Caring For Vulnerable Populations 2011 AHA Committee on Research Report January 2012 Caring for Vulnerable Populations An examination into emerging and effective care coordination practices for vulnerable populations through the example of caring for dual eligibles 1. Background on dual eligibles 2. Current programs to improve coordination 3. Core elements in care coordination programs 4. Future policy developments that may help improve care coordination Report available at: www.aha.org/caring/ AHA Committee on Research: http://www.aha.org/research/cor/index.shtml © 2011 American Hospital Association 2 Who are Dual Eligibles? 9.2 million Americans are dual eligibles: Medicaid beneficiaries who are also enrolled in Medicare. While 6 in 10 are 65 or older, more than 1/3 are younger individuals with disabilities. As compared to traditional Medicare beneficiaries, dual eligibles are: 15% more likely to have a cognitive or mental impairment 50% more likely to have diabetes 600% more likely to reside in a nursing facility 250% more likely to have Alzheimer’s disease 100% more likely to have heart disease Much less likely to receive specific measures of preventive care, follow-up care or testing Sources: Kasper, Judy, Molly O’Malley, and Barbara Lyons. “Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Service Use and Spending.” Kaiser Commission on Medicaid and the Uninsured, http://www.kff.org/medicaid/8081.cfm, July, 2010. Milligan, CJ et al. “Medicare Advantage Special Needs Plans for Dual Eligibles: A Primer,” The Commonwealth Fund, February 2008. Grabowski, DC. “Special Needs Plans and the Coordination of Benefits and Services for Dual Eligibles,” Health Affairs, 28 no. 1(2009): 136-146. © 2011 American Hospital Association 3 Since Dual Eligibles Use More Health Care Services . . . Health service utilization among dual eligibles as compared to Medicare population 56.4 Primary Care 69.5 60.3 Specialty Physicians 72.9 13.1 Emergency Room 28.3 44.3 Outpatient Hospital 58.2 11.7 Inpatient Hospital Medicare Eligible Only Dual Eligibles 17.9 2.6 5.2 5.1 9.8 Skilled Nursing Facility Home Health Care 0.4 0.8 Hospice 0 10 20 30 40 50 60 70 80 Percent of Population Utilizing the Service Source: Kasper, Judy, Molly O’Malley, and Barbara Lyons. “Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Service Use and Spending.” Kaiser Commission on Medicaid and the Uninsured, July, 2010. Accessed at: http://www.kff.org/medicaid/8081.cfm, © 2011 American Hospital Association 4 …They Account for a Disproportionate Share of Spending Dual Eligibles as a Share of 2006 Medicare Population and Spending 84% 16% Total Medicare Population, 2006: 43 million Dual Eligibles as a Share of 2007 Medicaid Population and Spending 61% 73% 85% 39% 27% 15% Total Medicare FFS Spending, 2006: $299 Billion Total Medicaid Population, 2007: 58 million Dual Eligibles Total Medicaid FFS Spending, 2007: $311 Billion Non Duals Source: Kaiser Family Foundation, “The Role of Medicare for the People Dually Eligible for Medicare and Medicaid,” January 2011. http://www.kff.org/medicare/upload/8138.pdf © 2011 American Hospital Association 5 Existing Service Delivery Models Lack Coordination at the Provider Level Program Financing Risk-adjusted, capitated payments Special to cover all Medicare Need Plans services (each plan determines Medicaid involvement) Program of AllInclusive Care for the Elderly Medicaid Managed Care Separate Medicare and Medicaid capitated benefit at an agreed-upon per member per month rate Some plans maintain FFS with additional payment for coordination; others use capitated model Population Care Coordination 298 plans serving more than 1,000,000 beneficiaries Patient ease through one plan Greater budget predictability Multidisciplinary care team No proven care improvement Varying degree of Medicaid coordination 71 sites nationally, servicing approximately 23,000 participants Approximately 2.5 million beneficiaries + Fully integrated funding stream Established quality measures Medical and nonmedical capabilities Sufficient up-front capital required High administration and workforce costs Centered on one physical location Incremental step toward risk sharing Improved care coordination FFS disincentives remain No set design standard Some exclusion of long-term care and behavioral health benefits Sources: (1) Milligan, C et al. “Medicare Advantage Special Needs Plans for Dual Eligibles: A Primer.” The Commonwealth Fund. February, 2008. (2) Centers for Medicare and Medicaid Services. Special Needs Plan Comprehensive Report: Medicare Advantage/ Part D Contract and Enrollment Data, Special Needs Plan Data. Accessed at: http://www.cms.gov/(3) McNabney, M. “Program of All-Inclusive Care for the Elderly” (presentation, American Hospital Association Committee on Research, Chicago, IL, March 2011). (4) Petigara, T et al. “Program of All-Inclusive Care for the Elderly.” Health Policy Monitor. April, 2009. © 2011 American Hospital Association 6 Affordable Care Act Offers Opportunities to Improve Dual Care Coordination The Federal Coordination Health Care Office will study and analyze the best methods to integrate dual benefits, improving coordination between the federal and state governments. The Center for Medicare and Medicaid Innovation will test innovative payment and service delivery models to improve quality and reduce unnecessary costs. In April it was announced the selection of 15 states to receive financial assistance to improve care coordination across sites of care for the dual eligible population. © 2011 American Hospital Association 7 Hospital Strategies to Care for Duals Incorporate Several Essential Elements Complete assessments 1 and reassessments Align financial incentives 7 Incorporate person- Develop network and community partnerships 8 Implement protocolbased planning Provide nonhealth care services 9 4 Conduct periodic visits Offer home-based care 10 Utilize team-based care Organize center-based day care 11 Facilitate data sharing and integrated information systems Incorporate cultural competency and equity of care standards 2 centered care principles 3 5 management 6 © 2011 American Hospital Association Offer home-based care 8 12 Core Element 1: Complete Comprehensive Assessments and Reassessments 1 A comprehensive assessment identifies all potential and 7 Align financialmedical incentives psychosocial supports aids necessary for an individualized care Develop network and 8 plan. Comprehensive programs community partnerships typically include annual Provideassessments nonhealth careto comprehensive 9 services evaluate any change in the patient’s clinical or social needs. Offer home-based care 10 Complete assessment and reassessment Incorporate person- 2 centered care principles Implement protocol-based 3 planning 4 Conduct periodic visits Example: Johns Hopkins ElderPlus Program Utilize team-based care center-based Individualized care plan is designed uponOrganize admittance to 5 management day care the program based on a comprehensive medical and behavioral assessment. Facilitate data sharing Incorporate cultural staff (including everyonecompetency from integrated and equity of 6 andMultidisciplinary information systems careworkers) standards physicians to housekeeping aids and social hold quarterly intake meetings to monitor care. Sources: (McNabney, M. “Program of All-Inclusive Care for the Elderly” (presentation, American Hospital Association Committee on Research, Chicago, IL, March 2011). Jaffe, S. “Federal Program Aims to Keep Seniors out of Hospitals and Nursing Homes.” The Washington Post. December 20, 2010. © 2011 American Hospital Association 9 11 12 Core Element 2: Incorporate PersonCentered Care Principles and Practices Place the individual and affiliated 7 family and friends (including informal caregivers, client advocates, and peers) at the center 8 of all planning decisions to achieve better results and promote patient 9 self-direction. 1 2 Incorporate personcentered care principles 3 4 10 5 Each patient works with a nonclinical health coach to proactively 11 manage care, making contact once every two weeks. New patients receive hour-long appointments, existing 30 minutes 12 Patients guaranteed same-day sick visits, follow-up call within 24 hours Patients have no copayments for physician visits or prescriptions filled at on-site pharmacy Example: AtlantiCare Special Care Center 6 Sources: Gawande, A. “The Hot Spotters: Can we Lower Medical Costs by Giving the Neediest Patients Better Care?” The New Yorker. January 24, 2011. Blash, L et al. “The Special Care Center: A Joint Venture to Address Chronic Disease.” Center for the Health Professions Research Brief. February, 2011. Page, L. “10 Ways Atlanticare’s Special Care Center Improves Outcomes and Lowers Costs.” Becker’s Hospital Review. February 4, 2011. © 2011 American Hospital Association 10 Core Element 3: Implement Protocol-Based Planning Evaluate and employ evidencebased protocols to manage common7 conditions affecting geriatric and other vulnerable populations, 8 reducing unwarranted provider variation. 9 1 2 3 4 Implement protocol-based planning Example: BOOST Program at SSM St. Mary’s Medical Center 5 1. 2. 3. 6 Charts flagged upon admission for eligible patients Names added to a white board for provider tracking Discharge process completed together by a physician and a nurse using the “teach back” technique. 4. Patient receives all discharge information on a one-page document to bring back to primary care physician. BOOST = Better Outcomes for Older Adults through Safe Transitions Sources: Budnitz, Tina. “Project Boost: Reducing Unnecessary Readmissions and so much More.” Society of Hospital Medicine. Available at www.hospitalmedicine.org/BOOST. Wellikson, L et al. “Aligning Hospitalists & PCPs: Coordination and Transitions” (presentation, American Hospital Association Committee on Research, Chicago, IL, March 2011). © 2011 American Hospital Association 11 10 11 12 Core Element 4:Conduct Periodic Visits 1 Include periodic visits (in person, by telephone, or via internet) with the patient and his or her family/ caregivers in their own home, complementing regularly scheduled medical care. 2 Example: GRACE, Wishard Health Services 3 4 Conduct periodic visits 5 6 8 9 Visit frequency varies but typically includes: 1. Comprehensive in-home assessment by10 nurse practitioner and social worker 2. In-home visit after care plan development 11 to discuss logistics 3. Phone contact at least once per month by 12 GRACE coordinators 4. Home visit after each hospitalization or ED visit. GRACE = Geriatric Resources for Assessment and Care of Elders Sources: Bielaszka-DuVernay, C. “The ‘GRACE’ Model: In-Home Assessments Lead to Better Care for Dual Eligibles.” Health Affairs, 30, no. 3 (2011): 431444. Counsell, SR et al. “GRACE: Geriatric Resources for Assessment and Care of Elders.” (presentation, Health Affairs, January, 2011). “IU Geriatrics.” Presentation provided by Stephen R. Counsell. © 2011 American Hospital Association 7 12 Core Element 5: Utilize Team-Based Care Management Centered on Primary Care Coordinate medical, behavioral, and long-term support services through the work of a multidisciplinary, accountable, and communicative care team. Integrate primary care physicians as the 2 core of the care team, supporting and collaborating with the multidisciplinary group. 1 3 Example: Commonwealth Care Alliance 4 5 Utilize team-based care management 6 8 9 Multidisciplinary primary care that includes 10 the following components: 1. Comprehensive assessments 2. Individualized care plans with integrated11 behavioral health 3. Team trained in social issues 12 4. RN, NP, behavioral health, MSW, and PCP assigned to each patient. 5. Capacity for home visits Sources: “Plan-Funded Team Coordinates Enhanced Primary Care and Support Services for At-Risk Seniors, Reducing Hospitalizations and Emergency Department Visits.” AHRQ Health Care Innovations Exchange. Accessed July 11, 2011. Simon, Lois. “Commonwealth Care Alliance: The Case for Primary Care Redesign and Enhancement as the Critical Strategy to Improve Care and Manage Costs” (presentation, Alliance for Health Reform Briefing, August, 2011). © 2011 American Hospital Association 7 13 Core Element 6: Facilitate Data Sharing and Integrated Information Systems 1 Provide mechanisms and create the necessary data-sharing 2 arrangements to collect, store, integrate, analyze, 3 and report data in a timely manner to promote care 4 coordination. Example: Montefiore Care Management Organization 5 6 Facilitate data sharing and integrated information systems Utilizes a data warehouse to measure quality of care for specific patient population. Combines claims with clinical data to identify patients that necessitate increased care coordination. Payer data facilitates ability to follow patients when they leave the Montefiore System. Examine ED visits, readmissions, medication compliance. Sources: Gardner, E. “Montefiore Medical Center: On the Cutting Edge of Accountable Care.” Modern Healthcare Insights. 2011. Chase, D et al. “Montefiore Medical Center: Integrated Care Delivery for Vulnerable Populations.” Commonwealth Fund: High-Performing Health Care Organization. October, 2010. Czinger, P. “Aligning Health IT with Delivery System Reform: Technology Gaps in Coordinating Patient Care.” (presentation, Bipartisan Policy Center’s Health IT and Delivery System Transformation Summit, Washington, DC, June 27, 2011). © 2011 American Hospital Association 14 7 8 9 10 11 12 Core Element 7: Align Financial Incentives 1 2 Organize financial arrangements and potential savings to encourage cooperation and alignment across the continuum of care. Align financial incentives 8 3 4 9 Example: Fairview Partners at Fairview Health Services • 5 • 6 7 Fairview Partners receives a per member, per month payment to provide comprehensive care for all services. Net income is distributed to its three partnerships, and Fairview assumes full operational responsibility for the continuum of care. Sources: “Conrad, J et al. “Fairview Partners” (presentation, American Hospital Association Committee on Research, March 2011). © 2011 American Hospital Association 15 10 11 12 Core Element 8: Develop Network and Community Partnerships Expand beyond the hospital and 1encourage relationships with nursing homes and long-term care providers, public health 2departments, community centers, and other organizations to 3improve care coordination and transitions 7 Develop network and community partnerships 4Example: The Care Coordination Network at Summa Health System 8 9 10 Summa worked with representatives from 28 area SNFs, EMS services, 5and the local agency on aging to create a task force with three main 11 objectives: 6 1. Standardize the SNF referral process with evidence-based guidelines 12 2. Create a clinical subcommittee to improve care transitions 3. Design and evaluate outcome measures to monitor network performance McCarthy, D et al. “Case Study: Summa Health System’s Care Coordination Network.” The Commonwealth Fund. Accessed August 23, 2011. “Cooperative Network Improves Patient Transitions Between Hospitals and Skilled Nursing Facilities, Reducing Readmissions and Length of Hospital Stays.” AHRQ Health Care Innovations Exchange. Accessed September 9, 2011 © 2011 American Hospital Association 16 Elements Incorporated Into The Most Integrated Programs 1 7 Provide nonclinical services such 2 as transportation to medical appointments. 8 3 Incorporate timely, patient- and family-centric, home-based care 4 options 5 Form or partner with a program that utilizes a center-based model 6 Develop care teams with awareness of the individual’s cultural perspective and language fluency. © 2011 American Hospital Association 17 Provide nonhealth care services 9 Offer home-based care 10 Organize center-based day care 11 Incorporate cultural competency and equity of care standards 12 Measure Progress Through Performance Metrics Type of Measure Utilization Relevant Metrics to Measure Program Process Number of ED visits Number of hospital admissions Number of preventable admissions Number of surgical procedures Length of survival Assessing Care of Vulnerable Elders (ACOVE) measures SF-36 Questionnaire or similar scale Medication compliance Total cost of care Cost per inpatient hospital stay Cost of specialty care visits Cost of primary care visits Mental health care spending Patient satisfaction in all settings – inpatient (HCAHPS), ambulatory, nursing home Affiliated partner satisfaction Quality and Outcomes Cost Satisfaction Number of labs and tests ordered Number of missed appointments Hospital length of stay Electronic health record meaningful use Assisted Daily Living (ADL) improvement Hospital Compare – process of care measures Mortality Durable medical equipment costs Nonhealth care service spending Cost of employed care coordinators Home health care costs Provider satisfaction Patient satisfaction Patient family/ caregiver satisfaction Applicable metrics will vary by program implemented © 2011 American Hospital Association 18 Key Take-Away: Caring for Vulnerable Populations While financial alignment may occur at a policy level, hospitals are well positioned to address the system, provider, and patient barriers impeding high-quality care for the most vulnerable populations. Report available at: www.aha.org/caring AHA Committee on Research: http://www.aha.org/research/cor/index.shtml Contact: Jill Seidman at email@example.com / 312-422-2641 © 2011 American Hospital Association 19 © 2011 American Hospital Association. All rights reserved. All materials contained in this publication are available to anyone for download on www.aha.org, www.hret.org, or www.hpoe.org for personal, noncommercial use only. No part of this publication may be reproduced and distributed in any form without permission of the publisher, or in the case of third party materials, the owner of that content, except in the case of brief quotations followed by the above suggested citation. To request permission to reproduce any of these materials, please email HPOE@aha.org.