BACKGROUND

• In November 2014, as part of early DSRIP planning, the Maimonides Medical Center (MMC)Department of Population Health convened a 30-Day Care Transitions Workgroup comprised ofrepresentatives from hospitals, care management agencies, community-based organizations,post-acute providers, and other local stakeholders to develop the 30-day care transitionsinitiative. This group defined the target patient population and workforce, developed operationalworkflows, and prepared for implementation.

• In October 2015, Community Care of Brooklyn (CCB) implemented a care transitions model at itsnetwork hospitals, which aims to reduce preventable hospital utilization among a high-need,safety net patient population by improving care coordination and addressing social determinantsof health.

CONTACT

Kayla Spence, Manager, Program Implementation and Partner Engagement, Maimonides Medical Center Department of Population Health (kspence@maimonidesmed.org)

Reducing Hospital Utilization by Addressing the Unique Needs of At-Risk Patients in BrooklynKayla Spence, Shari Suchoff, MPP, Karen Nelson, MD MPH, Kishor Malavade, MD, Rachel Leep, MPH, Natalie McGarry

Maimonides Medical Center Department of Population Health

TRANSITIONAL CARE TEAMS

• CCB’s care transitions model required five hospitals¹ to assemble high-functioning transitionalcare teams (TCTs), comprised of Transitional Care Nurses (TCNs) and Transitional Care Managers(TCMs) to work together to support patients deemed at-risk for readmission and ensure safe andeffective transitions of care.

• TCNs screen patients for risk of readmission using a modified LACE (Length of stay, Acuity ofadmission, Comorbidities, ER visits) tool and a social determinants of health screening tool.

• TCTs assess the screening results and ensure patients have supports in place to address any needsin the following areas:o Activities of daily livingo Education/health literacyo Financial support/securityo Food securityo Housing security/qualityo Legal/justice supporto Medical

• If gaps in support are identified, TCTs refer patients to the following community resources forsupport post-discharge:o Asthma home-based services: Services that connect providers with home care or

community-based programs to develop home-based self-management programs forasthmatic patients

o CCB-NYLAG LegalHealth Clinic: Medical-legal partnership that provides free legal assistanceto patients struggling with health-harming legal issues

o Health Coaches: Medical assistants or equivalent-level staff in primary care and mentalhealth clinics who have been trained and certified to engage patients in creating self-management goals and supporting patients’ care coordination and referral management

o Mental Health Peers: Licensed peer advocates that support patients with behavioral healthconditions in hospital settings and community practices

o NowPow: Web-based platform that connects patients and clients to community resourcesbased on identified needs

o Recovery Peers: Licensed peer advocates that support patients in need of substance useservices and assist individuals’ return to the community

• The TCN then creates an individualized, person-centered 30-day care plan comprised of thefollowing elements:o SMART (Specific, Measurable, Achievable, Relevant, and Time-bound) patient-directed goalso An assessment of patient’s strengths and challengeso Patient education, taught using the teach-back method and motivational interviewingo Effective linkages to follow-up care, including primary care, specialists, Health Home, home

health, durable medical equipment, and community-based social serviceso Medication reconciliation and management throughout the care plan period

• TCTs continue to work with patients for 30 days post-discharge, making follow-up calls to patientswithin 1 business day of discharge and weekly thereafter. TCTs schedule and remind patients offollow-up appointments and address any barriers to patients attending.

• TCTs conduct warm hand-offs to clinical and non-clinical providers to ensure continuity of care.

o Medication adherenceo Mental healtho Safetyo Social supporto Substance useo Transportation

INCORPORATING THE MAX METHODOLOGY

• CCB engaged each of its network hospitals in developing Medicaid Accelerated eXchange (MAX)Action Teams and helped the hospitals develop ongoing performance improvement strategies,such as action plans and the Plan, Do, Study, Act cycle, consistent with MAX requirements.

• Each MAX Action Team identified facility-specific priority populations and each population’sunique drivers of utilization. They developed action plans to address the drivers at the systemlevel and continue to convene interdisciplinary case conferences to discuss individual cases andidentify systems issues that can be addressed through performance improvement efforts.

• Consistent with supporting each hospital’s preparation for value-based contracting and overallDSRIP efforts, CCB’s agreements with participating hospitals include pay-for-performance andquality improvement measures.

MODEL WORKFLOW

Pat

ien

tTC

TP

CP

Off

ice

He

alth

Ho

me

Co

mm

un

ity

Re

sou

rce

s

Admitted

Meet with

patient and/or

caregiver

TCN conducts clinical

assessment

TCN develops

30-day care plan

TCT makes referrals to appropriate community resources

If patient is HH-eligible, TCT makes referral to onsite HH

care coordinator

Patient education

using teach-back and

motivational interviewing

Schedule follow-up

appts. with PCP and

specialists

Warm handoff to providers

using SBAR; discharge

summary to PCP

Call patient within 1 day of

discharge

Weekly follow-up calls to patient, caregiver, and

referred resources for 30 days,

modifying care plan as needed

Works with TCT to ensure

patient has access to an

appt. within 7 days of

discharge

Information from SBAR/ discharge summary

incorporated into pre-visit

planning

Conducts medication

reconciliation and patient education

Works with patient long-term on care planning and self-

management goals aimed at reducing

hospitalizations

Meets with patient

regarding HH

eligibility

If already enrolled, CM meets with patient and

discusses case with

TCT

Works with TCT to ensure

patient has transportation

to appts.

Works with patient long-term to help keep

them healthy and stable in community

Works with patient long-term to help keep them

healthy and stable in community

Work with TCT to ensure timely

delivery of services

Attends follow-up appts.

Scheduled by TCT

MONITORING AND EVALUATION

• The MMC Department of Population Health has conducted an evaluation of CCB’s 30-day caretransitions initiative in an effort to understand whether and to what extent the interventionaffects patients’ healthcare utilization.

• Performance on these metrics was established using Salient’s NYS Medicaid Enterprise System™(SIM), which houses claims, attribution, and DSRIP quality measure performance data for all NYSMedicaid patients.

• Patients were included in the analysis if they received a 30-day care plan as part of their dischargefrom an inpatient stay at one of five CCB network hospitals between April 2016–December 2017.

• A comparison control group of patients with inpatient stays at the five hospitals who did notreceive a 30-day care transitions care plan was established through claims data available in SIM.

• Patients in the intervention and control groups were aggregated into cohorts by month of careplan receipt and results for each of the following metrics were calculated for 90-day periods pre-and post-care plan receipt:1. All-cause ER utilization (number of members and number of visits)2. All-cause inpatient utilization (number of members and number of visits)

RESULTS – ER UTILIZATION

• There were reductions in percentages of members with ER utilization between the 90-day pre-intervention period and the 90-day post-intervention period for each quarter of programimplementation across all five hospitals ranging from -1.5% to -6.9%.

• Reductions were observed in the number of ER visits for each quarter of programimplementation, ranging from -0.8% to -18.7%.

ER Utilization Pre/Post Care Transitions Intervention²

Change in ER Utilization Pre/Post Care Transitions Intervention²

PROGRAM TIMELINE

2014 2015 2016 2017 2018

DSR

IP D

Y0

November 2014:30-Day Care Transitions

Workgroup begins meeting regularly

January 2016:IMC participates in the first MAX series program with the goal of

improving care for super utilizers

February 2016:HH CMAs placed at

CCB hospitals

December 2015:Health Coaching program launches in ambulatory

care sites

April 2016:Monthly TCT calls and case

conferences begin

October 2016:QI program

established, including regular care plan

audits

January 2017:MMC begins participating in second MAX

series; CCB hosts Amy Boutwell, MD, MPP to provide training on working with high-

utilizing patient populations

April 2017:Focus of CCB’s care

transitions model shifts to target high-utilizers;

CCB offers NowPowsubscription network-

wide

August 2017:CCB NYLAG LegalHealth clinic opens; recovery peers begin meeting with patients with

substance use disorder at MMC*

March 2018:Mental health peers begin meeting with patients discharged

from inpatient psychiatry units at

CCB hospitals

DSR

IP D

Y1

DSR

IP D

Y2

DSR

IP D

Y3

* Peers began work at Interfaith Medical Center in April 2018, Wyckoff Heights Medical Center in May 2018, and Kingsbrook Jewish Medical Center in August 2018

October 2015:Implementation of care

transitions model begins at CCB hospitals

RESULTS – INPATIENT UTILIZATION

• There were reductions in percentages of members with inpatient utilization between the 90-daypre-intervention period and the 90-day post-intervention period for each quarter of programimplementation across all five hospitals ranging from -11.5% to -18.7%.

• Reductions were observed in the number of inpatient admissions for each quarter of programimplementation, ranging from -12.4% to -27.3%.

Inpatient Utilization Pre/Post Care Transitions Intervention²

Change in Inpatient Utilization Pre/Post Care Transitions Intervention²

CONCLUSIONS

• Results showed reductions in ER and inpatient utilization among all cohorts of patients whoreceived the intervention, suggesting an association between the administration of a 30-day careplan and reduced ER and inpatient utilization in the 90-day period following care plan receipt.³

• The MMC Department of Population Health continues to monitor and evaluate ER and inpatientutilization and plans to analyze additional indicators, including primary care utilization; potentiallypreventable ER visits, admissions, and re-admissions; and the impact of Health Home enrollmentand engagement. The feasibility of obtaining individual-level reported data to test for statisticalsignificance of results is also being explored.

• The MMC Department of Population Health plans to continue exploring program impact onpatients with varying levels of utilization, including conducting further analyses to isolate programimpact on high utilizers.

• The MMC Department of Population Health is continuing to use evaluation findings for ongoingprogram improvement.

¹ Interfaith Medical Center, Kingsbrook Jewish Medical Center, Maimonides Medical Center, New York-Presbyterian Brooklyn Methodist Hospital, Wyckoff Heights Medical Center² For these analyses, current age, as opposed to historic age, was used, which slightly under-represents members in control group cohorts. Members of the control group cohorts were not restricted to just Medicaid beneficiaries enrolled three months before and three months after intervention periods; however, SIM review indicates this resulted in a less than 5% difference.³ The conclusions in this publication are not those of the New York State Department of Health.

Discharged