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
21
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
22
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
23
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
24
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
25
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?