Transitions of Care A Medicare Advantage QualityBLUE Pay for Performance Model

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Transitions of CareA Medicare Advantage
QualityBLUE Pay for Performance Model

• Geriatric Practice Change Agent Meeting
• Judith S. Black MD, MHA
• Medical Director, Highmark Senior Products
• September 27, 2007

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Agenda

• Rationale for the Program
• Overview of the Program
• Program Outcomes to Date
• Lessons Learned

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Transitions of Care - Definition and Rationale
A set of actions designed to ensure the
coordination of care as patients transfer between
settings. Transitional care encompasses both the
sending and the receiving aspects of the transfer
and includes preparation of the patient and
family, transfer of information, coordination
among practitioners.

• Closely managing patient movement from one level
  of care to another accomplishes the following
• Reduces fragmentation
• Improves patient satisfaction
• Results in a reduction in readmissions
• Ultimately impacts care costs
• Information related to advance care planning more
  consistently communicated to receiving facility
• Health plan moved from Per Diem to Case Rate in
  2005.

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Variation in Care - Hospital Readmit Analysis
The above 25 acute care facilities account for
85 of hospital admissions
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Variation in Care - SNF Readmit Analysis
SNF C ranked 29 by percent of admissions
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Highmark Initiative QualityBLUE Transitions
of Care Program

• Focused Initiative Three-year SecurityBlue
  Medicare Advantage (MA) Pilot Study
• Quality Indicator Transitions of Care
• Involve hospitals in year one. Focus on
  developing best practices standard for
  coordination of discharge, i.e., levels of
  transitions.
• In year two of the program select skilled nursing
  facilities will be asked to participate. Focus
  on care coordination between the SNF and the
  hospital or alternate sites.

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Facility Selection and Incentive

• Volume - top readmit rates
• Hospital/SNF relationships
• Geographic location
• Willingness to work with health plan.

• 3 to 5 of SNF payment
• 2.4 of hospital payment
• Amount payout equal projected cost savings.

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Payment Methodology

• Five Parameters
• Program Administration 5Planning
  35Action 40Measurement 10Results
  10

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Highmark MA P4P Timeline
1st Q 04
2ndQ 04
3rdQ 04
1stQ 05
3rdQ 05
4thQ 05
1stQ 06
2ndQ 06
4thQ 06
4thQ 03
4thQ 04
2ndQ 05
3rdQ 06
Develop Concept
Business Requirements Funding
6 Months
Hospital Engagement
6-10 Months
SNF Program Development
9 Months
Engage 2nd Hospital
Engage SNFs
SNF Profile
4 ½ Mths.
Develop Refine Data Elements (Pie Charts
Graphs)
2nd Expert Visit
Dr. Eric Coleman
Dr. Eric Coleman
1st Expert Visit
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Initiative Goals

• To improve the quality of care for the geriatric
  patient
• To develop appropriate reimbursement methodology
  to align reimbursement between health plans and
  institutions
• To identify indicators and measurement techniques
  that focus on transitions of care issues for
  the hospitals in year one
• To develop methods for ongoing monitoring of
  quality indicators.

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Hospital/SNF Performance Strategies

• Reduce readmissions from skilled nursing
  facilities
• Reduce admissions for patients transitioned home
  with diagnoses of heart failure, COPD, or
  pneumonia
• Prevent or reduce medication errors
• Facilitate effective communication sharing
  between facilities and enhance accountability of
  patient transfers
• Improve patient satisfaction by ensuring their
  preferences be passed from one setting to the
  next
• Ensure patients ability to manage their health
  care condition.

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Hospital/SNF Performance Strategies

• The Care Transitions Measure Tool
• To assess caregiver perception (satisfaction) of
  the transition process and to assess overall
  quality of care transitions.
• The UCHSC Care Transition Measure
• The hospital staff took my preferences into
  account in deciding what my health care needs
  would be after discharge
• Before I left the hospital, the people that were
  going to help me when I got home clearly
  understood what my health care needs were
• Before I left the hospital, I had a phone number
  I could call to get answers to my questions.

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Hospitals Outcomes to Date

• A work group was established to implement this
  quality initiative and
• Evaluated the current transfer/discharge process
• Developed a written model for the Care
  Transitions Program
• Standardized the transfer process to skilled
  nursing facilities
• Developed essential data elements to be conveyed
  to the receiving practitioner
• Enhanced discharge instructions for patients
  returning home including a system to establish
  follow up contact.

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Hospitals Outcomes to Date

• Developed a medication reconciliation tool
• Developed an advance care planning process
  implemented the POLST
• Designed educational programs to inform staff
  members of treatment/procedural changes
• Established electronic connectivity
• Rapid Response Team for 600 bed SNF
• Established Subcommittee with ED and SNF
• Developed tools, audits, and surveys to determine
  the impact of the program.

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SNF Outcomes to Date

• The Skilled Nursing Facilities developed a
  workgroup and accomplished the following
• Implemented a Performance Improvement Plan
• Senior Leadership committed to continuity of
  project
• Upon admission to the Skilled Nursing Facility,
  project the residents length of stay, establish
  needs and goals of the resident and regularly
  communicate the residents progress toward the
  goals with the family or responsible party
• Developed plans and begun using CTM and transfer
  impact survey.
• Established a performance improvement plan and
  timeline for incorporating the POLST.

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2007 Program Administration
Program Manual Ongoing Mtgs.
Results Distributed
Mid-Year Review
Reimburse- Ment Determined
Year-End Review
Scoring
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Program Year 2007-2008

• Hospitals will continue transition of care
  initiatives with goal to decrease readmissions
• Continue to refine the SNF measures. Less
  emphasis on Planning Action greater focus on
  Measurement Results
• Heritage Valley Skilled Nursing Facilities to
  begin program (The Villa, Friendship Ridge,
  Beaver Elder Care).

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SNF Outcomes to Date

• Implemented a mutually agreed upon format for
  transfer information
• Worked collaboratively with the hospital to
  utilize computer connectivity to enhance transfer
  communication.
• Working in a Collaborative on Medication
  Reconciliation.
• Participated in regular conference calls and
  meetings with hospital and health plan.

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What Were the Challenges?

• Selling the concept to Senior Management
• Establishing an effective internal Highmark team
  with commitment to new program
• Ongoing funding with a lag in financial data
• Resources with the expansion of the Hospital
  QualityBLUE Program.

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What Worked Well?

• Engagement
• Bringing in outside expert to help sell the
  program
• Providing comparison data and tools
• Sharing experiences
• Implementation
• Team experience with a commercial hospital
  QualityBLUE program
• Detailed scoring grid
• Team work with frequent contact.
• Relationship building
• Hospital/SNF working together.

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Lessons Learned

• Develop a detailed three year project timeline
• Dont underestimate the engagement time
• Collect data in auditable format.

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Key Success Factors

• Facility Champion
• Effective Team
• Willingness to share tools
• Leveraging off of other programs
• Striving for a win/win program
• Rewarding for process measures not just bottom
  line.

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Sustaining the Program
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Tools/References

• www.caretransition.org
• www.polst.org
• One Patient, Many Places Managing Health Care
  Transitions, a report from the HMO Workgroup on
  Care Management.
• Coleman, Eric A. et. al. The Care Transitions
  Intervention Results of a Randomized Controlled
  Trial. Arch Intern Med. 2006 166 1822-1828.
• Davis, M. Neila, et al. Improving Transition
  and Communication Between Acute Care and
  Long-Term Care A System for Better Continuity
  of Care. Annals of Long-Term Care. May 2005
  Vol. 13 No. 5 25-32.
• Coleman, Eric A., et al. Preparing Patients and
  Caregivers to Participate in Care Delivered
  Across Settings The Care Transitions
  Intervention. JAGS 52 1817-1825, 2004.
• Coleman, Eric A., Berenson, Robert A. Lost in
  Transition Challenges and Opportunities for
  Improving the Quality of Transitional Care. Ann
  Intern Med. 2004 140 533-536.