1. History of Partnerships in Colorado For Cost Reduction in Elder Care History of Partnerships in Colorado For Cost Reduction in Elder Care April 2011, CMS send fact sheet CBOs (Community Based Organizations) Starts the funding for CCTP & pre-ACOs (Community-based Care Transition Programs & Accountable Care Organizations) April 2011, CMS send fact sheet CBOs (Community Based Organizations) Starts the funding for CCTP & pre-ACOs (Community-based Care Transition Programs & Accountable Care Organizations) 1

2. The Problem– Poor Outcomes 20% of discharged older patients re-adm. < 30 days Poor medical control of AMI, Pneu., COPD, & HF Communication breakdown after discharge Patients cannot afford the medication Patients cannot get to services for care Not all older adults need the same level of follow-up No transitional programs for improving comm. or care Systems do not talk to each other for care coordination 20% of discharged older patients re-adm. < 30 days Poor medical control of AMI, Pneu., COPD, & HF Communication breakdown after discharge Patients cannot afford the medication Patients cannot get to services for care Not all older adults need the same level of follow-up No transitional programs for improving comm. or care Systems do not talk to each other for care coordination 2

3. History of Partnerships in Colorado For Cost Reduction in Elder Care History of Partnerships in Colorado For Cost Reduction in Elder Care 2011-2012, Colorado builds Partnerships Senior Resource Center (Jefco) DRCOG & AAA St. Anthony’s Hospital Lutheran Medical Center (Dennis Ondrejka) Colorado Foundation for Medical Care Senior Helpers Northwest Denver Connected for Health 2011-2012, Colorado builds Partnerships Senior Resource Center (Jefco) DRCOG & AAA St. Anthony’s Hospital Lutheran Medical Center (Dennis Ondrejka) Colorado Foundation for Medical Care Senior Helpers Northwest Denver Connected for Health 3

4. More Partners Obtain Letters of Intent from various Agencies & committee members represent: 4 Agencies HospitalsSkilled Nursing Facilities Adult Day CentersHospice & Palliative Care Home Health AgenciesTransportation Volunteer ServicesColorado Medical Society Long Term Acute CareMental Health Non-Medical In-Home Care Services Physician Partners

5. Vision of Project Provide Innovative services to address some of the needs of the older adult, community, and to generate funding 5

6. Location2010 -- 60+2020 -- 60+Absolute Change % Change Adams County 55,56095,30139,74171% Arapahoe County 87,493150,56763,07472% Jefferson County 100,535165,28164,74664% Denver County 90,738136,67745,93951% Colorado818,9051,300,309481,40459% Regional, State, and National Growth for Older adults (60 +) 2010 - 2020 Source: Colorado State Demography Office/April 2010 Census 6

7. Why work on Care Coordination? Safety & quality Practice environment Patient experience Resources

8. Eric Coleman Model Four Pillars: –Medication Self-Management –Dynamic Patient-Centered Record –Improve Follow-Up Coordination –Identify Red Flags & > support Four Pillars: –Medication Self-Management –Dynamic Patient-Centered Record –Improve Follow-Up Coordination –Identify Red Flags & > support 8

9. Key Changes Needed Assume shared accountability Provide patient support Build relationships & agreements Develop connectivity

10. Patients Report Experiencing Poor Coordination Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008. Percent U.S. adults reported in past two years : No one contacted you about test results, or you had to call repeatedly to get results Test results/medical records were not available at the time of appointment Your primary care doctor did not receive a report back from a specialist Any of the above Doctors failed to provide important medical information to other doctors or nurses you think should have it Your specialist did not receive basic medical information from your primary care doctor

11. 11 CBO Transitional Care Model and Services Developed by Dennis Ondrejka, 2011

12. Patient Support ≠ Case Management Clinical Care Management Logistical Clinical Monitoring % of panel <5% 10% 20% Care Coordination Clinical Follow-up Care Medication Mgmt Self-mgmt Support Clinical Monitoring

13. Things that must be improved Community Agencies? Tracking & following up on lab/imagining results; Identification & tracking of linkages to community resources. Medical Specialists? Guidelines for referral, prior tests, and information; Expectations about future care and specialist-to-specialist referral; Expectations for information back to PCMH. EDs/ Hospitals? Notification of visit/admission and discharge; Medication reconciliation after transition; Involvement of PCMH in post-discharge care.

14. Seniors’ Resource Center’s Had Drop in Programs for Seniors Care Coordination Adult Day Services In-Home Care Services Job Training Transportation Volunteer Services Volunteer Driver Services Rural Services Southwest Plaza Services Care Coordination Adult Day Services In-Home Care Services Job Training Transportation Volunteer Services Volunteer Driver Services Rural Services Southwest Plaza Services 14

15. Data Collection on Re-admissions (one hospital) Overall re-admission rate 9.08% Top 5 Diagnosis for re-admissions Pneumonia Septicemia Infection, Urinary Tract NOS Fibrillation, Atrial Acute Kidney Failure, unspecified Overall re-admission rate 9.08% Top 5 Diagnosis for re-admissions Pneumonia Septicemia Infection, Urinary Tract NOS Fibrillation, Atrial Acute Kidney Failure, unspecified

16. Root Cause Analysis for re-admissions (Data) Heart Failure Re-admissions 33 Records Reviewed Jan – July 2011 Refusal of Alternative Level of Care, including SNF and Hospice Medication Compliance issues No Primary Care Physician Self Management issues Heart Failure Re-admissions 33 Records Reviewed Jan – July 2011 Refusal of Alternative Level of Care, including SNF and Hospice Medication Compliance issues No Primary Care Physician Self Management issues 16

17. Eric Coleman Model To fix the issues How do we do it? Why do we do it? Hospital VisitMedication Education, PHR, Physician Follow-up, Warning Signs Home VisitMedication Recon, Rev/update PHR, Check on Physician Follow-up, Discuss side effects of meds Follow-Up Calls Discuss med questions, discuss PCP visit, encourage PCP visit if it has not happened, Discuss when/if PCP should be called Red FlagsEducation on side effects, warning signs & symptoms 17

18. Data on Coaching Programs one hospital’s results Coach’s Hours: Nurse – 1 year at Hospital X as a coach For 6 months it was.80 FTE 6 months it was.60 FTE Coach’s Hours: Nurse – 1 year at Hospital X as a coach For 6 months it was.80 FTE 6 months it was.60 FTE 18 NumbersReadmits Total Referred493 Total Approached329 Total Coached166 Total Coaching Intervention340 – 0.0% Partial Intervention13223 – 13.8% Average National Rate020.0% CTI Total Process – 1 visit at Hospital, 1 Home Visit, 3-Phone calls

19. Discharge Risk Assessment Tools LACE assessment PAM 6 assessment PAM 13 assessment Determines who needs the most follow-up and at what level. LACE assessment PAM 6 assessment PAM 13 assessment Determines who needs the most follow-up and at what level. 19

20. RED Project Re-engineered Hospital Discharge Program < readmissions 20 Educate the patient about his or her diagnosis throughout the hospital stay. Make appointments for clinician follow-up and post-discharge testing Discuss with the patient any tests or studies that have been completed in the hospital and discuss who will be responsible for following up the results. Organize post-discharge services. Confirm the Medication Plan. Educate the patient about his or her diagnosis throughout the hospital stay. Make appointments for clinician follow-up and post-discharge testing Discuss with the patient any tests or studies that have been completed in the hospital and discuss who will be responsible for following up the results. Organize post-discharge services. Confirm the Medication Plan.

21. RED Project Re-engineered Hospital Discharge Program < readmissions 21 Reconcile the discharge plan with national guidelines and critical pathways. Review the appropriate steps for what to do if a problem arises. Expedite transmission of the Discharge Resume (summary) to the physicians (and other services such as the visiting nurses) accepting responsibility for the patient’s care after discharge that includes: Assess the degree of understanding by asking them to explain in their own words the details of the plan. Give the patient a written discharge plan at the time of discharge that contains: Provide telephone reinforcement of the discharge plan and problem-solving 2-3 days after discharge. Reconcile the discharge plan with national guidelines and critical pathways. Review the appropriate steps for what to do if a problem arises. Expedite transmission of the Discharge Resume (summary) to the physicians (and other services such as the visiting nurses) accepting responsibility for the patient’s care after discharge that includes: Assess the degree of understanding by asking them to explain in their own words the details of the plan. Give the patient a written discharge plan at the time of discharge that contains: Provide telephone reinforcement of the discharge plan and problem-solving 2-3 days after discharge.

22. CCTP Projects Moved to Accountable Care Act (Obama Care, P4P program/ yr.) 2010201120122013201420152016201720182019202020212022 Insurance Reforms (no Cancelation for Children with Pre-existing Conditions, no Annual or lifetime limits, Children on Parents Ins. to age 26 Small Business Tax Credits for Insuring Employees Healthcare.gov launched to help people choose best plan-Insurance Exchanges Hospital Quality Payment Reduction/ readmission payment reductions, ACO created with physicians for quality care. Given additional funds for high quality outcomes Insurance Reform -no limitation for pre-existing conditions for adults, no limits, Essential Benefits Individual Ins. Mandate, Individual Tax Credit, Small Business Tax Credit Increased, Fines for failures Medicaid Expansion for those in very low income status Affordable Health Insurance Exchanges in States Fines for large Employers not providing health insurance Hospital acquired infection Penalties--Quality Issue Physician Value Based Payments Hospital penalties for lack of meaningful use technology not implemented ?????? 22