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HEALTH REFORMCREATES NEW CARE MODELS AND
OPPORTUNITIES FOR SOCIAL WORK
W. June Simmons, CEOPartners in Care Foundation
April 2nd, 2014
Society for Social Work Leaders in Healthcare
We Thank Our Funders
Our work in this area is made possible through the generous support of:
John A. Hartford Foundation Archstone Foundation AndAdministration for Community Living
Partners in Care FoundationWho We Are
Partners in Care is a transforming presence, an innovator and an advocate to shape the future of health care
We address social and environmental determinants of health to broaden the impact of medicine
We have a two-fold approach, creating and using evidence-based models for: provider/system practice change and enhance patient self-management
Changing the shape of health care through new community partnerships and innovations
Objectives
Participants will be able to:• Describe key Affordable Care Act issues impacting social
work/long term supports and services practice• Recognize key target populations for social work
intervention• Describe central social work strategies and interventions
in this changing environment
4
Ecological Social Work Practice Framework: A Perfect Fit for Health Reform
Community Resources & Partnerships
Institutional Practices
Other Caregivers
Patient/Family
State & National Policy
Enduring Social Work Framework
US outcomes are worse – need to spend more wisely
The Expanded Chronic Care Model: Integrating Population Health Promotion
Social Factors and Health Outcomes
Societal-level social determinants have individual-level impact
Issue Outcome
Low education, lack of social support, and social exclusion
Poor self-management and reduced care plan adherence
Housing and transportation issues
Increased health care costs and utilization
Health disparities and psychosocial issues
Preventable hospitalizations and mortality
The Affordable Care Act: A New Opportunity for
Social Work
Robyn Golden, LCSWDirector, Health and Aging
Rush University Medical CenterChicago, Illinois
ACA, Social Work, and Care Coordination
• ACA provisions create opportunity for new social work roles• Avenues to sustainable care coordination by social
workers increasingly available
• Provisions include• Changing incentives• Changing payment structures• Moving away from fee-for-service
Health Care’s Blind Side
• 2011 Robert Wood Johnson Foundation survey of 1,000 primary care physicians• 85% feel social needs directly contribute
to poor health• 4 out of 5 not confident can meet social
needs, hurting their ability to provide quality care
• Rx for social needs, if they existed, would be 1 in 7 Rx’s written
• Psychosocial issues treated as physical concerns
• Social work operates in this blind side
Moving toward the Second Curve
Adapted from Ian Morrison
First Curve Second Curve
Option on the Health Exchange
Direct Contracts
with Employers
Medicare Advantage
Plan
Accountable Care
OrganizationsBundled Payment
Pilots
Readmission Rate Penalties
Traditional Fee-for-Service Payment System
Population Health Per Capita Payment System
Patient Protection and Affordable Care Act 2010
Reform component What it meansWhat we need to
work on
Readmissions Financial penalties for excess readmissions
Quality and patient safety
Care coordination
Evidence-based care maps
Clinical documentation
Value Based Purchasing
Payment based on performance on core measures
Hospital Acquired Conditions
1% reduction in payment if in top quartile
Patient Protection and Affordable Care Act 2010
Reform component What it meansWhat we need to
work onCoverage expansion More patients with
insuranceManage access
Alignment and partnerships
Manage quality and cost
Manage populations
Care coordination
Informatics
Bundled payments Lump sum payments to providers for 10 conditions
Accountable Care Organizations
Manage care of specified beneficiaries; quality/cost; share of cost savings
Patient-centered medical home
Services, structures and access for continuous & comprehensive care
Bundled Payments• Bundled payment pilot began 01/31/2013
• Single Medicare payment to cover all services for an episode of care to be distributed among care providers:• Acute hospital services• Physicians’ services• Care coordination & transitional care services• Post-acute services
• Home health care• Skilled nursing facility services• Inpatient rehabilitation services
• Pilot testing four variations on bundling model over 3 years to assess efficacy
Medical Homes
• Change in outpatient care delivery toward coordinated, chronic care, including the following supportive services:• Care coordination• Case management• Health promotion• Transitional care• Patient and family support• Referral to community services
• Additional funding available for coordination through greater reimbursement
Accountable Care Organizations• Medicare Shared Savings Program (3022) creates incentive
for the establishment of Accountable Care Organizations (ACOs)• Networks of physicians and other providers • Integrated, cooperative services designed to foster collective
accountability• Share savings resulting from the ACO’s coordinated care
• Reduced Medicare expenditures• Improved beneficiary health outcomes
• No consensus on vital components of an ACO• Will have to address social issues to see true cost savings• Opportunity for social work to achieve
savings and quality improvement
The CMS Innovation Center (CMMI)
• Test innovative payment and service delivery models• To reduce program expenditures • To preserve or enhance the quality of care furnished to Medicare
and Medicaid beneficiaries
• Preference given to models that improve health care coordination, quality, & efficiency• Authority to expand any model
• Funding of $1 billion per year for 10 years• Released through ongoing Funding Opportunity Announcements • Targeted distribution within priority areas• Budget neutrality requirement waived during
testing
Thrive Under Reform• Key elements to making the ACA successful
• Engaging patients• Prevention and wellness• Not transactions but a journey• Transparency of performance• Focus on burden of treatment, not illness• Cost and quality in the same breath
• Where does social work fit?
Changing Times – New Opportunities
• Following patients across the continuum• Connecting sites of care within sectors• Connecting providers of care across sectors• Articulating the value of social work• Persistence is required
Social Work and Mental Health• Social workers can be a valuable member of the mental health team
• Care manager• Therapist• Advocate and educator of the healthcare team
• BRIGHTEN: Bridging Resources of an Interdisciplinary Geriatric Health Team via Electronic Networking
• Team-based approach to mental health in primary care• Along with the social workers, the team is comprised of:
• Patient• Geropsychologist• Geropsychiatrist• Physical Therapist• Occupational Therapist• Nutritionist• Chaplain• Pharmacist• Primary Care Physician
Social Workers and Interdisciplinary Teams in Practice
• Social workers are both valuable contributors to a team and effective leaders
• This can be seen in successful models utilizing social workers as team coordinators• Social Work and Mental Health
• BRIGHTEN: Virtual interdisciplinary program integrating mental health into primary care
• Social Work and Transitional Care• Bridge Model: Transitional care model provided by MSW’s from a
biopsychosocial perspective• Social Work and Patient Centered Medical Homes (PCMH)
• Ambulatory Integration of the Medical and Social (AIMS Model): Primary-care based care coordination
Targeting Home & Community-Based Services in Active Population Health Management
Congregate Meals, Socialization, Exercise
Evidence-Based Self-Managementfor Chronic Conditions
Care Transitions &HomeMeds/Home Support
LTSS/Caregiver Support
EOLCare
Continuum of Home and Community-Based Services for Older Adults
Incr
easi
ng F
unct
iona
l or C
ogni
tive
Impa
irmen
t
Dec
reas
ing
Num
bers
– In
crea
sing
Cos
t
Examples: Hospice & home palliative care
Examples: SNF diversion, Respite Care, Home Modifications, home monitoring, daily meals, assisted transportation
Examples : Stanford Healthier Living; Diabetes Self-Management; Matter of Balance
Examples: Coaching & Patient Activation, Home-delivered Meals; Referral to Self-Management Classes
Examples: Activity programs & education @ senior center
Targeted Patient Population Management with Increasing Disease/Disability
End ofLife
Complex Chronic Illnesses w/ major
impairment
Chronic Condition(s) with Mild Functional &/or
Cognitive Impairment
Chronic Condition with Mild Symptoms
Well – No Chronic Conditions or Diagnosis without Symptoms
Hot Spotters!
Evidence Based Self-Management, Home
Assessment and HomeMeds
Home Palliative Care
Post Acute and Long Term Supports and
Services
Avoidable Readmissions Penalty
• Incentive to improve care transitions & reduce avoidable readmissions
• Lost reimbursement to drive performance improvement• Penalty for each hospital based on risk-adjusted actual 30-day
readmission rate compared to expected readmission rate• Reduced Medicare DRG payments by 1%, rising to 3% in 2015• 3 target conditions starting in FY 2012, expanding to 7 in FY
2015
• Hospital-specific readmission rates posted on Hospital Compare website for public viewing
• Expand to skilled nursing homes & Home Health agencies
Community Based Care Transitions Program (3026)
• Provides funding to hospitals & community-based entities that furnish evidence-based transition services to Medicare beneficiaries at high risk for readmission
• Preference for medically underserved areas, small communities, rural areas & AoA programs
• Services must include at least one of 5 interventions• Arranging post-discharge services• Providing self-management support (or caregivers
support)• Conducting medication management review
• 5 year program started in 2011
Bridge Model: Primary Goals Addressed by Social Work
3 guiding tasks to reach the goal of preventing avoidable adverse events post-discharge:
1. Ensure patients receive appropriate services in their home post-discharge
2. Connect patients to their physician for follow-up appointments
3. Support caregivers to reduce stress and burden
Social Work and Transitional Care: Bridge Model
• Bridge social worker serves as primary care coordinator• Manages care coordination tasks• Facilitates inclusion of other team members
• Additional team members vary by client• Inpatient case manager & attending physician• Primary care physician• Pharmacist, therapists, other medical providers• Home health care provider• Community service provider
Social Work and Patient Centered Medical Homes (PCMH)
• Role for social workers in augmenting the patient’s primary care encounter• Address gaps in care resulting from insufficient time, staff,
resources• Provide compensatory support to meet patients’ medical and
psychosocial problems• Assess patients’ psychosocial considerations and their impact on
medical status• Educate providers how to support patient self-management
• This resource is central to PCMH success• True improvement in care, health, and cost cannot be done without
addressing the factors that impede patients’ medical care plan adherence
• Ambulatory Integration of the Medical and Social (AIMS) Model at Rush
Outcomes of Social Work Involvement and Leadership
• These three examples demonstrate success as a result of social work involvement• BRIGHTEN: Lower PHQ-9 scores & depression scores• Bridge: Increased communication with physicians & keeping medical
appointments; Decreased mortality• PCMH Social Work: Increased well-being; decreased stress; more
time for medical issues at next appointment
• However, social work evidence not extensive: ongoing challenge for field
Getting to the Table
• What can social work education programs do to get social work to the table?• Find cross-institutional ways to collaborate• Learn to communicate and market social work• Frame social work from other perspectives
• Speak the language of other professions
• Vary the message to fit the mission of the team• Find ways to partner with other disciplines
• Example: Delegating tasks to community health workers so social worker can focus on skilled activities
Future of IPEP and Geriatric Social Work
• We must prove the value of social work• Make clear business case• Show return on investment from social work involvement
• Clarify how social work helps to meet the Triple Aim of better care, better health, lower cost
• Frame within social determinant of health language and not just make it a guild issue• Not social workers can do it better• Social workers can do it, too
• Comparative effectiveness research to show outcomes of not having social worker involved
The Imperative
• Critical to incorporate:• The social determinants of health• Prevention• Care coordination
• It takes a village• Need a team to meet the needs of increasingly complex, older
patient population• Responsibility cannot solely reside with the physician
• To meet this imperative, we must innovate
5% spend 50%
1% spend 21%
The Upstream Approach: What would happen if we were to spend more
addressing social & environmental causes of poor health?
Most of Costliest 5% have Functional Limitations
http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf
Concentration of Risk
• Functional Limitation• Dementia• Frailty• Serious illness(es)
Dementia and Total Spend
• 2010: $215 billion/yr• By comparison: heart disease $102 billion; cancer
$77 billion• 2040 estimates> $375 billion/yr
Source: Hurd MD et al. NEJM 2013;368:1326-34.
Dementia Drives Utilization
Dementia No Dementia
Medicare SNF use 44.7% 11.4%
Medicaid NH use 21% 1.4%
Hospital use 76.2% 51.2%
Home health use 55.7% 27.3%
Transitions 11.2 3.8
Prospective Cohort of Community dwelling older adults
Source: Callahan et al.JAGS 2012;60:813-20.
In case you are not already worried…
The Future of Dementia Hospitalizations and Long Term Services+Supports
10 fold growth in dementia related hospitalizations projected between 2000 and 2050 to >7 million.
Zilberberg and Tija. Arch Int Med 2011;171:1850.
3 fold increase in need for formal LTSS between now and 2050, from 9 to 27 million.
Lynn and Satyarthi. Arch Int Med 2011;171:1852.
Because of the Concentration of Risk and Spending, Home and Community Care Principles
and Practices are Central to Improving Quality and Reducing Cost
Surprise! Home and Community Based Services are High Value
• Improves quality: Staying home is concordant with people’s goals.
• Reduces spending: Based on 25 State reports, costs of Home and Community Based LTC Services less than 1/3rd the cost of Nursing Home care.
This is Our Expertise
• Highest risk, highest cost population is ours: functional limitation, frailty, cognitive impairment +/- serious illness
• We need a fully integrated service line that also addresses keeping people out of the top 5%
Home and Community Based Services – a Specialty Practice Expertise
• Evidence-based approaches underlie all our work• In-Home assessment and supports, long and short term –
waivers/ Care Transitions• Caregiver skills and support
Determinants of Health & Contribution to Premature Death
Source: Stephen A. Schroeder, MD. We Can Do Better. NEJM 357:12
Predisposition30%
Social Circumstances 15%
Environmental Exposure 5%
Health Care 10%
Behavioral Patterns 40%
Scope of the Problem
• 1.7 million Americans die of a chronic disease each year
• Chronic diseases affect the quality of life for 90 million Americans
• 87% of persons aged 65 and over have at least 1 chronic condition; 67% have 2 or more
• 99% of Medicare spending is on behalf of beneficiaries with at least one chronic condition
Projected “Boomers” Health in 2030
• More than 6 of every 10 will be managing more than one chronic condition
• 14 million (1 out of 4) will be living with diabetes• >21 million (1 out of 3) will be considered obese
• Their health care will cost Medicare 34% more than others • 26 million (1 out of 2) will have arthritis
• Knee replacement surgeries will increase 800% by 2030
Source:“ When I’m 64: How Boomers Will Change Health Care ”,American Hospital Association, May 2007
Building Our New Business Model: Focus AreasEvidence Based
Self-Management
Assessments, Care Coordination &
Coaching
Efficient Delivery System Provider
Networks
Chronic Disease HomeMedsEvidence-Based Leadership Council
Chronic PainAdult Day/CBAS Assessment
Care Coordination Network
Diabetes (billable) Home Safety EvaluationCare Transitions Provider Network
A Matter of Balance Home Palliative Care
Savvy CaregiverShort & Long-Term Care & Service Coordination
Powerful Tools for Caregivers
Care Transitions Interventions
Arthritis Foundation Exercise & Walk with Ease
UCLA Early Memory Loss
What is Self-Management?The actions that individuals living with chronic
conditions must do in order to live a healthy life.
Problem-Solving
Planning
Physical Activity
Manage Fatigue
Medications
Working with Health Professionals
Family Support
Managing Pain
Communication
Healthy Eating
Understanding Emotions
Better Breathing
CDSMP: The “Gold Standard”
• Improves health and quality of life• Benefits people at all SES and education levels
• Reduces health care costs• Improvements and cost savings are sustained over time• Findings documented over 20 years of research in a
variety of settings• Offered in many countries and in over 20 languages
Some Leading Evidence-Based Programs
SELF-MANAGEMENT• Chronic Disease Self-Management• Tomando Control de su Salud• Chronic Pain Self-Management• Diabetes Self-Management Program PHYSICAL ACTIVITY• Enhanced Fitness & Enhanced Wellness• Healthy Moves• Fit & Strong• Arthritis Foundation Exercise Program• Arthritis Foundation Walk With Ease
Program• Active Start• Active Living Every DayMEDICATION MANAGEMENT• HomeMeds
FALL RISK REDUCTION• Stepping On• Tai Chi Moving for Better Balance• Matter of BalanceDEPRESSION MANAGEMENT• Healthy Ideas• PEARLSCAREGIVER PROGRAMS• Powerful Tools for Caregivers• Savvy CaregiverNUTRITION• Healthy EatingDRUG AND ALCOHOL• Prevention & Management of Alcohol
Problems
Reducing Readmissions a New Priority
• Readmission penalties inspiring rapid change• CMS testing new CBO Medicare models• Moving to all cause/all payers• Integrated regional delivery system• Multiple evidence-based approaches• New innovations in broadening array of settings
Goals of In-Home Coaching Transition Programs
• Engage patients (&/or caregivers) with chronic illness and activate self-care & behavior change
• Follow post-discharge to ensure meds/services received• Teach/coach regarding medications, self-care, symptom
recognition and management• Remind and encourage patients to keep follow- up
physician appointments – ensure transportation
How to achieve these goals differs across programs
Best Practices (Coach focus group)• Identify at-risk patients
• Case managers who know patient & family provide fewer, but more appropriate patients
• Hospital-based coach who gets to know staff, schedules, how to find patients – staff trusts more and therefore refers more
• 24 hours pre-discharge is ideal time
• Room Visit• “I’m here on recommendation from”…someone patient knows –
MD, case manager
• Efficiency• Field coach & hospital coach allows everyone to see more
patients• Teamwork gives us more flexibility – cover more times of
day and languages
Coleman Care Transition Intervention• Social Worker or Health Coach (one per 40 patients)• Duration-30 days post hospital/SNF
• One visit in hospital• One Home visit post-DC or post-SNF• Three follow-up calls within 30 days
• Based on four pillars• Medication Reconciliation & Management• Personal Health Record (PHR)• Primary care and specialist follow-up• Knowledge of red flags re: symptom exacerbation
• Results*• In RCT, CTI prevented 1 readmission per 17 patients • Savings $300,000 per 350 patients (cost<$170,000)
*California Healthcare Foundation-”Improving Care Transitions” October 3, 2007
Coleman/Bridge Commonalities• Identify at-risk patients
• Unit Nurse• Care Managers or Discharge Planners• EMR system data/risk algorithm
• Room Visit• Introduce & Explain• Determine need, coachability or appropriateness• Consent• Begin assessment• Leave info• Schedule visit or calls
• Follow-Up at home or by phone• Verify discharge orders complete: meds, equipment, home health, etc. • Ensure MD visits scheduled w/ transportation if needed• Connect with resources, including meals• Verify understanding of self-care• Encourage healthy behaviors
• HomeMeds for medication reconciliation & safety
Medications & Care Transitions
• 72% of post-discharge adverse events are related to medications—and close to 20% of discharged patients suffer an adverse event. *
• 35% of Medicare patients taking 5 or more medications experience adverse drug events
• HomeMeds program – a social work solution
*Mary Andrawis, PharmD, CMMI, presentation to Drug Safety Panel, May 10, 2011 (Forster et al. Annals of Internal Medicine. 2003; 128: 161-167./ CMAJ FEB 3, 2004;170-3)
HomeMedsSM proven solution in four important problem areas affecting seniors:
1. Unnecessary therapeutic duplication2. Falls and confusion related to possible inappropriate psychoactive
medication use3. Cardiovascular problems such as continued high/low blood
pressure or low pulse4. Inappropriate use of non-steroidal anti-inflammatory drugs (NSAIDs)
in those with high risk of peptic ulcer/gastrointestinal bleeding
Coach & software identify medication-related problems and pharmacist works with patient and prescribers to resolve them.
Value-Added Service: HomeMedsSM
The Right Meds… The Right Way!
www.homemeds.org
Evidence-based Protocols
Identified by expert panel – chosen for in-home intervention and positive response by prescribers (minimize “alert overload”)
1. Unnecessary therapeutic duplication
2. Use of psychotropic drugs in patients with a reported recent fall and/or confusion
3. Use of non-steroidal anti-inflammatory drugs (NSAID) in patients at risk of peptic ulcer
4. Cardiovascular medication problems• High BP, low pulse, orthostasis and low systolic BP
Care Transitions: Buy vs. Build Decision
Patients discharged to geographically disparate parts of the County
Lancaster
San Pedro
Considerations: Driving distances to patient home Knowledge of local services Training and experience Language / Culture Data collection / patient monitoring
Woodland Hills
Regional Model = centralized, cost- effective, efficient and
experienced!
Individual Hospital Approach: Each hospital must hire, train, manage and pay transitions
directors and health coaches
Partnering with Skilled Nursing Facilities & Home Health Agencies to Prevent Hospital
Readmissions
Kelley Hart, LVN, Katie Gurvitz, MHA, Michelle Hofhine, RN
Turning on the High Beams
October 10, 2013
The Problem
Discharged to SNF
Home with Home Health
Cedars-Sinai 20.2% 18.3%
All UHC Hospitals(Average)
17.8% 17.1%
All-Cause 30-day readmission rateJuly 2010 – June 2011
The Cedars-Sinai 30-day all-cause readmissions rate for SNF & Home Health patients was higher than the average for all UHC
hospitals.
Project Charge
Focus SNF Patients and Home Health Patients
Metric 30-day all-cause readmissions to CSMC
Target 50% reduction
Our Results
Discharged to SNF
Home with Home Health
Baseline30-day readmission
rate25% 14%
Pilot Period30-day readmission
rate11% 7%
By engaging in robust performance improvement, Cedars-Sinai Health System identified interventions that reduced 30-
day readmissions for SNF & Home Health patients by more than 50%.
Root Causes for SNF Readmissions
• Infrequent visits by a physician or advanced practice nurse
• Patient not seen by physician within first week of discharge
• SNF nursing staff unable to communicate with physician when needed
• Patient/Family not communicating Red Flags to SNF staff
• Lack of clinical oversight on weekends• Medication Management/Reconciliation between hospital
and SNF• Patients at end of life without an Advance
Directive/POLST completed
A chart review of 150 SNF patients revealed recurring factors that likely contributed to preventable readmission within 30 days.
SNF Intervention: Enhanced Care Program
Pilot 1: October/November 2011Pilot 2: January/February 2012
A Nurse Practitioner followed 115 CSMC patients in the SNF.• They saw the patient in the hospital
• They saw the patient in the SNF 24 hours after discharge
• They saw the patient 1-2 times per week in the SNF
• When they saw something, they said something… (to the patient’s MD, the SNF staff & to
the family)
Root Causes for Home Health Readmissions
• Patients & families often turn away Home Health agencies after hospital discharge
• Inconsistency in frequency of home visits post-discharge
• 45% of readmissions occurred on a Saturday or Sunday
• Patient/Family not communicating Red Flags to Home Health agency
• Medication Management/Reconciliation
• Physicians not responsive when Home Health Agencies have questions/concerns
A chart review of 45 Home Health patients revealed recurring factors that likely contributed to preventable readmission within 30 days.
ResultsThis intervention, tested twice, has demonstrated a statistically significant reduction in 30-day all-cause
readmissions.
n
30-day All-Cause Readmission Rate
Baseline Data:(Jan- Mar 2011) 150 25%
Test of Change I(Oct-Nov 2011) 48 10%
Test of Change II(Jan-Feb 2012) 67 12%
Cycle I: Enhanced Home Health
WHOAll CSMC Discharges to a high volume Home Health agency
WHAT
In-hospital visit by nurse + 6 touch-points after discharge
• Home visit within 48 hours of discharge• Friday “Tuck-in” Phone call• Weekend Visits• Medication Reconciliation• 24-hour call number staffed by a nurse
WHEN November 1 – 30, 2011
WHYTo determine if more rigorous home health services can prevent readmissions. (Baseline = 19% readmit rate)
75
Enhanced Home HealthOnly 6.8% of the 59 TOC patients were readmitted within 30 days of discharge.
This rate is less than 50% of the baseline rate observed during FY 2011.
Patient Population Time Frame% Readmitted
(All-Cause)
CSMC discharges home with Home Health (any agency)
Jul 2010 -Jun 2011 19%
CSMC discharges home with TOC Home Health Agency*
Jul 2010 -Jun 2011 14%
Test of Change (n=59 patients) November 2011 6.8%
* The agency selected for the Test of Change had the highest proportion of Home Health referrals from Cedars-Sinai Medical Center .
Conclusions
• Readmissions can be prevented when hospitals take the lead to collaborate with partner agencies in the community.
• Intervening during the 14 days following hospital discharge is crucial for preventing avoidable readmissions.
• Clinical resources in the community (SNF, Home Health, CBO Coaching) need to be bolstered on weekends.
• Involvement & leadership from Primary MD are key in executing improvements related to readmissions.
Avoidable Hospitalizations for Duals
77
Sources: Centers for Medicare and Medicaid Services; Kaiser Family Foundation,
Medicare Payment Advisory Commission
Over $4 billion potentially avoidable…not to mention the patient suffering this
represents
Medicaid spending – pressure points
The elderly & disabled account for majority of Medicaid spending; a subset – the duals eligibles make up 15% of enrollees and account for 40% of program spending 70% of all Medicaid duals spending is on Long-Term Care (LTC) (mental disabilities, spinal chord injuries, severe chronic illnesses, nursing home care, home health care, etc.) States may have a Medicaid problem, but Medicaid has a long-term care problem
Enrollees Expenditures on benefits
Children 20%
Elderly 25%
Disabled 43%
Adults 13%Children 49%
Elderly 10%
Disabled 15%
Adults 25%
Total = 59.5 million Total = $318 billionSOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute estimates based on 2007 MSIS and CMS64 data.
$2,135 $2,541
$14,481
$12,499
Long-Term Care
Acute Care
Dual Eligibles – The Ultimate Case Study: Age + Poverty = Worse Health, Higher Cost
79
Sources: Centers for Medicare and Medicaid Services; Kaiser Family Foundation,
Medicare Payment Advisory Commission
Why the Costs Are So High
• For Medicare the reason for high costs among duals is the elevated need for acute care resulting from increased prevalence of chronic disease associated with age, disability, poverty and need for innovations in care and self-care
• Medical interventions alone are not enough• With targeted evidence-based interventions at home,
much better results can be achieved
80
Healthcare & Fiscal Pressures on Government Budgets
Federal funding on Medicaid & CHIP projected to double to 4% of GDP by 2035 States worried that balancing the federal budget would mean shifting costs to the states through block grants, or blended/reduced federal matching rates
0% 10% 20%
1960
1970
1980
1990
2000
2005
2008
2009
2019P
US Healthcare Spending as % of GDP
ACA Medicaid Expansion in 2014
ACA streamlines Medicaid eligibility rules Expands potential enrollment Federal government provides extra fiscal support for expansion till 2020
Medicaid today & tomorrow Potential enrollment growth
8 M
14 M
23 M
The Base Case (CBO estimate) built on a 55% take up rate Actual enrollment could range from 8M – 23M Medicaid eligibility & enrollment simplification could boost take up rates
Source: Health Affairs N0. 30 (11), (2011)Source: Kaiser Family Foundation
How Home and Community Services Address and Improve Health Outcomes
Multiple, complex chronic conditions Evidence-based enhanced self-care programs (e.g,
Chronic Disease Self Management (CDSMP), Diabetes Self Management (DSMP)
Complex medications/adherence (HomeMeds )℠ Multiple ER visits – gaps in care/communication Post-hospital support to avoid readmissions Nursing home diversion/return to community In-home palliative care in last year of life
83
The Need for Social Work Leadership
• Dramatic changes in the shift from hospital to home and community-based care/patient-centered care
• Requires understanding community culture• understanding regulatory requirements
• multicultural approach• understanding of different practice settings
84
Hot Spotting
• High costs come from specific target groups, where the investment of a new intervention yields better health and quality of life outcomes while driving down costs
• Target Medi-Cal, keeping people out of nursing homes and……
• Impact Medicare more directly by reducing ER, hospital admissions and readmissions
Dramatic change is required
• Medicine seeks medical solutions• We must bring and sustain community-based solutions• Prevention, self management and support for functional
losses and mental health issues key• Ethnic and economic health disparities key• We must bridge into a new world with different culture,
language and requirements
Duals Demonstration Project – How the Risk Will Shift
• Total financial responsibility for the full continuum of Medicare and Medi-Cal services will now include:
• medical care• behavioral health services, and• long-term services and supports (LTSS):
• In-Home Supportive Services (IHSS)• Community-Based Adult Services (CBAS)• Multipurpose Senior Services Program (MSSP)• Nursing facilities when needed
• Social supports help dual eligible beneficiaries maintain their health and live at home as long as possible
87
America’s Dual Eligibles
88
Sources: Centers for Medicare and Medicaid Services; Kaiser Family Foundation,
Medicare Payment Advisory Commission
Challenge of the Dual eligibles
or 2.1% of GDP
America’s Dual Eligibles
90
Sources: Centers for Medicare and Medicaid Services; Kaiser Family Foundation,
Medicare Payment Advisory Commission
How to Best Care for the Duals to Achieve Optimal
Health Outcomes
Targeting Criteria for a Home Visit
1.Age 65+ and2.ED/hospital use in past year, plus:
a) Five or more prescribed meds; or
b) Warfarin/antiplatelet or insulin/diabetes meds; or
c) Dx CHF, COPD, depression, anxiety, bipolar, psychosis; or
d) Mild cognitive impairment; or
e) Recent treatment for fall or confusion; or
f) Age 80+; or
g) Any patient there is a concern about
The Problem
•Medication Errors are:• Serious: Over 700,000 people go to ED each year for adverse drug
events• Costly: Drug-related morbidity/mortality > $170 billion (ER,
hospital/readmissions, SNF use, etc.)• Common: Up to 48% of community-dwelling elders have medication-
related problems• Preventable: At least 25% of all harmful adverse drug events are
preventable
The Solution: HomeMeds℠
• HomeMeds ℠ is designed to enable community agencies to keep people at home, out of hospital & nursing home, by addressing medication safety
• Practice change with workforces that already go to the home – more cost effective use of existing effort
• Target problems for significance, accessibility to in-home staff, and likelihood of positive prescriber response.
• Focus on adverse effects (falls, vitals, confusion) … then determine if medications may be part of the cause.
Why should non-healthcare agencies work on medication safety?
• To thrive, CBOs need to play a new role connecting the home with the healthcare system• Meds are major factor in readmissions
• Home provides unique perspective otherwise unavailable to healthcare providers.
• Quality measures for health plans and providers relate to issues such as medication use and fall prevention – HEDIS, Medicare Advantage Star Ratings
• New focus on population health – identifying and proactively addressing health for high-risk patients
Core Components
• Collect comprehensive medication list• Note how each drug is being taken
• Record BP/pulse, falls, uncharacteristic confusion, symptoms, and indicators of adverse effects
• Use evidence-based protocols to screen for risks • Computerized risk assessment and alert process• Consultant pharmacist addresses problems with
prescribers, seniors, families & staff.
Evidence-based Recognition
• AoA recognition as an evidence-based prevention program – Highest Level of Evidence
• ACL Aging & Disability Evidence-based Programs and Practices(http://acl.gov/Programs/CDAP/OPE/docs/HomeMeds_InterventionSummary.pdf)
• Quality of research: 3.2/4
• Readiness for dissemination: 4/4
• US Agency for Healthcare Research and Quality (AHRQ) Innovation Exchange
• Strong evidence rating
(http://www.innovations.ahrq.gov/content.aspx?id=2841)
Expected Results
Home visit uncovers many “secrets” prescribers may not know about
• OTCs – Over-the-counter medications • Prescriptions from other providers• Adverse effects such as falls, dizziness, confusion• Adherence issues• Out-of-system meds: Drugs from other countries, borrowed,
Wal-Mart $4
Roles of the pharmacist
• Screen alerts to confirm problems
• Communicate with prescribers
• Consult with staff
• Identify problems beyond protocols
• Assist with complex cases
• Educate staff about medications/risks
• Avg. 20 min./client
Consumer Feedback…
Mr. Johnson went from 20 meds to just 8.
“You have saved us money on monthly refills and my life!
We cannot thank you enough!”
Who’s Implementing HomeMeds?
• Medicaid programs for Dual Eligibles• Care Transition programs• CBOs under contract with medical groups• Area Agencies on Aging & Senior Centers• Meals on Wheels• Home Health/Homecare Agencies• Assisted Living & Affordable Housing• Native American Tribal Community
Innovative Applications
• Contract with at-risk medical group • Targeted one-time home visit by social worker• HomeMeds screening and general safety assessment (ADLs,
environment, cognitive status, caregiver/family support, PHQ-2/9)
• HomeMeds pharmacist intervention• Reports to Case Manager, PCP, EHR system• Care plan and referrals
Pioneers in Palliative Care
• Developed with Kaiser / Dr. Brumley • In-Home Palliative Care
• Hospice – a big decision• Communication in need of major training
Key elements of our model• Trust in home care team• Call Center 24/7• Decision support
What is Long Term Care?
• Encompasses a wide array of medicine, social, personal and supportive and specialized housing services
• Social, self management and environmental factors are crucial to determining full positive impact of medicine
• Needed by people who have lost some capacity for self-care
• Care at home or in a nursing home• Most who need LTC are over age 76 (63%)
Activities of Daily Living (ADLs)
• Personal care activities people engage in every day • Fundamental to caring for oneself to maintain personal
independence• Assessment determines level of care/ assistance
needed• Certifies LTC level of care/payment level
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ADL Functions
• ADL Functions • Bathing• Dressing• Grooming• Mouth care• Toileting• Transferring bed/chair• Climbing stairs• Eating
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Each function is ratedto determine level of support required:
-INDEPENDENT
-NEEDS SOME HELP
-VERY DEPENDENT
-CANNOT DO
Instrumental Activities of Daily Living (IADLs)
• Related to independent living• Valuable for evaluating level of disease• Determinant of person’s ability to care for themselves
and their environment
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IADL Functions
• IADL Functions • Shopping• Cooking• Managing medications• Using the phone and
looking up phone numbers
• Doing housework• Doing laundry• Driving or using public
transportation• Managing finances
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Each function is ratedto determine level of support required:
-INDEPENDENT
-NEEDS SOME HELP
-VERY DEPENDENT
-CANNOT DO
AAAs and Sponsors of MSSP Offer Core Resources
• Area Agencies on Aging – crucial safety net• MSSP sponsors can evolve expanded home care
expertise • Scaling up from solid base and clinical infrastructure safer
than “reinventing”• Scaling best led by neutral community player, not health
care entity
Current MSSP Services Model: (can be adapted for Duals as CMS rules change)
Community Care
Coordination
Referred Services• IHSS• Adult day health• Regional Center• Independent Living
Centers• Home Health• Palliative/Hospice Care• DME• Caregiver Support• Senior Center Programs• Evidence-based Health
Impacting Self-Care programs
• Long-term home-delivered meals
• Housing Options• Communication Services• Legal Services• Benefits Enrollment • Money management• Utilities
Purchased Services(Credentialed Vendors)
• Safety devices, e.g., grab bars, w/c ramps, alarms
• Home handyman• Emergency response
systems• In-home psychotherapy• Emergency support
(housing, meals, care)• Assisted transportation• Homemaker, personal
care and respite services• Replace
furniture/appliances for safety/sanitary reasons
• Heavy cleaning & chores• Home-delivered meals –
short term• Medication management
(HomeMeds)
Social Worke
rRN
Client &
Family
How We Could Work Together
• Home and Community Services Network• A proposed model for experienced in-home care coordination
through a central portal
• Key Elements:• Contracted, credentialed network of trusted vendors and linked
partnerships• Community Care Management including in-home• Administrative simplicity with full access to both arrange and
purchase community care resources
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Overlapping Networks & Service LinesEvidence-Based Self-Management Network
• National Network - EBLC
• Statewide TA Collaborative
• L.A. AAA/Senior Center Providers
Care Transitions/SNF
Diversion Network
LTSS Network•Nonprofit Waiver Contract Holders for Care Coordination•Vendor Network•Respite care•Meals•Assisted Transportation•Home Modifications•Home alert & monitoring•DME
Home and Community Services Network - Key Elements
• Full geographic coverage of L.A. County - one portal for all
• Credentialed contractors for purchase of home and community-based services and personal care
• Common data system• Strong business case • MSSP model is prototype
• Build on base of 3,400 clients/170 care coordination staff – RNs and Social Workers in 7 locations
• Cost effective, proven, and uniform model of care
• Ability to scale up and differentiate• Tiered care management models possible
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Call to Action – The Time is Now
• So many opportunities to touch lives for the better• Time to innovate• Always partner with others• The Society is a great resource
Visit our Website
• This presentation and others are posted• June Simmons, MSW• WWW.PICF.ORG• [email protected]