ACTIVATEThe FSL and Dignity Health Care Transition Initiative

Marc M. Lato, MDVice 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 rates

Expanded 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 care

Discharge planning begins at admission

One visit post-hospitalization / Additional home visits if

needed

ACTIVATE

Design Overview

ACTIVATE IncorporatesColeman’s Four Pillars

Medication Management – Patient has knowledge about

medication and has medication management system

Use 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 Intervention

Transitional Care Nurse (TCN)

In-Hospital Assessment

Home Visit by the TCN

Psycho-social Assessment

Comprehensive 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 Enrolled Completed Pending Readmission Readmission

Rate (%)

201128%

2012 61 56 0 1018%

2013 49 46 0 38%

2014 63 52 11 24%

Cumulative 173 162 11 159%

• Additional 44 Enrolled at Bedside but had No Home Services

• Closing Rate was 80% (173/217)

CATCH Model

Clients Activated Through Community and Hospital

CATCH Recap

Target Population

Patient of Internal Medicine Clinic (IMC)

Uninsured and Underinsured

Multi-morbidities with at least one in acute stage

38 being served; 18 completed the 12-month program

Number of hours spent with client

Front-loaded in first month; 10-15 hours including home

visit

Average of 5 hours per month following that

Components of Program

A 12-month care program

Joint home visit of IMC Resident and FSL Social Worker (S/W)

Psycho-social assessment is obtained

Quarterly client visits to IMC with metrics captured

S/W coaches care plan adherence between IMC visits

Partners provide Transport, Counseling, Public Benefits

Success 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 hospitalization

Adequate discharge planning

Adequate post-discharge follow-up

Improved coordination between inpatient and outpatient

team of caregivers

While 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-morbidities

Uninsured 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 protocols

Support public benefits application process

Encourage / monitor patient self-management

Access additional community resources

Effect 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 deepened

Home vs. Discharge meds reconciled

PCP follow-up visits tracked; patient status shared

Caregivers engaged

Personal Health Record created

Telephonic 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 services

One of the largest not-for-profit charitable entities in the State; collaborations with many community partners

Contracted with many Health Insurers

Medicare licensed/certified

Demonstrated 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/ Support

Group Homes for SMI Adults

Senior Centers

Community Action Programs

Respite Care

FSL Services

Care Management

In-home Assessments

Counseling

DME/Adaptive Equipment

Demonstration

ACTIVATE

CATCH

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St. Joseph’s – HSAG Program

• Invite highly utilized SNFs to meeting December 2013

• Key SNF decision makers (Exec Director /Director of Nursing (DON)

• Work With HSAG to develop program and format

• Gain agreement to share similar data confidentially

• Use well known tool to aggregate the data (Advancing Excellence)

• Agree to make participation priority

• Lunch and meeting facility provided by the hospital

Dignity Health/St Joseph’s –HSAG SNF Collaborative

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11 Area SNFs invited

10 have come consistently

8 Meetings occurred over the first year

Advancing Excellence tool training session facilitated by HSAG

Requests for Additional Key topics by the SNFs

HSAG and St. Joseph’s provided reference material

St. Joseph’s /HSAG SNF Collaborative

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Topics

• Resources – St. Vincent DePaul, Piper Med and Dental Clinic

• Circle the City – Respite- and SNF-like care for the homeless

• Sepsis bundle – Most expensive hospital admission, major readmission reason

• Blood transfusion protocols

o Possibility of calling in blood transfusion and saving admission

St Joe/HSAG SNF Collaborative

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Topics

• St Joseph’s Infusion Suite – Education

– Hours of Operation

– Possible use for transfusion

HSAG 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

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Future Direction

• Monthly Meetings

• Continue Advancing Excellence Tool

• Consider INTERACT 3.0 for use in SNF

• Add Key Home Health providers

• Add 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?