ACTIVATE The FSL and Dignity Health Care Transition Initiative - PowerPoint Presentation

ACTIVATEThe 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

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 ratesExpanded to: Chandler Regional & Mercy Gilbert in January 2013 Current Model

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 careDischarge planning begins at admissionOne visit post-hospitalization / Additional home visits if neededACTIVATE Design Overview

ACTIVATE Incorporates Coleman’s Four Pillars Medication Management – Patient has knowledge about medication and has medication management systemUse 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 InterventionTransitional Care Nurse (TCN)In-Hospital AssessmentHome Visit by the TCNPsycho-social AssessmentComprehensive 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 EnrolledCompletedPendingReadmissionReadmission Rate (%) 2011 28% 2012 61 56 0 10 18% 2013 49 46 0 3 8% 2014 63 52 11 2 4% Cumulative 173 162 11 159% Additional 44 Enrolled at Bedside but had No Home ServicesClosing Rate was 80% (173/217)

CATCH Model C lients Activated Through Community and Hospital

CATCH Recap Target Population Patient of Internal Medicine Clinic (IMC)Uninsured and UnderinsuredMulti-morbidities with at least one in acute stage38 being served; 18 completed the 12-month programNumber of hours spent with clientFront-loaded in first month; 10-15 hours including home visitAverage of 5 hours per month following that

Components of Program A 12-month care programJoint home visit of IMC Resident and FSL Social Worker (S/W)Psycho-social assessment is obtained Quarterly client visits to IMC with metrics capturedS/W coaches care plan adherence between IMC visitsPartners provide Transport, Counseling, Public BenefitsSuccess Measures (First Six Months of Enrollment) 55% Reduction in ER visits 53% Reduction in All-Cause Admissions CATCH Recap

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 hospitalizationAdequate discharge planningAdequate post-discharge follow-upImproved coordination between inpatient and outpatient team of caregiversWhile readmissions have been declining through 2013, the study of best practices for reducing readmissions remains an area of growth and innovation CMS Historical Perspective on Readmissions * 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

Target Population Focused on Super-Utilizers: Patients that over utilize the ER (usually known to staff) or the hospital (identified by Case Management)Multi-morbiditiesUninsured 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 protocolsSupport public benefits application processEncourage / monitor patient self-managementAccess additional community resourcesEffect 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 deepenedHome vs. Discharge meds reconciled PCP follow-up visits tracked; patient status sharedCaregivers engagedPersonal Health Record createdTelephonic 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 servicesOne of the largest not-for-profit charitable entities in the State; collaborations with many community partnersContracted with many Health Insurers Medicare licensed/certifiedDemonstrated success in implementing highly effective community based Transitional Care programs within Dignity Health Dignity Health Expansion 90 Day Program

Home Modifications and Safety Low Income Senior Housing Caregiver Training/ SupportGroup Homes for SMI AdultsSenior CentersCommunity Action ProgramsRespite CareFSL Services Care Management In-home Assessments Counseling DME/Adaptive Equipment Demonstration ACTIVATE CATCH

21 St. Joseph’s – HSAG Program Invite highly utilized SNFs to meeting December 2013Key SNF decision makers (Exec Director /Director of Nursing (DON)Work With HSAG to develop program and formatGain agreement to share similar data confidentiallyUse well known tool to aggregate the data (Advancing Excellence)Agree to make participation priorityLunch and meeting facility provided by the hospitalDignity Health/St Joseph’s –HSAG SNF Collaborative

22 11 Area SNFs invited 10 have come consistently8 Meetings occurred over the first yearAdvancing Excellence tool training session facilitated by HSAG Requests for Additional Key topics by the SNFsHSAG and St. Joseph’s provided reference materialSt. Joseph’s /HSAG SNF Collaborative

23 Topics Resources – St. Vincent DePaul, Piper Med and Dental ClinicCircle the City – Respite- and SNF-like care for the homelessSepsis bundle – Most expensive hospital admission, major readmission reasonBlood transfusion protocolsPossibility of calling in blood transfusion and saving admission St Joe/HSAG SNF Collaborative

24 Topics St Joseph’s Infusion Suite – EducationHours of OperationPossible use for transfusionHSAG Presentation - 2 OIG Reports Medicare Nursing Home Resident Hospitalization Rates 11/2013 Adverse Events in SNFs for Medicare Beneficiaries 02/2014 St. Joseph’s/HSAG SNF Collaborative

25 Future Direction Monthly MeetingsContinue Advancing Excellence ToolConsider INTERACT 3.0 for use in SNFAdd Key Home Health providersAdd the Dignity-affiliated ACO (Arizona Care Network)Consider adding Key Facility Medical Directors Determine 1 initiative for group’s participation St Joseph’s/HSAG SNF Collaborative

QUESTIONS?