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  1. Healthy Aging and the Importance of Transitions of Care Rob Schreiber MD Chief Medical Officer, HSL American College of Health Care Administrators March 17, 2011

  2. Objectives • Environmental Scan: review the prevalence, cost and impact of chronic Illness in our health system. • Discuss importance of prevention and health promotion to reduce risk of chronic illness impact • Discuss the opportunities for the Aging Service Provider network to partner with medical system through the ACA act to reinvent healthcare • Discuss present and future innovative opportunities that can redefine health care delivery and improve health outcomes while lowering costs

  3. The New Reality • Healthcare consumes now 18% of GDP and will increase to 34% by 2040 • 79% of US healthcare $ spent on chronic care • Medicaid expenditures are growing so rapidly that states can not meet demand • Nursing home beds are decreasing in the communities • Health care reform is going to result in payment for outcomes and not service

  4. We Face an Epidemic of Unparalleled Proportions • More than 1.7 million Americans die of a chronic disease each year. • One-third of the years of potential life lost before age 65 is due to chronic disease. • Four chronic diseases—heart disease, cancer, stroke, and diabetes—cause almost two-thirds of all deaths each year. Mensah: www.nga.org/Files/ppt/0412academyMensah.ppt#18

  5. Number of Chronic Conditions per Medicare Beneficiary 95% 63%

  6. NCOA Survey of Chronic Conditions: Findings 2009 • The survey examines the attitudes of Americans with chronic conditions and explores their quality of life, health needs and experiences with the health care system • A bleak and broken health care system for millions of Americans suffering from a variety of chronic conditions. • The survey also identifies barriers to self-care and what is needed to better manage overall health. • Points to need for cost-effective self-management programs and support as part of comprehensive health reform http://www.ncoa.org/improving-health/chronic-disease/healthier-lives.html

  7. Diversity in who is affected and how. Hurting, tired, depressed and stressed Reliance on healthcare system that’s not working Need help learning how to take better care of my health in a way that works for me and my life Have multiple health problems and conditions make it difficult for them to take better care of myself Struggles Delaying medical care Barriers to self-care Seeking realistic, practical, customized help Themes from People with Chronic Conditions

  8. Life Expectancy by Health Care Spending Mensah: www.nga.org/Files/ppt/0412academyMensah.ppt#22

  9. The IOM Quality report: A New Health System for the 21st Century • “The current care systems cannot do the job.” • “Trying harder will not work.” • “Changing care systems will.”

  10. IOM Report: Six Aims for Improving Health Systems • Safe - avoids injuries • Effective - relies on scientific knowledge • Patient-centered - responsive to patient needs, values and preferences • Timely - avoids delays • Efficient - avoids waste • Equitable - quality unrelated topersonal characteristics

  11. Retooling for an Aging America:Building the HealthCare Workforce • IOM 2008 • Report Calls for a fundamental reform in the way we care for older adults http://books.nap.edu/catalog.php?record_id=12089#toc

  12. IOM Retooling Taskforce Three Prong Approach • Enhance the competence of all individuals in the delivery of geriatric care • Increase the recruitment and retention of geriatric specialists and caregivers; and •  Redesign models of care and broaden provider and patient roles to achieve greater flexibility.

  13. What Impacts Health Most? Source: McGinnis and Foege, JAMA 1996 & the CDC

  14. “Actual Causes of Death” Behavioral Risk Factors Behavior% of deaths, 2000 • Smoking 19% • Poor diet & nutrition/ 14% Physical inactivity • Alcohol 5% • Infections, pneumonia 4% • Racial, ethnic, economic ? Disparities McGinnis & Foege, JAMA, 1993; Mokdad et al, JAMA, 2004

  15. U.S Preventative Services Task Forces Principal Findings • Most effective interventions address personal health practices: smoking diet, safety, physical activity, substance abuse • Need more selectivity guided by individual risk factors • Counseling and patient education are most important criteria than certain diagnostic tests • Preventative services could be incorporated into visits for illness • Patients need to assume greater responsibility for their health

  16. Healthy Aging ……More than a program Healthy aging is a systems change strategy, not simply a program or service.

  17. Challenges Facing Medical Care Providers and Health Systems • Payment for Quality, prevention and outcomes • Penalized for bad outcomes • Freezing of payments and/or cuts in Medicare payments • Public Report Cards show a significant gap in best practice and the care delivered • Being asked to restructure and redesign process of care • Dong more with less

  18. Estimated Cumulative Percentage Changes in National Health Care Expenditures, 2010 through 2019, Given Implementation of Possible Approaches to Spending Reform. HIT denotes health information technology, NP nurse practitioner, and PA physician assistant Estimated Cumulative Percentage Changes in National Health Care Expenditures, 2010 through 2019, Given Implementation of Possible Approaches to Spending Reform. HIT denotes health information technology, NP nurse practitioner, and PA physician assistant NEJM, November 26, 2009, Volume 361:2109-2011, Hussey et al.

  19. “Patient Protection and Affordable Care Act” Focus on 4 issues relevant to healthcare reform • Providers • Self-Management • Care Coordination • requires three “I”s: information, infrastructure, and incentives • Research • Patient-Centered Outcomes Research Institute (PCORI) • Integration of the PCORI’s research findings with decision supports, guidelines, and other aspects of EHR

  20. “Patient Protection and Affordable Act” • Lays groundwork for wide-ranging continuum of care reform • Establishes framework for care coordination • CLASS –Community Living Assistance Services and Supports • Office of Dual Eligible • CMS Innovation Center

  21. ACA Promoting Innovation • Testing of programs that will lead to improvements in care coordination • Expand beyond a narrow medicalized scope of practice toward connecting older adults in need of long-term care to supportive service in the community • Transformation of payment and delivery system models of care such as ACO, medical health homes • Bundling of payments for acute and post-acute services • Funding to expand provider base to deliver long-term care services through direct workforce investments

  22. A Different Health System Evolving • Self-management, self-determination, self-advocacy • Community-based, collaborative solutions • Prevention in delay of sickness and impairment • Evidenced based outcomes, comparative effectiveness • Development of Health Aging Communities • Challenge ageism, health disparities

  23. Value Proposition • Quality/Cost • “Outcomes not service” is the new mantra for community based providers • Jim Firman CEO of NCOA • Health system is transforming-what will be your role in it??? • Will you act or react? • Goal is to be relevant, add value

  24. Opportunities For Aging Service Providers: Preventing Hospitalizations • Preventing Readmissions-improving transitions from Hospital to Home • Care Transitions Program • STARR Program • MA QIO Homecare Intervention • Project RED • Project BOOST • Avoidable hospitalizations through community interventions

  25. National Perpective • 17.6% of Medicare beneficiaries are re-hospitalized within 30 days of discharge, accounting for $15 billion in spending • Estimates show that 76% of these readmissions may be preventable • Of Medicare beneficiaries re-admitted within 30 days, 64% receive no post-acute care between discharge and re-admission Source: MedPAC:June 2007 Report To Congress: Promoting Greater Efficiency in Medicare

  26. Hospitals are Dangerous Places for Elderly Patients • A frail, demented 81 yo woman with frequent falls and previous bleeding in her brain is incidentally found to have AF on a routine cardiologist visit and is admitted to the hospital for anticoagulation. • A delirious 85 yo woman brought to the ED for blood in her urine is restrained and given large doses of antipsychotics for a head CT scan. • A dying 90 yo woman with AD is given atenolol, lisinopril, lipitor, and aspirin for heart disease.

  27. Danger Also Lurks in Transitions to and from the Acute Hospital • Thyroid medication is never resumed upon discharge. Patient is severely hypothyroid 6 months later. • Hospital decision not to treat future pneumonias in a 90 yo woman with end-stage Parkinson’s Disease is never transmitted to the NH and she is readmitted for pneumonia 1 week later. • Family is angry about early discharge to a skilled nursing facility, unaware of a rehabilitation plan.

  28. Adverse Events Common Coming and Going • 46% of hospitalized patients have 1 or more regularly taken medications omitted without explanation. Potential for harm estimated at 39%. • Cornish Arch Int Med 2005; 165: 424-9 • Transfers from NH to hospital have an average of 3 med changes. 20% lead to adverse drug events. • Boockvar Arch Int Med 2004 (164) 545-50 • 19 % have 1+ adverse events within 3 weeks of d/chg. 66% are adverse drug events. • Forster et al. Annals of Internal Med 2003;138:161-7

  29. Provider Issues • Cookbook medicine and the fear of litigation, demerits, or income penalties. • Poor communication of patient meds, history, and preferences. • Losing the forest for the trees: No quarterback, fragmentation of care by subspecialties • Lack of geriatric knowledge and perspective • Failure to involve patients and caregivers

  30. Why try to Reduce Hospitalizations in the Nursing Home? • Hospitalization is often bad for frail nursing home patients • Many hospitalizations can be avoided by improving care in the NH setting • Financial and regulatory incentives are likely to change over the next few year • We can improve care and avoid unnecessary expenditures • Savings can be re-invested to further improve care • Impact on quality MDS indicators

  31. 1 in 5Medicare fee-for-service Hospitalized patients are re-admitted within 30 days N Engl J Med 2009; 360:1418-28

  32. Clinical Causes of Rehospitalizations • 70% of post-surgical hospitalizations are for medical reasons such as pneumonia, heart failure and sepsis • Roughly 90% of hospitalization with in 3 days appear to be unplanned and a result of clinical deterioration

  33. STARR Initiative (IHI) Medicare 9th Scope of Work Care Transitions Program Project RED Project Boost Interact II Tool MOLST/POLST EB Interventions to Prevent Rehospitalizations

  34. STARR Initiative(State Action on Avoidable Re-hospitalizations) • IHI led Commonwealth Funded • 3 states-MA, MI, WA • Goals • Reduce Statewide 30-day rehospitalization rates by 30% • Increase patient and family satisfaction with transitions in care and with coordination of care • 20 hospitals in Commonwealth have project teams

  35. Medicare 9th Scope of Work Care Transitions Initiative • Fourteen state QIOs • Goal: • Prevent rehospitalizations and improve care transitions • Identify and work with one defined cohesive cross-setting community with common referral patterns for health care • 10/14 Using the Care Transitions Program

  36. Care Transitions ProgramTM • 4 week process involving • Care Transitions CoachesTM • Implementation of the CARE (Continuity Assessment Record & Evaluation) Tool •  Focus on medication self management, red flags, followup, PHR  •  RCT showing significant decrease in rehospitalization rates at 30 and 90 days Coleman et al., Arch Int Med, 2006, http://www.caretransitions.org/

  37. Project RED (Re-engineered Discharge) http://www.bu.edu/fammed/projectred/ • Goal: Reduce rehospitalizations by using • In hospital nurse discharge • After Hospital Care Plan • After Discharge Clinical Pharmacist Call • AHRQ Funded RCT Results • improved readiness for discharge • improved PCP follow-up • 30% decrease in overall hospital use (ER, inpatient) A Reengineered Hospital Discharge Program to Decrease Rehospitalization: A Randomized Trial, Jack et al., Ann Intern Med. 2009;150:178-187.

  38. MOLST/POLST • Medical/Physician Orders for Life Sustaining Treatment(MOLST) • POLST paradigm exists in 20 states • Goal: establish a standardized process for communicating patient’s end of life care wishes across the continuum • Part of an advanced caring process • Being piloted In MA http://www.mass.gov/Ihqcc/docs/expert_panel/2009_06_08_MOLST_presentation.pps , http://www.polst.org/

  39. Nursing Home Hospitalizations and Readmissions: A Particular Problem

  40. Hospitalization of Nursing Home Residents • Common • Expensive • Often traumatic to the resident and family • Fraught with many complications of hospitalization (e.g. deconditioning, delirium, incontinence/catheter use, pressure ulcers, polypharmacy) • Sometimes an inappropriate use of the emergency room and acute hospital

  41. As many as 45% of admissions of nursing home residents to acute hospitals may be inappropriate Saliba et al, J AmerGeriatr Soc 48:154-163, 2000 In 2004 in NY, Medicare spent close to $200 million on hospitalization of long-stay NH residents for “ambulatory care sensitive diagnoses” Grabowski et al, Health Affairs 26: 1753-1761, 2007

  42. Hospital Readmissions within 30 days from SNFs are common • Of ~1.8 million SNF admissions in the U.S. in 2006, 23.5% were re-admitted to an acute hospital within 30 days • In Massachusetts the rate is 26% • Cost of these readmissions = $4.3 billion Mor et al. Health Affairs 29 (No. 1): 57-64, 2010

  43. Common Reasons for Transfers • Medical instability • Availability of: • On-site primary care providers • Stat tests, IVs • Inadequate assessments to identify early changes • Communication gaps • Family issues/preferences • Lack of advance directives (DNR, DNH)