Transcript Slide 1

Inter-Professional Care
Coordination:
Looking to the Future
Susan C. Reinhard, RN, PhD, FAAN
Senior Vice President
AARP Public Policy Institute
May 24, 2011
Purpose
• Provide context for panel discussions
• Highlight consumers’ view on why inter-professional care
coordination is needed
• Review evidence on care coordination as background for
why transitional care is the focus now
• Summarize public policy opportunities provided in ACA
Context: Chronic Conditions
Finally, the US and developed countries are
talking about chronic conditions!
Why?
What can we/professionals do?
Inter-professional Care Coordination has
become the promise for the future
WHY? Because Many Older Americans
Have Multiple Chronic Conditions
1 Chronic Condition
2-4 Chronic Conditions
5+ Chronic Conditions
60%
50%
40%
30%
20%
10%
0%
Ages 50-64
Ages 65-74
Ages 75-84
Ages 85+
Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” Washington, DC. 2009.
Health Spending Increases with the
Average Annual Spending for
Adults 50+
Number of Chronic Illnesses
$15,937
$16,000
$14,000
$12,000
$10,293
$10,000
$7,382
$8,000
$5,411
$6,000
$3,994
$4,000
$2,000
$1,425
$0
0
1
2
3
4
5
Number of Chronic Conditions
Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” Washington, DC. 2009.
Average Health Care Spending
for Adults 50+
Health Care Spending for Older
Americans with Selected Chronic
Conditions is Higher Than Average
$40,000
$37,236
$35,000
$30,000
$25,000
$20,170
$20,000
$15,268 $14,814
$15,000
$14,422
$13,437
$12,100
$10,000 $6,440
$5,000
$0
National
Average
Kidney Congestive Cancer
Disease
Heart
Failure
Heart
Disease
Stroke
Arthritis
Diabetes
Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” Washington, DC. 2009.
Many Chronic Conditions are on the
Rise among Medicare Beneficiaries 65+
60%
1997
2006
50%
40%
30%
20%
10%
0%
High Blood
High
Diabetes
Pressure Cholesterol
Cancer
Mental
Illness
Back
Problems
Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” Washington, DC. 2009.
AARP Public Policy Institute
23% of Medicare beneficiaries with 5+ chronic conditions
account for 68% of Medicare spending
< 5 Chronic
Conditions
32%
77%
5+ Chronic
Conditions
68%
23%
Beneficiaries
Expenditures
Anderson, GF. “Medicare and Chronic Conditions”. New Eng J Med. 353;3:305 (Jul 21, 2005).
Top Chronic Conditions for Medicare
65+ Based on Aggregate Cost, 2006
Chronic
Condition
Parts A & B
Total Cost
Change (19972006)
Parts A & B
Cost/Case
Change (19972006)
Hypertension
$163.2 B
81%
$10,653
21%
Heart Disease
(other)
$130.4 B
65%
$15,358
24%
Cholesterol
$104.3 B
52%
$8,820
36%
Arrhythmias
$74.9 B
37%
$19,509
24%
Diabetes
$74.6 B
37%
$12,643
20%
CHF
$72.2 B
36%
$25,841
31%
Mental
Conditions
$71.3 B
36%
$19,624
26%
COPD
$63.9 B
32%
$18,511
27%
Delivery System Problems
• Health care systems (public and private) need
improvement, especially chronic care delivery
• Barriers to improvements in care for people with chronic
conditions include:
– Fragmented care delivery,
– Poor transitions across settings, and
– Poorly aligned payment incentives that fail to recognize
the value of better integration of services
Delivery System Problems
• Medicare is not perfect and needs
improvement
• Care is not well coordinated,
particularly for those with chronic
conditions
• Fee-For-Service payments encourage over
utilization of services
AARP Public Policy Institute
Research on Improving Care
Coordination and Transitions
Beyond 50.09 Chronic Care: A Call to Action for
Health Reform--Consumers’ Views
• Data Analysis of Care Coordination for Chronic Conditions
• Focus Groups of patients and caregivers with transitions
• National Opinion Surveys
– Patients with chronic conditions and transitions
– Caregivers of patients with chronic conditions and
transitions
• Promising Models of Chronic Care Coordination
– Transitional Care Model - Mary Naylor
– Care Transitions Intervention - Eric Coleman
– Guided Care (medical home w/ transitional care) – Chad Boult
Patients Report Problems
with Transitions
The most frequently reported issues around transitions
between hospitals (and other health care facilities) and
home were:
– Loss of mobility and/or independence
– Uncertain expectations for recovery and/or prognosis
– Pain
– Anxiety
– Not remembering their clinician’s instructions
– Feeling abandoned
Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” Washington, DC. 2009.
Caregivers Report Problems
with Transitions
The most frequently reported issues around transitions
between hospitals (and other health care facilities) and
home were:
– Finding resources, such as medical equipment and
services
– Arranging for assistance in and around the home, both
paid and unpaid
– Communication with doctors and other health
professionals
– Finances/affordability
Source: AARP. “Beyond 50.09: Chronic Care: A Call to Action for Health Reform.” Washington, DC. 2009.
Chronic Care Coordination
Based on these findings, AARP advanced bipartisan
legislation in both houses (rare)
Medicare Transitional Care Act—components
incorporated into ACA—one of AARP’s top 6 “asks”
Advocacy from N3C and others very successful!
Source: National Coalition on Care Coordination (N3C)
N3C Definition of Care
Coordination
Policy Brief: Implementing Care Coordination in the Patient Protection
and Affordable Care Act:
“Care coordination” is a person-centered, assessment-based,
interdisciplinary approach to integrating health care and social
support services in a cost-effective manner in which an individual’s
needs and preferences are assessed, a comprehensive care plan is
developed, and services are managed and monitored by an evidencebased process which typically involves a designated lead care
coordinator.”
Source: National Coalition on Care Coordination (N3C)
Evidence: Medicare
Coordinated Care Efforts
Since 1999, Medicare has tested more than 30
chronic care programs involving more than 300,000
traditional Medicare beneficiaries.
– To name a few, these programs have included
Medicare Health Support (also known as the Chronic
Care Improvement Program),
– The Medicare Coordinated Care Demonstration,
– Care Management for High-Cost Beneficiaries and
– The Physician Group Practice Demonstration
Source: Bott DM, Kapp MC, Johnson LB, Magno LM. “Disease management for chronically ill
beneficiaries in traditional Medicare.” Health Affairs (2009);28(1):86-98.
Evidence: Medicare
Coordinated Care Efforts
• Final evaluations on 20 Medicare Coordinated
Care demonstrations found only three had
improved quality without substantially increasing
Medicare spending, net of program fees.
• Interim assessments of 15 other programs
suggest that only four have been able to cover
their fees and approximately breakeven.
Source: Bott DM, Kapp MC, Johnson LB, Magno LM. “Disease management for chronically ill
beneficiaries in traditional Medicare.” Health Affairs (2009);28(1):86-98.
Medicare Coordinated Care Efforts
An exhaustive survey (Boult, 2009) of successful
models of comprehensive health care delivery that
have shown potential to improve the quality,
efficiency and outcomes of care for chronically ill
older persons found that 15 models, including,
among others, transitional care, have improved
at least one outcome.
Medicare Coordinated Care Efforts
In particular, studies (JAMA, 2009) suggest that a number of
elements are important for the success of chronic care
coordination programs, including:
– Targeting high cost patients who are at high risk for hospitalization;
– Frequent in-person contact with a health professional (at least once per
month);
– Teaching patients how to take their medications;
– Strong care coordinator ties to primary care practitioners (i.e.,
care coordinators co-located with physicians and each physician’s patients
assigned to a single coordinator);
– Care coordinators with timely information about hospitalizations
and discharges; and
– Financial incentives to encourage cooperation and collaboration by
physicians and other clinicians.
Transitional Care Research
Focus on Transitional Care has become a strong focus of
care coordination because:
• Evidence-based research has shown that Transitional Care
Services can smooth transitions across care setting,
improve care coordination, and reduce costs for high risk
patients.
• Transitional Care Services can also be easily incorporated
into larger health care delivery system and payment
reforms.
Source: Brown, Randall. (Brown, 2009) “The Promise of Care Coordination: Models that Decrease Hospitalizations and
Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses.” A Report Commissioned by the National Coalition
on Care Coordination, March 2009.
Transitional Care Research
Some key elements of effective Transitional Care Services:
– coordinating early face-to-face contact with patients and families while
still in the hospital,
– improving discharge planning by using check lists and patient education
tools,
– implementing early follow-up after discharge with in-person home visits,
– performing comprehensive assessment of the patient’s health status,
clinical needs, home environment, and social support network,
– developing a care plan,
– educating and assisting patients and caregivers about how to navigate
the health care system, find resources and obtain community and
supportive services, such as meals-on-wheels and Aging and Disability
Resource Centers, and
– following-up to monitor, provide oversight and care coordination, as
needed, for up to 90 days.
Source: Brown, Randall. (Brown, 2009) “The Promise of Care Coordination: Models that Decrease Hospitalizations and
Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses.” A Report Commissioned by the National Coalition
on Care Coordination, March 2009.
National Attention to Chronic
Care
• ACA has multiple policy tools to change the way people with chronic
conditions get better care, and many involve inter-professional care
coordination
• CMS leadership offers fresh, strong, collaborative approach
– “Discovery of duals” by top leaders
• 45% of Medicaid spending
• 25% of Medicare spending
– Acknowledgement of family caregivers in Congress and CMS
– CMS officials working together to develop integrated RFPs that bring
primary, acute, behavioral and LTC together
Payment Reforms that Support Care
Transitions and Coordination
• Hospital Readmission Reduce Incentives (§ 3025)
– Penalties for avoidable readmissions (the “stick”)
• Accountable Care Organizations (§ 3022)
– Medicare Shared Savings Program
– Provider bonuses for saving money and improving quality
• National Payment Bundling Pilot (§ 3023)
– Bundled payment for episodes of care
– Physicians, acute hospitals and post-acute care providers
Medicare Payment Reforms that Support
Care Transitions and Coordination
Avoidable Readmission Penalty (§ 3025)
– Incentive to improve care transitions and reduce
avoidable readmissions
– Reduced Medicare DRG payments by 1%, rising to 3%
– For certain avoidable readmissions exceeding a
threshold (TBD)
– 3 Target conditions TBD starting in FY 2012, 7 in 2015
– Readmission window TBD (ie, 30 days post discharge)
– Hospital-specific readmission rates will be published on
Medicare Hospital Compare website
– Expand to skilled nursing homes and HH Agencies
Medicare Innovations to Improve
Care Transitions and Coordination
The “Carrots”
• Medicare Community-Based Care Transitions Program
• Medicare Independence at Home Demonstration
• CMS Center for Medicare & Medicaid Innovation
• Patient-Centered Medical Home Demonstration
• Medicaid Health Homes for Chronic Conditions
• Community Health Teams for Medical Homes
• Workforce Improvements that support Transitional Care
See PPI Fact Sheet: Health Reform Initiatives to Improve Care Coordination and
Transitional Care for Chronic Conditions
Innovations to Improve Care
Transitions and Coordination
Community-Based Care Transitions
Program (§ 3026)
– Hospitals with high Medicare readmission rates,
applications accepted as of April 12, 2011
– Partner with Community-based organizations
– Preference for medically underserved areas, small
communities, rural areas and AOA programs.
– Targeting high risk fee-for-service Medicare
beneficiaries (many likely to have LTC needs, duals)
• Risk score
• Cognitive impairment, depression, multiple
readmissions, other factors (TBD)
Innovations to Improve Care
Transitions and Coordination
Community-Based Care Transitions Program
(§ 3026) continued
– Services must include at least one of 5 interventions
• Arranging post-discharge services
• Providing self-management support (or caregiver
support)
• Conducting medication management review
– Funding of $500 million over 5 years
– CMS will have authority to expand the program if it will
reduce Medicare spending without reducing
quality
Innovations to Improve Care
Transitions and Coordination
Independence at Home Demonstration
(§ 3024)
– Starting in 2012 (or sooner), funding of $5 million/5 years
– House Calls to help Medicare beneficiaries remain at home
• Medical Practices (MDs and Nurse practitioners) must have
experience delivering home-based primary care, available 24 x 7
• Target Medicare Beneficiaries with Multiple Chronic Illnesses
–
–
–
–
2 or more chronic conditions; 2 or more functional dependencies (ADLs)
Hospitalized in past 12 months (non-elective)
Rehab therapy in past 12 months
Voluntary enrollment of up to 10,000 beneficiaries
– Bonus for savings exceeding 5%
Medicare Innovations to Improve
Care Transitions and Coordination
CMS Center for Innovation
• Testing promising models for improving chronic care
coordination
• Funding of $1 billion per year for 10 years
• Budget neutrality requirement waived during testing
• Authority to expand any model
– Reduces cost but not quality
– Increases quality but not cost
Medicare Innovations to Improve Care
Transitions and Coordination
Patient-Centered Medical Home Demonstration
– Addressing needs of high-risk Medicare beneficiaries with chronic
conditions
– Home health providers and interdisciplinary teams provide
chronic care management to Medicare beneficiaries
– Geriatric assessments and comprehensive care plans to coordinate
care
Medicaid Innovations to Improve
Care Transitions and Coordination
Medicaid Health Homes for Chronic
Conditions (§ 2703)
– Also known as Medical Homes
– State Medicaid Option
• Targets high-risk Medicaid beneficiaries
– 2 chronic conditions or
– 1 existing chronic condition plus risk of 1 or more
additional or
– Serious mental illness
• Services
– Enhanced integration and coordination of primary care, acute
care, behavioral care, and long term care
– Care management, transitional care, community support
services
Medicaid Innovations to Improve
Care Transitions and Coordination
Medicaid Health Homes for Chronic Conditions (cont)
• Funding
– Planning grants starting in 2011, rolling
– CMS will base approval on Letter to State Medicaid Directors, Nov
16, 2010, and subsequent regulations
– Matching funds totaling up to $25 million ($500,000 each?)
– Over 20 states have expressed interest in planning grants
• Conditions
•
During first 2 years, 90% federal matching funds for Health Home
services
– States must track avoidable readmissions
– Estimate savings from care coordination
– Report lessons learned
Innovations to Improve All Care
Transitions and Coordination
Community Health Teams (§ 3502)
• Interdisciplinary teams contract with Medical Homes
– Collaborate with community support services
– Teams must be designated by states or Indian tribes
– Chronic care coordination, discharge planning,
transitional care, medication therapy management
(§ 3503), mental health referrals, 24 x 7 availability
– HHS grants: ACA does not authorize funding but HHS
has indicated funding will be available
• Teams must become self-sustaining in 3 years
• Targets patients with chronic conditions regardless of payer
type (Medicare, Medicaid, private)
Duals
• CMS RFP on duals: $1 million per state to 15
states, including New York, to support design
• Inter-professional care coordination critical
• Person-centered models that integrate the full
range of acute, behavioral health and long-trm
supports and services
• Does not prescribe managed care per se---CMS
open to innovative models
Selected Workforce Improvements
Key workforce improvement programs authorized under ACA
include (funding is pending for several of these initiatives):
• establishment of a National Health Care Workforce Commission to
review projected workforce needs (ACA § 5101);
• training grants in primary care to educate students in teambased approaches to care, including patient-centered medical
homes (ACA § 5301);
Resources
• AARP Public Policy Institute
– Health Reform Legislation – Key Facts
• www.AARP.Org
• Center to Champion Nursing in America
– http://championnursing.org/
• White House / HHS Health Reform Information
– www.HealthCare.Gov
• Medicare
– www.Medicare.Gov
– www.CMS.Gov
Inter-Professional Care
Coordination
• Thank you!
• Questions?
• Susan C. Reinhard, RN, PhD
[email protected]
202-434-3840