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Agenda
Introduction to ILS
Care Transition
The ILS Post Acute Support System (PASS™ )
Benefits of PASS™
Questions & Answers
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About ILS GroupIndependent Living Systems (ILS):
• Founded in 2001
• Health Care Management and Services Organization uses managed care concepts in the management of long-term care delivery, and focuses on the use of home and community based services as an alternative to institutional care.
• Services individuals in: MAPD / SNP plans (60,000), Capitated Medicaid LTC (2,000), Pediatric Medicaid plans (8,000), School & Community Nutrition (10,000)
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ILS Group Principal Clients
Health Plans• Medicare Advantage &
Part D Plans• Dual Special Needs Plans• Chronic Special Needs Plans• Medicaid Plans
Hospitals• CMS Pilot Hospitals • Public Hospital Systems• Private Hospital Systems
Long-Term Care Diversion Program Plan & MCOs:• Florida Nursing Home
Diversion• New Mexico CoLTs• Tennessee CHOICES• PACE Programs
County / State Governmental Programs:• AAAs• ADRC / ARCs
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The Problem…
19.6% of Medicare Patients nationally are readmitted within 30 days; 28.2% - 60 days, 34.0% 90 days.
The reasons (diagnoses) for readmissions were:• Heart Failure / Heart Attack• Pneumonia • COPD
The “factors” related to readmissions include: • Medications & Medication Management• Access to care / Lack of outpatient care• Lack of support systems & community services
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Costly Readmission Rates
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Correlation to Unbalanced use of HCBS Resources
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The Solution – Care Transition
What is “Care Transition”?
The term “care transition” refers to the movement of patients through the continuum of care as their conditions and care needs change.
The ILS Post-Acute Support System (PASSTM) program focuses on the care transition between the institutional setting (Acute inpatient, Sub-Acute, Nursing Home) back to the home & community setting.
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Post-Acute Support System PASS™
Based on Care Transition Intervention (CTISM) Program developed by Dr. Eric Coleman, University of Colorado.
Care Transition program designed to coordinate and manage the transition of individuals from the Acute Inpatient setting to the Home & Community Setting.
• PASS™ is not case management, discharge planning or home health.
• PASS™ is patient advocacy, education, communication and coordination.
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PASS™ Value Proposition
Improve total care transition from inpatient to home
Facilitate communication between patient, caregiver & providers
Improve outcome (reduction in readmissions), provide consistency, reduce errors & unnecessary services (reduction in costs)
Patient advocacy, patient empowerment & patient education
Improved coordination of care and care transition
Improved overall health status and health education
Improved communication between patient, caregiver and providers
Reduced acute inpatient re-admissions and associated costs
Reduced overall health care costs and unnecessary expenses
Benefits / OutcomesObjectives
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Post-Acute Support System
Driven by the PASS™ Coach and supported by Care Support Representatives and PASS™ system technology.
Interaction with patient:• Face-to-face during inpatient admission• Face-to-face at Home post discharge (48 – 72 hours)• Telephonic, day 2, 7, 14 & 30 post discharge
Enhanced components added to evidence-based foundation.
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Targeted population:• Any individual admitted with one or more of the following
chronic conditions:
• AMI, CHF, COPD, PNE, etc
• Any individual with two (2) or more inpatient admissions within a 6 month period.
• Any individual already in a case management or disease management program.
Target populations are identified and developed during implementation.
Post-Acute Support System
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PASS™ “Five Points”
Medication Self Management
Nutrition Management
Personal Health Record
PCP & Specialist Physician Follow-Up
Red Flags / Signs & Symptoms
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Medication Self-Management
Goal: patient is knowledgeable about medications & has a medication management system.
Hospital Visit: discuss importance of knowing medications & ensure adherence / compliance.
Home Visit: reconcile pre & post hospitalization medication lists & correct any discrepancies.
Follow-up Calls: answer any remaining medication questions, provide support / resource, reinforce education.
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Nutrition Management
Goal: patient is knowledgeable about nutritional status, meal planning & diet as it relates to chronic conditions.
Hospital Visit: initial nutrition & nutritional knowledge assessment.
Home Visit: nutrition education, meal planning & home-delivered meal package.
Follow-up Calls: reinforce education, answer any questions, provide support / resource.
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Physician Follow-up Visits
Goal: patient schedules & completes follow-up visits with PCP / Specialists & is empowered to be an active participant in these interactions.
Hospital Visit: recommend PCP / Specialists follow-up visits.
Home Visit: emphasize importance of follow-up visits & need to provide PCP with recent hospitalization information. Practice & role-play questions for PCP.
Follow-up Calls: provide advocacy & support in getting appointment, if necessary.
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Red Flags / Signs & Symptoms
Goal: patient is knowledgeable about indicators that suggest his/her condition is worsening & how to respond.
Hospital Visit: discuss signs & symptoms, red flags and drug reactions.
Home Visit: assess condition, reinforce hospital visit discussions.
Follow-up Calls: reinforce when / if PCP should be called, provide support / resource.
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PASS™
Fully Integrated Care Transition
Nutrition Management
Medication Management
Personal Health Record
PCP & Specialist Physician Follow Up
Red Flags / Signs & Symptoms
Inpatient (Acute/Sub-Acute) Admissions:
Nutrition Management
Medication Management
Personal Health Record
PCP & Specialist Physician Follow Up
Red Flags / Signs & Symptoms
Post Discharge - Home (48-72 hrs):
Nutrition Management
Medication Management
Personal Health Record
PCP & Specialist Physician Follow Up
Red Flags / Signs & Symptoms
Follow-up Calls 2, 7, 14, 30 days Post Discharge:
PASS
™ C
oach
& C
are
Supp
ort
Repr
esen
tati
ves
Refe
rral
s to
Com
mun
ity
Reso
urce
s
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PASS™ Information System
Secure HIPAA compliant, web-based, real-time system providing:• Patient Tracking: tracks client through the various interactions
and components for each episode.• Electronic PHR: maintains an electronic record of the client’s
PHR including history & medications.• Data Collection: allows for data collection to provide feedback
on admissions, discharge transitions and readmissions.• Care Plan Management: tracks interventions identified for a
clients care plan and additional services coordinated including transportation, home physician visits, telemedicine, etc.
• Reporting: designed to provide standard and Ad-hoc reporting.
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PASS™ MCO Implementation:Factors to Consider
Business Model Presentation• Presentation of intervention (PASS™)• Presentation of incentives:
• Financial: cost savings exceeds cost of intervention• Quality of Care: improved coordination of care and member
satisfaction/retention• Pilot Program Opportunities – (6-8 month)
• ROI Program (savings ROI ranges from 2:1 to 4:1)
Data Analysis• Evaluation of claims data to determine trends, variables and
factors behind readmissions – this determines high risk “targets”• Hospitals, Diagnoses, Physician Encounters, Benefits
• Determination of full cost of readmission (admission)
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Hospital Relationship Building• Introduction of intervention in target facilities. Issues to
consider:• In-network facility vs Non-network facility• Facility’s national readmission rates
Coordination of Care & Post Episode Services• Follow-up Physician coordination• Health plan contacts for coordination of identified
services:• Case Managers, Vendors, Network Services
• Coordination / Referrals for community based services
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PASS™ MCO Implementation:Factors to Consider
PASS™ MCO Implementation
Challenges & Barriers Solutions That WorkData Analysis • Obtaining data from MCO.
• Developing formulas for readmission rate (baseline) & factors
• Standardized file formats.• Data Analysis support
from established data sources.
Hospital Relationships
• Developing relationships (through MCO relationships) with facilities
• Present intervention as opportunity to improve performance and efficiency for hospital.
Hospital Process
• Difficulty identifying patients• Developing workflows with
hospital staff
• Present opportunities for intervention to “assist” hospital staff.
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PASS™ MCO Implementation
Challenges & Barriers Solutions That WorkProcess Clarification & Coordination
• Confusing Care Transition with Case Management, Concurrent Review, Discharge Planning or Home Health
• Standardized process delineation.
• PASS Coach opportunities to provide support to these processes
Member Acceptance
• Lack of member understanding of service.
• MCO communication to member for education – added benefit.
• Consent processPhysician Acceptance
• Lack of physician understanding
• MCO communication to physician for education.
• Consistent communication
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Hospital Perspectives Facing significant revenue reductions because of potential
readmission payment reforms:• Hospital Planning – most hospitals with a significant Medicare census
have initiated an effort to deal with this issue• Dedicated Resources– care transition coaching cannot become an
additional duty of discharge planners or case managers.• Evidenced Based Model -better to use model with proven results.
Program needs formalized protocols and procedures, IT support, etc.• Opportunity for Marketing – program can become concierge service,
nutrition program and meals on discharge can differentiate hospital, post discharge follow up can bond patient to hospital and its other services. Program improves communication between hospital and staff MDs.
• Reporting and Evaluation - Data tracking and ongoing evaluation of program is key!
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PASS™ “Best Case” Implementation
Client 1:500 Bed Private Hospital &
Physician Practices
Client 2:1000 MA MSO & Medical
Center (At Risk)
Client 3:2000 MA Member Health Plan
(County Coverage)
Admitsto Hospital
Pilot to manage specific MC admits based on Dx, & previous case management
Manage admits for designated Dx to designated hospitals
Manage admits for designated Dx to all
hospitals in the County
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Questions?
For more information:Jeffrey T. King, RN, MBA - [email protected]
Josefina Carbonell - [email protected]
Independent Living Systems5201 Blue Lagoon Drive, Suite 270Miami, FL 33126www.ilshealth.com / (305)262-1292
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