Transcript HEP Phase III Launch - Practice Change Fellows

DRAFT
Transitions of Care
A Medicare Advantage QualityBLUE
Pay for Performance Model
Geriatric Practice Change Agent Meeting
Judith S. Black MD, MHA
Medical Director, Highmark Senior Products
September 27, 2007
Agenda
• Rationale for the Program
• Overview of the Program
• Program Outcomes to Date
• Lessons Learned
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Transitions of Care - Definition and Rationale
A set of actions designed to ensure the coordination of care as
patients transfer between settings. Transitional care encompasses
both the sending and the receiving aspects of the transfer and
includes preparation of the patient and family, transfer of
information, coordination among practitioners.
• Closely managing patient movement from one level of care to another
accomplishes the following:
• Reduces fragmentation
• Improves patient satisfaction
• Results in a reduction in readmissions
• Ultimately impacts care costs
• Information related to advance care planning more consistently
communicated to receiving facility
• Health plan moved from Per Diem to Case Rate in 2005.
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Variation in Care - Hospital Readmit Analysis
Discharge DRG
Weight
Total Readmission
Rate
Hospital A
1.16
13.55%
Hospital B
1.23
13.84%
All Acute Hospitals
1.36
14.23%
Readmission Rates for the Top 25 Facilities by Acute Admissions
20%
15%
10%
5%
The above 25 acute care facilities account for 85% of hospital admissions
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25
24
23
22
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20
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18
17
16
15
14
13
12
11
10
9
7
Ho
sp
ita
lB
6
5
4
Ho
2
sp
ita
lA
1
0%
Variation in Care - SNF Readmit Analysis
Readmission Rate
Concurrent Risk
SNF A
26%
7.14
SNF B
28%
6.31
SNF C
26%
7.43
All SNF Facilities
21%
6.04
Readmission Rates for the Top 25 SNF Facilities by Admissions
June 2005 - May 2006
35%
30%
25%
20%
15%
10%
5%
0%
1
2
3
4
5
SNF
A
7
8
9
SNF C ranked # 29 by percent of admissions
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SNF 12
B
13
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16
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Highmark Initiative:
QualityBLUE Transitions of Care Program
• Focused Initiative: Three-year SecurityBlue Medicare
Advantage (MA) Pilot Study
• Quality Indicator: Transitions of Care
– Involve hospitals in year one. Focus on developing “best
practices” standard for coordination of discharge, i.e., levels of
transitions.
– In year two of the program select skilled nursing facilities will be
asked to participate. Focus on care coordination between the SNF
and the hospital or alternate sites.
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Facility Selection and Incentive
• Volume - top readmit rates
• 3 to 5% of SNF payment
• Hospital/SNF relationships
• 2.4% of hospital payment
• Geographic location
• Amount payout equal
projected cost savings.
• Willingness to work with
health plan.
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Payment Methodology
Five Parameters
Program Administration
Planning
Action
Measurement
Results
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5%
35%
40%
10%
10%
90-100%
Maximum Level
80-89%
Threshold Level
70-79%
Minimum Level
< 70%
No Pay-for-Performance Payment
Highmark MA P4P Timeline
4thQ
03
1st Q
04
2ndQ
04
3rdQ
04
4thQ
04
1stQ
05
2ndQ
05
3rdQ
05
4thQ
05
1stQ
06
2ndQ
06
3rdQ
06
4thQ
06
Develop
Concept
Business
Requirements
& Funding
6 Months
Hospital Engagement
6-10 Months
SNF Program
Development
9 Months
Engage 2nd
Hospital
Engage
SNF’s
4 ½ Mths.
SNF Profile
Develop & Refine Data Elements (Pie Charts & Graphs)
1st
Dr. Eric
Expert Coleman
Visit
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2nd
Dr. Eric
Expert Coleman
Visit
Initiative Goals:
• To improve the quality of care for the geriatric patient
• To develop appropriate reimbursement methodology
to align reimbursement between health plans and
institutions
• To identify indicators and measurement techniques
that focus on “transitions of care” issues for the
hospitals in year one
• To develop methods for ongoing monitoring of
quality indicators.
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Hospital/SNF Performance Strategies:
• Reduce readmissions from skilled nursing facilities
• Reduce admissions for patients transitioned home with
diagnoses of heart failure, COPD, or pneumonia
• Prevent or reduce medication errors
• Facilitate effective communication sharing between
facilities and enhance accountability of patient transfers
• Improve patient satisfaction by ensuring their
preferences be passed from one setting to the next
• Ensure patient’s ability to manage their health care
condition.
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Hospital/SNF Performance Strategies:
• The Care Transitions Measure Tool
– To assess caregiver perception (satisfaction) of the transition
process and to assess overall quality of care transitions.
• The UCHSC Care Transition Measure
– The hospital staff took my preferences into account in
deciding what my health care needs would be after discharge
– Before I left the hospital, the people that were going to help
me when I got home clearly understood what my health care
needs were
– Before I left the hospital, I had a phone number I could call
to get answers to my questions.
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Hospitals Outcomes to Date
• A work group was established to implement this quality
initiative and;
– Evaluated the current transfer/discharge process
– Developed a written model for the Care Transitions
Program
– Standardized the transfer process to skilled nursing
facilities
– Developed essential data elements to be conveyed to
the receiving practitioner
– Enhanced discharge instructions for patients returning
home including a system to establish follow up contact.
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Hospitals Outcomes to Date
– Developed a medication reconciliation tool
– Developed an advance care planning process &
implemented the POLST
– Designed educational programs to inform staff
members of treatment/procedural changes
– Established electronic connectivity
– Rapid Response Team for 600 bed SNF
– Established Subcommittee with ED and SNF
– Developed tools, audits, and surveys to determine
the impact of the program.
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SNF Outcomes to Date
The Skilled Nursing Facilities developed a workgroup and
accomplished the following:
• Implemented a Performance Improvement Plan
• Senior Leadership committed to continuity of project
• Upon admission to the Skilled Nursing Facility, project
the resident’s length of stay, establish needs and goals of
the resident and regularly communicate the resident’s
progress toward the goals with the family or responsible
party
• Developed plans and begun using CTM and transfer
impact survey.
• Established a performance improvement plan and
timeline for incorporating the POLST.
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2007 Program Administration
Program
Manual &
Ongoing
Mtgs.
Results
Distributed
Mid-Year
Review
ReimburseMent
Determined
Year-End
Review
Scoring
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Program Year 2007-2008
• Hospitals will continue transition of care
initiatives with goal to decrease
readmissions
• Continue to refine the SNF measures. Less
emphasis on Planning & Action & greater
focus on Measurement & Results
• Heritage Valley Skilled Nursing Facilities to
begin program (The Villa, Friendship Ridge, Beaver
Elder Care).
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SNF Outcomes to Date
• Implemented a mutually agreed upon format for transfer
information
• Worked collaboratively with the hospital to utilize
computer connectivity to enhance transfer communication.
• Working in a Collaborative on Medication Reconciliation.
• Participated in regular conference calls and meetings with
hospital and health plan.
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What Were the Challenges?
• Selling the concept to Senior Management
• Establishing an effective internal Highmark team with
commitment to new program
• Ongoing funding with a lag in financial data
• Resources with the expansion of the Hospital
QualityBLUE Program.
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What Worked Well?
• Engagement
– Bringing in outside expert to help sell the program
– Providing comparison data and tools
– Sharing experiences
• Implementation
– Team experience with a commercial hospital
QualityBLUE program
– Detailed scoring grid
– Team work with frequent contact.
• Relationship building
– Hospital/SNF working together.
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Lessons Learned
• Develop a detailed three year project timeline
• Don’t underestimate the engagement time
• Collect data in auditable format.
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Key Success Factors
• Facility Champion
• Effective Team
• Willingness to share tools
• Leveraging off of other programs
• Striving for a win/win program
– Rewarding for process measures not just bottom line.
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Sustaining the Program
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Tools/References
• www.caretransition.org
• www.polst.org
• “One Patient, Many Places: Managing Health Care Transitions,” a report
from the HMO Workgroup on Care Management.
• Coleman, Eric A. et. al. “The Care Transitions Intervention – Results of a
Randomized Controlled Trial.” Arch Intern Med. 2006; 166: 1822-1828.
• Davis, M. Neila, et al. “Improving Transition and Communication Between
Acute Care and Long-Term Care: A System for Better Continuity of Care.”
Annals of Long-Term Care. May 2005; Vol. 13 No. 5: 25-32.
• Coleman, Eric A., et al. “Preparing Patients and Caregivers to Participate in
Care Delivered Across Settings: The Care Transitions Intervention.” JAGS
52: 1817-1825, 2004.
• Coleman, Eric A., Berenson, Robert A. “Lost in Transition: Challenges and
Opportunities for Improving the Quality of Transitional Care.” Ann Intern
Med. 2004; 140: 533-536.
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