laura davie co-director center on aging and community living amy newbury
DESCRIPTION
Laura Davie Co-Director Center on Aging and Community Living Amy Newbury Care Transitions Pilot Site Director (Formally) Aging and Disability Resource Center. NASUAD Home & Community Based Services Conference - PowerPoint PPT PresentationTRANSCRIPT
Laura Davie Co-Director
Center on Aging and Community Living
Amy Newbury Care Transitions Pilot Site Director
(Formally)Aging and Disability Resource Center
NASUADHome & Community Based Services ConferenceCommunity-Hospital Partnership to Facilitate Improvements in Care TransitionsTuesday, September 10, 2013
Community-Hospital Partnership to Facilitate Improvements in Care
Transitions2
Session Goals Understanding of the enhanced BOOST
model
Strategies for community and hospital partnerships
Sharing pilot outcomes/lessons learned
Community-Hospital Partnership to Facilitate Improvements in Care Transitions
3
1-866-634-9412
www.servicelink.org
NH ServiceLink Aging and Disability Resource Centers
Berlin
Littleton
TamworthLebanon
Laconia
Claremont
Rochester
Concord
Portsmouth
ManchesterKeene
Salem
Nashua
Belknap County•LaconiaCarroll County•TamworthCoos County•BerlinGrafton County•Lebanon•LittletonHillsborough County•Manchester•Nashua
Merrimack County•ConcordMonadnock Region•KeeneRockingham County•Portsmouth•SalemStrafford County•RochesterSullivan County•Claremont
Community-Hospital Partnership to Facilitate Improvements in Care Transitions
4
SLRC Functions
1) Access to comprehensive information and awareness about services for individuals with public or private payment mechanisms (Information and Awareness function)
2) A single point of entry into public programs, including Medicaid funded in-home care and nursing home care (Streamlined Access function)
3) Screening for and assessment of Medicaid eligibility (Streamlined Access function);
4) Options Counseling (Options Counseling function)
5) Long-term care counseling (Information and Awareness function)
6) Tools for short term case-tracking (Quality Assurance and Evaluation function)
7) Counseling, respite care counseling, and other supports for family caregivers (Information and Awareness function)
8) Statewide coordination and counseling to Medicare beneficiaries under the State Health Insurance Assistance Program (SHIP) (Streamlined Access function).
9) Serve as Local Contact Agencies (MDS 3.0 Section Q)
10) Community Based Veterans Directed Programs (pilot)
Community-Hospital Partnership to Facilitate Improvements in Care Transitions
NH ADRC Care Transitions Pilot Roles and Responsibilities
Bureau of Elderly and Adult Service at NH DHHS (BEAS): Administrator SLRC Network Pilot oversight & directed policy and data collection
Center on Aging and Community Living at UNH: Agent of the State for the ACL grant Sub-contracted with SLRC sites Technical assistance and evaluation
ServiceLink Resource Center Network: Contracted agencies with BEAS to perform activities in
alignment fully functioning ADRC model Implemented care transitions pilot (three communities)
Hospitals: Partnered with local ADRCs for implementation and program
design
5
Community-Hospital Partnership to Facilitate Improvements in Care Transitions
NH ADRC Person-Centered Care Transitions Pilot
6
Three local NH Aging and Disability Resource Center (ADRC) sites piloted care transitions models (2010-2013)
Care Transitions Intervention (CTI) and Better Outcomes for Older Adults through Safe Transitions (BOOST)
On-site staff All payer sources CTI- Increase linkages with NH’s ADRC services
(care-giver support, information and referral specialist, long term care counselor, and Medicaid specialist)
BOOST- provide on-site long term care counselorCommunity-Hospital Partnership to Facilitate Improvements in Care Transitions
CommunityProfile
BOOST Model8
Vision Reduce 30 day readmission rates Improve patient satisfaction scores Improve flow of information between hospital
and outpatient physicians and providers Identify high-risk patients and target specific
interventions to mitigate their risk Improve patient and family preparation for
dischargewww.hospitalmedicine.org/BOOST/
Community-Hospital Partnership to Facilitate Improvements in Care Transitions
Developing the Enhanced BOOST Model
9
Divine intervention Building upon existing partnership with
hospital and community (Business Agreement)
Working with Society of Hospital Medicine & Piedmont Hospital
Established Care Transitions Advisory Group Leadership Team Meetings Developed referral process (flow chart)
Community-Hospital Partnership to Facilitate Improvements in Care Transitions
10
Developing the Enhanced BOOST Model
11
Divine intervention Building upon existing partnership with
hospital and community (Business Agreement)
Working with Society of Hospital Medicine & Piedmont Hospital
Established Care Transitions Advisory Group Leadership Team Meetings Developed referral process (flow chart)
Community-Hospital Partnership to Facilitate Improvements in Care Transitions
12
New Hampshire ServiceLink Aging and Disability Resource Center, January 2013
Care Transitions Specialist Role
13
Linkages with Community LTSS Options Counseling (not just about
Medicaid) Person Centered Approach BOOST rounds Additional Follow Up across Enhanced
BOOST model Liaison across care environments No time restriction
Community-Hospital Partnership to Facilitate Improvements in Care Transitions
Evaluation(March 2012-September 2013)
14 Referrals Total
Referrals to the formal pilot from the hospital 343
Participants who completed formal pilot 343 “Consults" conducted at the hospital (non-pilot patients) 123 Total referrals to made to other SLRC programs by the CTS 150
Top 4 referrals to other SLRC programs
Caregiver Specialists 13
Long Term Support Counseling 119
Information and Referral Specialist 8
Other: (Medicare /Assisted Technology) 10
Community-Hospital Partnership to Facilitate Improvements in Care Transitions
15
Evaluation(March 2012-September 2013)
Community-Hospital Partnership to Facilitate Improvements in Care Transitions
Participant Age Number Percent
age 60+ 159 46%
under age 60 93 27%
unknown 91 27%
Total 343
Outcomes16
Person-Centered Hospital care transitions pilot (2010-2013) Outcome 1: Reduce hospital readmission rates for
target population. Outcome 2: 80% of participants report feeling prepared
for discharge. Outcome 3: 50% of medical and social providers report
good communication of medical and social services. Outcome 4: The referral process to link patients to
community resources is improved. Outcome 5: 80% of participants report confidence in
their ability to navigate the medical and social systems. Community-Hospital Partnership to Facilitate Improvements
in Care Transitions
Outcome 1: Reduce hospital readmission rates for target population
17
Lakes Region General Hospital:
Readmission rate for BOOST participants
and non-BOOST participants
Readmission rate for Belknap SLRC
care transitions specialists
participants March 1, 2011-
February, 28, 2012 4.38% 0.85%
March 1, 2011 – December
31,2012 5.21%
0.42%
Case Mix BOOST providers
Case MixSLRC- CTS
March 1, 2011- February, 28,
2012 1.259 1.532
March 1, 2011 – December
31,20121.47 1.28
Outcome 2: 80% of participants report feeling prepared for discharge
18
Staff took my preferences into
account
Left hospital with good understand
Left hosital and understood the
puprose of taking meds
40% 40%
53%
37% 37%
22%
7% 7% 4%
14% 15% 14%
3% 7% 7%
Strongly Agree Agree Disagree Strong DisagreeDK/NA
Responses on Consumer Satisfaction SurveyFeeling prepared for discharge
Perc
ent o
f re
spon
dent
s
Outcome 3: 50% of medical and social providers report good communication of medical and social services19
0
4
8
12
16 14 13
35
1 10 0
Agree Somewhat agree Somewhat disagree Disagree
Nu
mb
er o
f P
artic
ipa
nts
Outcome 4: The referral process to link patients to community resources is improved
20
Linkages Number of Linkages
Total community referrals made by CTS 96
Examples of community referrals:
chronic disease self-management 5
Home Health/Home Maker 16
Transportation 16
Personal Emergency Response System 11
Outcome 5: 80% of participants report confidence in their ability to navigate the medical and social systems.
21
0%20%40%60%80%
100%75% 75% 75% 75%
11% 14% 10% 11%14% 11% 14% 14%
Confidence in their ability to navigate the medical and social system
Agree/Strong Agree Strong Disagree/ DisagreeDon't Know/Did Not Answer
Percent of respondents
Our Takeaway’s to build on22
The ADRC model (social/community based) is a critical partner within the medical system to improve the quality of acute transitions for individuals.
Growing hospital awareness and investment in partnering with ADRC’s (social/community based systems).
Explore and refine data collection practices.
Community-Hospital Partnership to Facilitate Improvements in Care Transitions