/20150803/NEWS/150809981

9. What Causes Poor Transitions of Care & Often Hospital Readmissions?

10. Transition Issues Dramatically Impact Patients & Their Family Caregivers Patient & Caregiver Caregiver ERERICUICU In-PatientIn-Patient Patient & Caregiver OUTPATIENT: Home Home Home Care Home Care PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Caregiver Caregiver Hospice HospiceOUTPATIENT: Home Home Home Care Home Care PCP PCP Specialty Specialty Pharmacy Pharmacy Case Mgr. Case Mgr. Caregiver Caregiver Hospice HospiceSNFSNFALFALF

11. OUTPATIENT: Home Home Care PCP Specialty Pharmacy Case Mgr. Caregiver Hospice Patient & Caregiver ERICU In-Patient Patient & Caregiver SNFALF NO Medication Reconciliation NO Personal Medicine List NO Coordinated Care Plan NO Discharge Care Plan NO Care Plan NO Medication Reconciliation NO Personal Medicine List NO Care Plan NO Medication Reconciliation NO Personal Medicine List Transition Issues Dramatically Impact Patients & Their Family Caregivers & Providers

12. New Models of Improving Transitions of Care  Dr. Eric Coleman – Transition Coaching - http://www.caretransitions.org http://www.caretransitions.org  Dr. Mary Naylor – Advanced Nurse Practitioners - http://www.nursing.upenn.edu/media/transitionalcare/Pages/default.as px http://www.nursing.upenn.edu/media/transitionalcare/Pages/default.as px  Guided Care - Dr. Chad Boult - Guided Care Nurse - http://www.guidedcare.org http://www.guidedcare.org  Boston University Medical Center - Project RED – Re-engineering Discharges – http://www.bu.edu/fammed/projectred/http://www.bu.edu/fammed/projectred/  Society of Hospital Medicine – Project BOOST- http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTr ansitions/CT_Home.cfm http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTr ansitions/CT_Home.cfm  Transition of Care Clinic - Tallahassee Memorial Hospital – Dr. Dean Watson, Chief Medical Officer  Rush Enhanced Discharge Planning Program – Rush University Medical Center - Robyn Golden, MA, Director of Older Adult Programs. robyn_golden@rush.edu.robyn_golden@rush.edu 

13. Health Care Policy Brings Innovation, Creativity, & Opportunity Comprehensive Primary Care

14. Moving Towards Collaborative Care Source: Robert Wood Johnson Foundation (November 2011). Implementing the IOM Future of Nursing Report—Part II: The Potential of Interprofessional Collaborative Care to Improve Safety and Quality. Accessed on 04/06/2012 at http://www.rwjf.org/humancapital/product.jsp?id=73585http://www.rwjf.org/humancapital/product.jsp?id=73585

15. NTOCC’s Seven Essential Interventions Categories Medications Management Transition Planning Patient and Family Engagement / Education Information Transfer Follow-Up Care 1 2 3 4 5 Health Care Providers Engagement 6 Shared Accountability across Providers and Organizations 7 http://www.ntocc.org/Toolbox/browse/

16. Reducing Readmissions Means Improved Communication & Strong Team Collaboration

17. A Different Level of Physician Engagement Todays Health System transformation call for a different level of physician engagement – organizing care around the patient – means working together in teams – Embracing the bigger mission of the organization “An engaged physician workforce is also linked to enhanced patient care, greater efficiency and lower cost and improved quality and patient safety.” http://www.hhnmag.com/display/HHN-news- article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Magazin e/2014/Apr/gatefold-medsynergies

18. Creating the Collaborative Clinical Team http://www.crystalgraphics.com/ Collaboration among physicians, pharmacist, nurses, case managers, social workers, allied health and supporting staff is critical to achieving the goals of the team, the organization and changing the way we deliver healthcare today

19. The Pharmacy Opportunity Leadership role in interdisciplinary efforts to establish accurate and complete medication lists – Hospital admission and discharge – Any change in level of care Encourage community-based providers and health care systems to collaborate in medication reconciliation efforts Educating patients and their caregivers on their role in retaining a current list of medications Assisting patients and caregivers through the provision of a personal medication list Providing a Comprehensive Medication Review (CMR) ASHP. Medication Therapy and Patient Care: Organization and Delivery of Services–Positions. 2009.

20. Case/Care Manager Skills Are Required For Success in These New Models! Courtesy: www.CMSA.org – CMSA Standards of Practice 2010www.CMSA.org

21. Patient & Caregiver ERICU In-Patient Patient & Caregiver OUTPATIENT: Home PCP Specialty Pharmacy Case Mgr. Caregiver SNFALF ED Case Mgr Hospital Case/Care Mgr Managed Care/ Case Mgr Continuum Case/Care Mgr Connecting the Case/Care Management Community Through Team-Based “Hand-Overs ” Patient Navigators & Community Health Workers

22. Integrated Behavioral & Medical Collaborative Care  Initial agreed upon clinical and functional goals  First line evidence-based intervention through primary care clinician  Psychiatrist-supervised systematic diagnostic assessment with baseline symptom documentation  Comprehensive medication review, management and coordination with the pharmacist and care team  Treatment to target--care escalation based on follow-up findings (psychiatrist involvement and treatment change)  Symptom stabilization and return to primary care follow-up  Integrated case management professionals  Psychiatric consultation team  Psychiatrist-led BH team assesses all medical admissions for BH comorbidity as a part of hospitalist group teams Case Management Society of America & Cartesian Solutions, Inc.™©

23. Innovative Health Information Technology  Technology Enabled Transitions  Using data analytics and the EHR to shift from event based treatment to continuity of care  Approach to a preventive medicine comprehensive wellness focus  Integrated and interactive transfer of information in a timely and effective manner to providers, patients and family caregivers  Understanding data in forming new interventions or programs  Make it more than a financial business move but a focus of improving the patient-experience and becoming the change agent for a failing healthcare system

24. Don’t Forget The Patient & Their Family Caregiver – You Are Their Team

25. How Well Do We Know our Patients and their Family Caregivers?  Do they want the same outcomes as their clinical team?  Do we really understand our patient and their family caregiver?  So we know the specifics of their world?  Do we care about those specifics or are we tuned to a check list of what needs to be done to meet performance measures and/or get reimbursed?  Are we focused on how to prevent a readmission?  How do we define success?  Clinical Indicators  Health Status  Adherence  Cost Containment – Length of Stay, Meets Criteria

26. The Patient Definition of Success?  Let me know you care by what it is in your policies, programs and outreach  Be proactive and teach me to be proactive  When you are developing programs think about what if this were me or my loved one  Provide resources that I need and teach me how to use them  Understand my perspective because we want the same things, those things may just ne defined a little differently  Remember you are on my side & team – I am not just a patient or on your team

27. I am the Patient Ask Me

28. Pharmacy Employer PCP/Medical Home Specialist Pat ient & Caregiver Hospital Community Health Center Health Plan Adherence Assessment & Support Health Promotion Motivational Advocacy Prescription Assessment & Care Plan Motivational Interventions Advocate Assessment Medication Reconciliation Care Plan Adherence Assessment & Support Coordination & Care Plan Non-Adherence Behavior Health Change Facilitation Increase Productivity LTC Home Health Hospice Area Agencies on Aging Facilitation Assessment & Support But we need to go further in recognizing that care coordination is a collaborative process supported by a multidisciplinary teams who must coordinate, communicate and transfer information with each other and their patients and family caregivers

29. Continued Support for Care Coordination & Transitions of Care

30. Transitional Care Codes Implemented January 2013 99495: Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge 99496: Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least high complexity during the service period Face-to-face visit, within 7 calendar days of discharge. National Average $142.96National Average $231.11

31. FY2015 Medicare Physician Fee Schedule (PFS) – Effective January 2015 – CPT Code 99490  Chronic Care Management Codes (CCM)  Focus on paying for team based care  Patients with two or more chronic conditions  Separate fee for managing multiple conditions  20 minutes of clinical labor time & may be provided outside of normal business hours  Billed no more frequently than once a month  Care management services may be provided by social workers, nurses, case managers, pharmacist  Services must be available 24X7 to patients and their family caregivers  Providers using the CCM code must have an electronic health record or other health IT http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets- items/2014-07-03-1.html

32. Policy & Advocacy: Opportunities in 2016  Senate Innovation for Healthier Americans  Senate Chronic Care Working Group  CMS Physician Payment Rule  CMS’s MACRA implementation  CMS’s IMPACT Act implementation  CMS’s Discharge Planning

33. Development of New Care Coordination Measures  AHRQ – Care Coordination Measurers Atlas  NQF – Performance Measures for Care Coordination  CMS – SOW for QIOs focus on Care Transitions & Care Coordination  TJC – Core Performance Measures & Patient Safety Standard #8 Medication Reconciliation  URAC – Incorporated Transition of Care in revised CM Standards – Case Management Measures  NCQA – Complex Case Management Standards  AMA – PCPI Transitions of Care  ANA – Framework for Measuring Nurse’s Contribution to Care Coordination  PCORI – Patient-Centered Outcomes Research Institute

34. What Can We Do? Focus on patient-centered care Continuous quality improvement Effective Team practice with financial and performance measure alignment including patient measures Team leadership and communication Cultural sensitivity and community focus Integrating behavioral health care with primary care

35. Don Berwick on Partnerships for Patients “ No Single entity can improve care for millions of hospital patients alone. Through strong partnerships at national, regional, state and local levels – including the public sector and some of the nation’s largest companies – we are supporting the hospital community to significantly reduce harm to patients” April, 2011

36. Transitions Of Care & Care Coordination Resources  CAN – Caregiver Action Network- Family Caregiving Resources – www.caregiveraction.org www.caregiveraction.org  CAPS - Consumers Advancing Patient Safety – Toolkits www.patientsafety.orgwww.patientsafety.org  NTOCC - National Transitions of Care Coalition – Provider & Consumer Tools www.ntocc.org www.ntocc.org  CMSA - Case Management Society of America – CM Medication Adherence Guidelines & Disease Specific Adherence Guidelines, CMSA Standards of Practice – CKP - www.cmsa.org– www.cmsa.org  ICM – Integrated Case Management - http://www.cmsa.org/Individual/NewsEvents/IntegratedHealthManagementTrainin g/tabid/380/Default.aspx http://www.cmsa.org/Individual/NewsEvents/IntegratedHealthManagementTrainin g/tabid/380/Default.aspx  AMDA’s (Dedicated to Long Term Care Medicine TM ) Transitions of Care in the Long Term Care Continuum practice guideline - http://www.amda.com/tools/clinical/TOCCPG/index.html http://www.amda.com/tools/clinical/TOCCPG/index.html  ACC and IHI – Hospital to Home – Reducing Readmissions, Improving Transitions - http://www.h2hquality.org/ http://www.h2hquality.org/  AHRQ – Agency for Healthcare Research and Quality - Questions Are The Answers – www.ahrq.org www.ahrq.org  NASW – National Association for Social Workers - http://www.socialworkers.org/Resources http://www.socialworkers.org/Resources  VNAA Blue Print for Excellence – www.vnaablueprint.orgwww.vnaablueprint.org

37. Resources for Development Measures  The Joint Commission (TJC)- http://www.jointcommission.org/assets/1/18/TJC_Annual_Report_2014 _FINAL.pdf http://www.jointcommission.org/assets/1/18/TJC_Annual_Report_2014 _FINAL.pdf  Agency for Healthcare Research and Quality (AHRQ)- http://www.ahrq.gov/professionals/prevention-chronic- care/improve/coordination/atlas2014/ccm_atlas.pdf http://www.ahrq.gov/professionals/prevention-chronic- care/improve/coordination/atlas2014/ccm_atlas.pdf  National Quality Forum (NQF) - http://www.qualityforum.org/measures_reports_tools.aspx http://www.qualityforum.org/measures_reports_tools.aspx  URAC - https://www.urac.org/wp-content/uploads/CaseMgmt- Standards-At-A-Glance-10-9-2013.pdfhttps://www.urac.org/wp-content/uploads/CaseMgmt- Standards-At-A-Glance-10-9-2013.pdf  National Committee for Quality Assurance (NCQA) http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures/HEDIS2 015.aspx http://www.ncqa.org/HEDISQualityMeasurement/HEDISMeasures/HEDIS2 015.aspx  American Medical Association (AMA) - http://www.ama- assn.org/apps/listserv/x-check/qmeasure.cgi?submit=PCPIhttp://www.ama- assn.org/apps/listserv/x-check/qmeasure.cgi?submit=PCPI  American Nurses Association (ANA)- http://www.nursingworld.org/Framework-for-Measuring-Nurses- Contributions-to-Care-Coordination http://www.nursingworld.org/Framework-for-Measuring-Nurses- Contributions-to-Care-Coordination

38. Questions Thank You Cheri Lattimer Executive Director NTOCC & CMSA clattimer@cm-innovators.com