National Coalition on Care Coordination (N3C)
Care Coordination and the Role of the Aging Network
Monday, September 12, 2011
Washington, DCHyatt Regency on Capitol Hill
Yellowstone/Everglades4:00 PM – 5:15 PM
Growth in Population of Older Americans& Increase in Chronic Disease
The population of older adults is rapidly increasing: By 2030, the number of Americans over 65 is expected to reach 72 million, double the 65+ population of 2003
Older adults are at high risk for chronic conditions including cardiovascular disease, diabetes, and cancer, that require ongoing medical management
Chronic conditions result in high health care costs and reduced quality of life
Psychosocial Issues also Common
A significant subset of older adults also face substantial psychosocial issues, including:
Depression, limited mobility, and diminishing finances and/or cognitive skillsThese issues add to service needs, plus…− Complicate access to and effective utilization of
health and medical services
Delivery System Problems
Health care systems (public and private) need improvement, especially chronic care delivery
Barriers to improvements in care for people with chronic conditions include:
Fragmented care delivery, Poor transitions across settings, and Poorly aligned payment incentives that fail to recognize the value of better integration of services
S Reinhard, PPI, AARP
Delivery System Problems
Medicare is not perfect and needs improvementCare is not well coordinated, particularly for those with chronic conditionsFee-For-Service payments encourage over utilization of services
S Reinhard, PPI, AARP
The Genesis of the National Coalition on Care Coordination (N3C)
• The American Society on Aging (ASA), and the New York Academy of Medicine (NYAM), Social Work Leadership Institute (SWLI) convened a distinguished group of thirty experts from health, human services and long-term care prior to the 2008 ASA Annual Conference on Aging to address key issues in care coordination.
• The meeting resulted in the formal establishment of the National Coalition on Care Coordination (N3C).
• Today consists of 40 members
2011 N3C MembershipSteering Committee: American Geriatrics Society National Council on Aging (NCOA)American Society on Aging National PACE AssociationConsumer Coalition for Quality Health Care New York Academy of Medicine Matz, Blancato & Associates Partners in Care Foundation Medicare Chronic Care Practice Research Network (MCCPRN)
Members: American Association of Retired People Long Term Care Educational Foundation, Area Agency on Aging (Mid-Columbia) George Mason University American College of Physicians National Academy of Certified Care Managers American Medical Association National Alliance for Caregiving Benjamin Rose Institute National Association of Professional Geriatric Care Managers Case Management Society of America National Association of Area Agencies on Aging (n4a) Center for Health Care Strategies National Association of States United for Aging Center for Medicare Advocacy, Inc. and Disabilities (NASUAD) Connecticut Community Care, Inc. National Transitions of Care CoalitionCOPE Health Care Strategies Paraprofessional Healthcare Institute (PHI) Family Caregiver Alliance Rush University Medical Center Gerontological Society of America SCAN Health PlanHudson Health Plan SeniorBridge Health and Medicine Policy Research Group Society of Hospital Medicine Illinois Coalition on Aging University of Illinois College of NursingLeadingAge (formerly American Association of University of Pennsylvania School of Nursing
Homes and Services for the Aging) Urban Institute
N3C Accomplishments
Over its history has convened major sessions at the 2009, 2010 and 2011 American Society on Aging conferencesConvened additional meetings with stakeholders in Washington D.C.Commissioned papers discussing current models of care coordinationMaintained a visible presence working withrelevant individuals in Congress and the Administration in the following areas:
N3C Accomplishments cont’d
During development of language in the Affordable Care ActImplementation of the ACA including filing comments on proposed rules including and meetings with offices such as CMMIMeeting with Administration officials and appropriate Congressional staff on the upcoming reauthorization of the OAA
N3C Mission and Goals
• Improve the quality of life for vulnerable older adults by promoting care coordination as an essential part of health care reform.
• Convene experts from health, long term care, aging and public policy to develop consensus on effective models of care coordination and build evidence for the effectiveness of care coordination.
• Understand how expertise of coalition members can be most effectively utilized.
• Identify opportunities to work with coalition members as allies, thought partners, and policy advocates.
N3C Mission and Goals, cont’d
• Develop evidence based specifics about Care Coordination, its benefits, and personnel qualifications.
• Educate federal and state policy makers on care coordination.
• Provide interested parties with specifics about the role and benefits of care coordination as part of health care reform.
N3C Definition of Care Coordination
Care coordination is a person and family-centered, assessment-based, interdisciplinary approach to integrating health care and social support services in a cost-effective manner in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an evidence-based process which typically involves a designated lead care coordinator.
N3C research/ SWLI review of current programs
The majority of programs described in the literature originate in the health care system:
Created and implemented either by an insurer or a health provider system
Programs implemented by community based organizations appear to be under-represented in the literature
We know there are a lot of them; they are not being evaluated and reported on as frequently as medical-based programs
Population Served
Programs included serve a diverse population of older adults with respect to:
Physical healthMental health and cognitive functionAvailable social supportLocation (e.g. rural/urban)
Setting for Service Delivery
Includes:*ClinicsHomeAdult Day CentersSenior CentersVA Medical CentersPhone
* SWLI review focused on community and home-based programs. Hospital-based and residential care programs were excluded by search criteria
Program Staffing
Commonly nurse lead, with an interdisciplinary team that may include MDs, pharmacist, OT/PT, dietician, social worker community liaison, psychiatrist, psychologistCare manager often works in conjunction with or maintains communication with primary care provider
Program Services
Baseline and ongoing assessment*Development of individualized care plan*Care management*Communication with PCP*Referrals to medical and supportive services*Medication managementHealth educationMental health servicesCommunication/advocacy with health care providerDischarge planningCaregiver support
* Most commonly included in reviewed programs
Care Coordination Program Objectives
Improved service utilizationIncreased use of social and community supportive services and outpatient servicesLess ER useFewer and shorter hospital and nursing home stays
Improved (or sustained) health, functioning, mental health, and quality of life for care recipientsReduced caregiver burdenImproved knowledge and behaviors, including chronic disease self managementReduced health care costsSatisfaction with services
Program Outcomes
Outcomes measured vary widely between articlesMost common positive outcomes include improved service utilization, functioning, mental health, quality of life, satisfaction with services, and reduced caregiver burdenAmong articles reporting cost outcomes, program costs may be offset by reductions in the cost of institutional services
Effective Practices
Analysis is ongoing and difficult due to variability in program structure, services, and outcomes measuredPreliminary findings regarding effective practices include
Program targeting to identify the population who can most benefit from a given interventionBaseline and ongoing assessment of health and social needsInterdisciplinary approach to allow providers to address a spectrum of health and social service needsEnhanced communication among providers, frequently including the primary care physicianFlexible provision of services and service intensityConnection to existing community health and supportive services
Effective Practices (continued)
Although less frequently reported on, literature also highlights the importance of:
Shared electronic health recordEvidence-based protocols to assess health and social condition and develop care planTechnology-assisted, in-home monitoring (by telephone or remote health monitoring systems) to enhance communication between community-dwelling older adults and providers, especially in rural areas
Promising models include:
• Geriatric Resources for Assessment and Care of Elders (GRACE)
• After Discharge Care Management of Low Income Frail Elderly (AD-LIFE)
Both models improve the quality of care for low income seniors by the longitudinal integration of geriatric and primary care services across the continuity of care
Integration with affiliated pharmacy, mental health, hospital, home health, and community-based services
Where N3C Advocacy for Care Coordination and Support for New and Existing Models of Care Has Succeeded
• Advocated Care Coordination as central focus of provisions in PPACA targeting older adults
o Center for Medicare Innovationo Support for new and existing models of care coordination
(PCMH, Independence at Home and others)
• Focused on evidence in support of care coordinationo Center for Medicare and Medicaid Innovation focus on best
practices and evidence-based measures
• Focused attention on the challenges for the reimbursement mechanisms that support care coordination
o Bundled payments and “value based purchasing” (Medicare Accountable Care Organizations and shared savings)
Where N3C Succeeded, Cont’d
• Focused on vulnerable populations and integration of health and long term care
o Care coordination models for dual eligibles focus on integration of health and long term care
• Long-term care measureso Class Independence Benefit Plano Continued support for Aging and Disability Resource Centers
• Support for home and community based serviceso Community based health teams in Patient Centered Medical
Homes (PCMH), Community-Based Care Transitions Program, ADRC Support
Federal Initiatives to Support State/Community-Based Approaches
to Coordinated Care
The Aging Network
http://aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/toolkit/docs/AgingNetwork_Structure_Program.pdf
Wagner’s Chronic Illness Model Change that Works
ProductiveInteractions
Improved Functional and Clinical Outcomes
Informed,Activated Patient
Prepared,Proactive Practice Team
Health SystemOrganization of Health Care
Self-Management
SupportDecision Delivery Support System
Design
Clinical InformationSystems
Overview
Alignment through implementation of the Affordable Care Act – Strategic Framework on Multiple Chronic Conditions – National Quality Strategy– Federal HIT Strategic Plan– Partnership for Patients
Themes recurring across multiple initiatives:– Importance of care coordination– Focus on care transitions– Role of community-based services– Focus on the patient and family caregivers
Triple Aim: Better care, better health, lower cost
J Howell, ONC
National Quality Strategy
AimsBetter Care: Improve quality, by making health care more patient-centered, reliable, accessible, and safeHealthy People and Communities: Improve health of population Affordable Care: Reduce cost of quality health care
Six Priorities and Goals to help focus public and private efforts:Safer Care: eliminate preventable health care-acquired conditionsEffective Care CoordinationPerson- and Family-Centered CarePrevention and Treatment of Leading Causes of Mortality: prevent and reduce harm caused by cardiovascular diseaseSupport Better Health in CommunitiesMake Care More Affordable
National Quality Strategyhttp://www.healthcare.gov/center/reports/quality03212011a.html#append
Partnership for Patients
Public-Private Partnership to make care safer, potentially save up to $50 billion
Two Goals of the Partnership:Keep hospital patients from getting injured or sicker: decrease preventable hospital-acquired conditions 40% by 2013 cf. 2010
– Up to $500M from CMS Innovation CenterHelp patients heal without complication: decrease preventable complications during transition from one care setting to another so that hospital readmissions will be reduced 20% by 2013 cf. 2010
– Up to $500M available through Community-Based Care Transitions Program authorized by Section 3026 of ACA
J Howell, ONC
Partnership for Patients: Community-Based Care Transitions Program
5 years beginning April 12, 2011; rolling application processProgram Goals:
Improve the quality of care transitionsReduce readmissions for high-risk Medicare beneficiariesDocument measureable savings to the Medicare program by reducing unnecessary readmissions
Creates source of funding for effectively managing transitions from acute to community-based settingsEligible entities paid on per-discharge basis for Medicare benes at high risk of readmission, including those with multiple chronic conditions, depression, or cognitive impairment.
J Howell, ONC
Community-Based Care Transitions Program: Selection Criteria
Preference given to Administration on Aging grantees that
Provide care transition interventions in conjunction with multiple hospitals and practitionersProvide services to medically-underserved populations, small communities, and rural areas
Applicants must Identify root causes of readmissions and define target population and strategies for identifying high-risk patients Specify transition interventions, including improving provider communications and patient activationIndicate how community and social supports and resources will be incorporated to enhance beneficiary post-hospitalization management outcomes
J Howell, ONC
State Demonstrations to Integrate Care for Dual Eligible Individuals
Partnership between Federal Office of Integrated Care and the Innovation Center – Testing delivery system and payment reform that improves the
quality, coordination, and cost-effectiveness of care for dual eligible individuals.
On April 14, 2011, 15 states awarded contracts for up to $1million to design new models for serving dual eligibles:
West: California, Colorado, Oregon, WashingtonMidwest: Oklahoma, Michigan, Minnesota, Wisconsin South: North Carolina, South Carolina, TennesseeEast : Connecticut, New York, Massachusetts, Vermont
Models will be person-centered and fully coordinate primary, acute, behavioral and long-term supports and services.
J Howell, ONC
CLASS ACT
CLASS ACT and care coordination:− Based on the model in the Federal Long Term
Care Insurance, N3C will work to have care coordination as a benefit in the LTSS package.
Bundled Payment
Described as the health care reimbursement “middle ground” between fee-for-service and a capitated payment system.CMS introduced the Bundled Payment for Care Improvement initiative and is seeking applications for different models of bundled care
Participants in models would set a target for reimbursement, test new models of care, receive payment for services under the traditional fee-for-service system, and at the conclusion of an episode share in the savings compared to the target price. Letters of intent due Sept. 22
CARE COORDINATION AND THE OLDER AMERICANS ACT
N3C has recognized the reauthorization of the Older Americans Act is an ideal opportunity to strengthen links between health and long term care and the medical and social models of care.The OAA, through the Aging Network, is a pioneer in development of coordinated services for older adults.
Through State Units on Aging, Area Agencies on Aging, service providers, and Aging and Disability Resource Centers
Care Coordination and the OAA Reauthorization
In anticipation of reauthorization, N3C submitted a paper to Administration on Aging proposing changes to OAA to strengthen
�care coordination: http://www.nyam.org/social-work-leadership-institute/docs/N3C-Changes-to-OAA.pdf
N3C’s recommendations are based on the principle that care coordination must:
be assessment driven,include a comprehensive care plan, require ongoing evaluation, andutilize a qualified care coordinator
Care Coordination and the OAA
Definition:The OAA should include care coordination within its definitions of its programs and services. In particular ADRC’s.
Integration:The OAA should encourage SUA’s and AAA’s to integrate care coordination into their plans.
The care coordinator should be widely accessibleThe care plan should be client centered
Care Coordination and the OAA
Administration:The Assistant Secretary should work with the Administrator of CMS to coordinate efforts and develop ways to ensure that older adults with multiple chronic illnesses receive coordinated care. This can include sharing best practices and disseminating information to the network and health care providers.AOA should ensure a standardized process that the aging network uses to build and Improve linkage between social and medical/health services.
Care Coordination and the OAA
Title III:Support improved outreach by area agencies with health and medical care entities around care coordination
Title IV:N3C supports testing of care coordination models under Title IV subject to funding as well as develop appropriate training curriculums.
OAA Reauthorization
U.S. Senate Subcommittee on Primary Health and Aging in the Health, Education, Labor and Pensions committee held listening sessions on the Older Americans Act
Brian Lindberg presented N3C’s care coordination recommendations on August 23
Status of OAA reauthorization remains unclear.
Further Information
Websites:– General http://www.healthcare.gov/– Innovation Center http://innovations.cms.gov/– SWLI/N3C http://www.socialworkleadership.org/
For Questions:[email protected] 822 7325
