2.  DRCOG has been the region’s Area Agency on Aging (AAA) for 37 years  Administer funds for and implement programs mandated by the Older Americans Act (OAA)  Advocate on behalf of older adults and their families  Act as regional planning entity – conduct strengths and needs assessments of older adults & develop plans on how best to meet those needs  Provide regional coordination of services and activities  Serve eight counties including Adams, Arapahoe, Broomfield, Clear Creek, Denver, Douglas, Gilpin and Jefferson

3. Community-based Care Transitions Program (CCTP): Mandated by section 3026 of the Affordable Care Act, CCTP is a nationwide program of the Centers for Medicare & Medicaid Services (CMS) designed to test models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries.

4.  2008-2011 pilot project through CMS  Designed to engage patients in their own health care and reduce hospital readmissions  14 communities across the nation participated, including the Northwest Denver Connected for Health project led by the Colorado Foundation for Medical Care (CFMC)  Results recently published in the Journal of the American Medical Association (JAMA)  Prevented 1,800 readmissions over the 18 months of the project  Prevented 6,800 new hospital admissions  Showed that for every $1M spent on supporting transitions out of hospitals, Medicare realizes $4M in savings from avoided readmissions

5.  Goals:  Improve transitions  Improve quality of care  Reduce readmissions for high risk Medicare beneficiaries  Document measurable saving to the Medicare program  Requirements:  Partnership between community based organizations (CBO) and hospitals  Implementation of evidence based intervention method  Enroll only Medicare fee-for-service beneficiaries  Term:  2 year project with 3 additional one-year extensions possible  Potential expansion beyond initial 5 year term  Benefits:  Opportunity to “link” medical and non-medical  Engage participants in their own care  A chance to experiment with “No Risk Dollars” and be a leader in finding solutions to hospital readmissions

6.  Preference and Priority  Specifically reference within the application  Various community efforts  Regional approach proposed  Provider Network  Automatic link to community service providers  Single point of entry  One place for all hospitals to call to initiate care transitions

7.  Coalition established to rally hospitals and community service providers around improving care transitions in the Denver metro region.  Met for over a year to solidify partnerships and determine best approach for our community  Submitted successful application for CCTP funding (announced January 14, 2013)  One of 82 in the country

8.  DRCOG’s AAA  Hospital partners:  Exempla Saint Joseph Hospital  HealthOne Hospitals:  Medical Center of Aurora  North Suburban Medical Center  Presbyterian/St. Luke’s Hospital  Rose Medical Center  Sky Ridge Medical Center  Swedish Medical Center  Other partners  30+ Skilled Nursing Facilities  9 Home Health and/or Hospice Agencies  Physicians/physician groups  Multiple “downstream” community service providers (local non-profits, etc.)  Other community leaders:  State Unit on Aging  AARP  CFMC  The Colorado Hospital Association  The Colorado Regional Health Information Organization  The Colorado Medical Society

9. Northwest Metro Hospitals Physicians Long-term Care Facilities Community Care Management Skilled & Non-skilled In-home Care Nutrition Services Transportation Services Transitions Coaches Southeast Metro Hospitals Physicians Long-term Care Facilities Community Care Management Skilled & Non-skilled In-home Care Nutrition Services Transportatio n Services Transitions Coaches Central Denver Hospitals Physicians Long-term Care Facilities Community Care Management Skilled & Non-skilled In-home Care Nutrition Services Transportatio n Services Transitions Coaches DRCOG AAA/ADRC (CBO) Medicare FFS Beneficiaries

10. THE DENVER REGIONAL CARE CONNECTION WILL TARGET MEDICARE FEE-FOR-SERVICE BENEFICIARIES BASED ON THE FOLLOWING CRITERIA:  Diagnosis  Sepsis  Pneumonia  Heart failure  Chronic obstructive pulmonary disease  Discharge Disposition  Home without home health  Home with home health

11.  Intervention Model  Dr. Eric Coleman’s Care Transitions Intervention® (CTI®)  Supported and measured by Patient Activation Measure® (PAM®)  Coaching that begins in the hospital and continues after discharge designed to:  Engaging patient and/or family in care  Medication self-management and reconciliation  Ensure relevant medical follow up  Establish alert/response systems when red flags arise  Supportive Services  Care management:  In-home assessment of existing and needed supports  Establishes specifics of service package  Package of services based on PAM® score:  Nutrition Services  Non-skilled Personal Care and/or Homemaker Services  Transportation Services

12. PAM ® ScoreLevel of InterventionSupportive Services Available 4 Standard care – no DRCC intervention. Information on AAA/ADRC. 3 Follow-up phone call by transitions coach post-discharge:  Review discharge information  Confirm follow-up visit with PCP. Call from AAA/ADRC options counselor:  Discuss needs; refer to community services as appropriate. 2 PAM ® -Tailored CTI ® Coaching:  Hospital visit  Post-discharge home visit  3 follow-up phone calls Call from AAA/ADRC options counselor to assess need for and set up access to:  Meals (up to 5)  Transportation (up to 1 round trip)  In-Home Services (up to 4 hours) 1 PAM ® -Tailored CTI ® Coaching:  Hospital visit  Post discharge home visit  3 follow-up phone calls Visit from CCTP care manager and referral to supportive services providers:  Meals (up to 10)  Transportation (up to 2 round trips)  In-Home Services (up to 6 hours)

13. ROLL OUR STRATEGY  Start with two hospitals, one coach and build from there  Initially – PSL/St. Joe’s WORKFLOW  Hospital rounds trigger referral to DRCOG coach following:  Verification of payer,  Diagnosis, and  Verbal consent to have coach visit  Patient info then goes into queue for DRCOG Coaching staff  DRCOG coach verifies not part of ACO and screens for program (completes PAM®)  DRCOG gets written consent to participate and takes from there

14.  Based on our root-cause analysis, previous experience outcomes and national evidence for the proposed interventions, we expect our program will result in:  Increased patient activation,  Reduced readmission rates,  Reduced admission rates, and  Decreased Medicare costs within our community.

15. Chandra Matthews, MSW DRCOG Area Agency on Aging cmatthews@drcog.org 303.480.6736 cmatthews@drcog.org