Transcript The Title Slide opens up the presentation and provides the

ACTIVATE
The FSL and Dignity
Health Care Transition
Initiative
Marc M. Lato, MD
Vice President of Medical Management
February 12, 2015
ACTIVATE - Advance Clients’ Transition to
Independence Via Actions That Empower
Current Model
Established: January 2012
 Partners: SJHMC, FSL, Mercy Care Plan (funder)
Patients:
 Mercy Care Plan LTC (ALTCS) dual eligible
 With multiple co-morbidities / high re-hospitalization
rates
Expanded to:
 Chandler Regional & Mercy Gilbert in January 2013
ACTIVATE
Design Overview
 Enhanced model of Transitional Care
 Draws on best practices from CMS models (Coleman,
RED)
 Adds an embedded RN to work with the in-hospital medical
staff and coordinate post-discharge care
 Discharge planning begins at admission
 One visit post-hospitalization / Additional home visits if
needed
ACTIVATE Incorporates
Coleman’s Four Pillars
 Medication Management – Patient has knowledge about
medication and has medication management system
 Use of Personal Health Record (PHR) Patient
understands and uses PHR to facilitate communication and
ensure continuity-of-care plan across providers
 Primary Care/Specialist Follow-up: Patient schedules
and completes follow-up visit with PCP or specialist and is
empowered to be an active participant in these interactions
 Knowledge of Red Flags: Patient recognizes the
symptoms that indicate that their condition is worsening
and how to respond to them
Key Components
( 30 Day Program)
 8-10 Hours of Intervention
 Transitional Care Nurse (TCN)
 In-Hospital Assessment
 Home Visit by the TCN
 Psycho-social Assessment
 Comprehensive Holistic Focus on Each Patient’s Goals and
Needs
 Home Safety Inspection
 Telephonic Support by Transitional Care Coach (TCC)
Program Successes
 Reduction in Mercy Care LTC Plan Readmissions
 30-Day Readmission rate reduced from 28% to 8%
(Cumulative Enrollees)
 Reduction in the number of inpatient days
 Improved Health Care Outcomes
 Enhanced Patient Empowerment
 Disease Management
 Red Flags
 Reduced Health Care Cost
ACTIVATE Statistics
Year
Enrolled
Completed
Pending
Readmission
2011
Readmission
Rate (%)
28%
2012
61
56
0
10
2013
49
46
0
3
2014
63
52
11
2
Cumulative
173
162
11
15
•
•
18%
8%
4%
Additional 44 Enrolled at Bedside but had No Home Services
Closing Rate was 80% (173/217)
9%
CATCH Model
Clients Activated Through Community
and Hospital
CATCH Recap
Target Population
 Patient of Internal Medicine Clinic (IMC)
 Uninsured and Underinsured
 Multi-morbidities with at least one in acute stage
 38 being served; 18 completed the 12-month program
Number of hours spent with client
 Front-loaded in first month; 10-15 hours including home
visit
 Average of 5 hours per month following that
CATCH Recap
Components of Program
 A 12-month care program
 Joint home visit of IMC Resident and FSL Social Worker (S/W)
 Psycho-social assessment is obtained
 Quarterly client visits to IMC with metrics captured
 S/W coaches care plan adherence between IMC visits
 Partners provide Transport, Counseling, Public Benefits
Success Measures (First Six Months of Enrollment)
 55% Reduction in ER visits
 53% Reduction in All-Cause Admissions
CMS Historical Perspective
on Readmissions
 1 in 5 Fee For Service (FFS) Medicare beneficiaries had a
hospital readmission within 30 days*
 $15 billion lost due to readmissions - 80% of this deemed
preventable with:
 Provision of quality care during initial hospitalization
 Adequate discharge planning
 Adequate post-discharge follow-up
 Improved coordination between inpatient and outpatient
team of caregivers

While readmissions have been declining through 2013, the
study of best practices for reducing readmissions remains
an area of growth and innovation
* Jencks et al, NEJM 2009; 360:1418-1428 April 2,2009
ACTIVATE Expansion
90-Day Program for Dignity Health
Where do we go
from here?
 Apply learnings from successful projects (ACTIVATE and
CATCH)
 Integrate learnings from internal hospital initiatives
 e.g., Readmissions / Discharge Committees, Pharmacy
Concierge Program, Resource Room inquiries, etc.
 Operationalize all best practices into a comprehensive
Transitional Care program and expand to a much wider audience
 Collaborate with other internal/external care programs
Dignity Health Expansion
90 Day Program
Target Population
 Focused on Super-Utilizers:
 Patients that over utilize the ER (usually known to staff) or
the hospital (identified by Case Management)
 Multi-morbidities
 Uninsured and Medicare FFS (ACN invited to refer their
patients)
Dignity Health Expansion
90-Day Program
Timeframe
 Transitional Care period expanded from 30 to 90
days to:
 Ensure medication protocols
 Support public benefits application process
 Encourage / monitor patient self-management
 Access additional community resources
 Effect real behavioral changes
Dignity Health Expansion
90-Day Program
Operational Highlights (avg. 13 hours)
In-home Visits (initial, then as needed, and closure visit)
 Psycho-social assessment; patient-Coach relationship deepened
 Home vs. Discharge meds reconciled
 PCP follow-up visits tracked; patient status shared
 Caregivers engaged
 Personal Health Record created
Telephonic Follow-up (Transitional Care Coach)
 “Red flags” reviewed
Medication Protocol Compliance Assessed
Community Resource Referrals Enabled
Dignity Health Expansion
90 Day Program
WHY FSL?
 40 Years experience in providing direct care services
 One of the largest not-for-profit charitable entities in the
State; collaborations with many community partners
 Contracted with many Health Insurers
 Medicare licensed/certified
 Demonstrated success in implementing highly
effective community based Transitional Care programs
within Dignity Health
FSL Services
 Home Modifications and Safety  Care Management
 Low Income Senior Housing
 In-home Assessments
 Caregiver Training/ Support
 Counseling
 Group Homes for SMI Adults
 DME/Adaptive Equipment
 Senior Centers
Demonstration
 Community Action Programs
 ACTIVATE
 Respite Care
 CATCH
Dignity Health/St Joseph’s –HSAG SNF Collaborative
St. Joseph’s – HSAG Program
• Invite highly utilized SNFs to meeting December 2013
• Key SNF decision makers (Exec Director /Director of Nursing (DON)
• Work With HSAG to develop program and format
• Gain agreement to share similar data confidentially
• Use well known tool to aggregate the data (Advancing Excellence)
• Agree to make participation priority
• Lunch and meeting facility provided by the hospital
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St. Joseph’s /HSAG SNF Collaborative
11 Area SNFs invited
10 have come consistently
8 Meetings occurred over the first year
Advancing Excellence tool training session facilitated by HSAG
Requests for Additional Key topics by the SNFs
HSAG and St. Joseph’s provided reference material
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St Joe/HSAG SNF Collaborative
Topics
•
Resources – St. Vincent DePaul, Piper Med and Dental Clinic
•
Circle the City – Respite- and SNF-like care for the homeless
•
Sepsis bundle – Most expensive hospital admission, major
readmission reason
•
Blood transfusion protocols
o
Possibility of calling in blood transfusion and saving admission
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St. Joseph’s/HSAG SNF Collaborative
Topics
• St Joseph’s Infusion Suite – Education
– Hours of Operation
– Possible use for transfusion
HSAG Presentation - 2 OIG Reports
Medicare Nursing Home Resident Hospitalization Rates 11/2013
Adverse Events in SNFs for Medicare Beneficiaries 02/2014
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St Joseph’s/HSAG SNF Collaborative
Future Direction
•
Monthly Meetings
•
Continue Advancing Excellence Tool
•
Consider INTERACT 3.0 for use in SNF
•
Add Key Home Health providers
•
Add the Dignity-affiliated ACO (Arizona Care Network)
•
Consider adding Key Facility Medical Directors
•
Determine 1 initiative for group’s participation
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QUESTIONS?