Maxim Transition Assist Maxim Transition Assist March 9 2016 March - - PowerPoint PPT Presentation

Maxim Transition Assist Maxim Transition Assist

March 9 2016 March 9, 2016

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Maxim Healthcare Services…

Maxim Nationwide: Maxim Nationwide:

• 250+ offices across 40+ states
• Approximately 60,000 caregivers and 46,000 patients nationwide
• Specialized in skilled in‐home nursing care for the medically fragile and technology

dependent patient populations

The Maxim Transition Assist Approach The Maxim Transition Assist Approach

Maxim Transition Assist

PCP Office Home

• Transitional Care Nurse (RN)

 Home Assessment  Final Transitional Care Plan

Hospital PCP Office

Pre‐hospital Care

• Community Health Worker (CNA)

 Education and reinforcement  Psychosocial support  Care Coordination

• Program Manager

 Scheduling

 Preliminary Risk Assessment (all patients)

• Nurse Practitioner

 Secondary Risk Assessment (high risk patients)

Post‐hospital Care

 Staff coordination

 Preliminary TC Plan

The Readmission Problem…

• Approximately 20% of Medicare patients are readmitted within 30 days of

discharge (1).

• The rate is higher for patients with certain conditions, such as COPD (20.9%),

congestive heart failure (24.7%) (approaching 50% at 6 months), HIV (26.4%), and co gest e ea t a u e ( . %) (app oac g 50% at 6

• t s),

( 6. %), a d chronic renal failure (27.4%). (2),(3),(4).

• In fact, for several conditions, such as sickle cell anemia, gangrene, hepatitis, and

white blood cell diseases, the 30‐day readmission rate is over 30% (5).

• The transition from hospital to home is clearly a high risk period and drives a

The transition from hospital to home is clearly a high risk period and drives a substantial amount of medical spending. According to CMS, readmissions account for $26 billion in Medicare costs, of which $17 billion is potentially avoidable (6).

(1) Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee‐for‐service program. N Engl J Med. 2009;360(14):1418‐28. Epub 2009/04/03. doi: 10.1056/NEJMsa0803563. PubMed PMID: 19339721. (2) Ross JS, Chen J, Lin Z, Bueno H, Curtis JP, Keenan PS, et al. Recent national trends in readmission rates after heart failure hospitalization. Circulation Heart failure. 2010;3(1):97‐103. Epub ( ) , , , , , , f f p f ; ( ) p 2009/11/12. doi: 10.1161/CIRCHEARTFAILURE.109.885210. PubMed PMID: 19903931; PubMed Central PMCID: PMC2830811. (3) Butler J, Kalogeropoulos A. Worsening heart failure hospitalization epidemic we do not know how to prevent and we do not know how to treat! J Am Coll Cardiol. 2008;52(6):435‐7. Epub 2008/08/02. doi: 10.1016/j.jacc.2008.04.037. PubMed PMID: 18672163. (4) Elixhauser A, Steiner C. Readmissions to U.S. Hospitals by Diagnosis, 2010. HCUP Statistical Brief #153. April 2013. Agency for Healthcare Research and Quality (AHRQ). Epub 2013/04. http://www.hcup‐us.ahrq.gov/reports/statbriefs/sb153.pdf. (5) Id. (6) CMS: Findings from Recent CMS Research on Medicare. Washington DC: Centers for Medicare & Medicaid Services, 2014. https://kaiserhealthnews.files.wordpress.com/2014/10/brennan.pdf.

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The Real Problem…

Psychological Factors

• Anxiety/Depression
• Behavioral Disorders/

Addiction

• Personality Disorders
• Cognitive Impairment

Social Determinants

Reduced Engagement Reduced Adherence

Readmission

• Poor Housing/

Homelessness

• Unemployment
• Poor Education

Reduced Access

• Lack of Transportation
• Poor Nutrition
• Lack of Caregiver

Support

Readmissions are not the problem. They are a symptom of larger underlying societal problems

pp

• Dysfunctional Family

Dynamics

• Social Isolation

The Readmission Solution…

• Patient engagement at admission and continuity through

post discharge period p g p

• Transitional Care Team creates a partnership with the

hospitalist, primary care and specialty care teams

• Complements Home Health and other Post‐Acute Care

Services

• Focus on psychosocial barriers to adherence through

Focus on psychosocial barriers to adherence through patient engagement and social service support

Role of the Community Health Worker

Patient Engagement

• Frontline public health workers who are trusted members of the community served
• Serving as a liaison between communities and health and social service systems

l h d Health Education

• Providing culturally appropriate health education

Care Coordination

• Ensuring people get community health services they need

Psychosocial and Medical Support

• Providing informal counseling and social support
• Providing direct service, such as basic first aid and administering health screening

tests, when applicable tests, when applicable Community Empowerment

• Advocating for individual and community needs
• Building individual and community capacity

Adapted from American Public Health Association Policy Statement 2001‐15 (Jan 2001).

“High Risk” vs “Low Risk” Readmission Rates (h it l id ) (hospital wide)

14 0% 16.0% 18.0%

RightCare RA Rate (ADT Data)

4.0% 6.0% 8.0% 10.0% 12.0% 14.0% Feb March April May June July August September RightCare High Risk Patients (RC Risk Score >= 3.0) 15.5% 12.7% 11.0% 9.2% 12.1% 15.5% 12.6% 8% RightCare Low Risk Patients 6.3% 4.7% 4.7% 6.8% 5.8% 7.0% 5.6% 4% 0.0% 2.0%

Readmission Rate for Program Participants vs P P ti i t non‐Program Participants

25 0% 30.0% 35.0%

MTA Program RA Rate (Program Data)

Represents:

• Discharged to LTC/SNF
• Discharged to SAR

Feb March April May June July August September 0.0% 5.0% 10.0% 15.0% 20.0% 25.0%

• Left w/o being seen
• Refused consent
• Other

Feb March April May June July August September Consented/Admitted to MTA program (Completed NP Assessments) 29.4% 23.3% 11.8% 16.7% 17.5% 18.5% 12.5% 13.1% Not Admitted to MTA program (LWBS, SNF, SAR, Ref Consent, Other) 7.6% 7.8% 7.2% 4.1% 9.3% 11.1% 10.6% 6%

Take Aways…

• 30‐day hospital readmissions are a symptom of deeper

underlying problems.

• Maxim Transition Assist has reduced program participants’ 30‐

day readmission rates from 29.4% to 10.7%.

• We’ve done this by creating a continuous partnership that

We ve done this by creating a continuous partnership that engages patients and focuses on the underlying factors that increase risk of hospital readmission.

• The core of our approach is the use of Community Health

Workers.

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Sample of Anecdotal Examples of CHW Support

• 46 year old female with MS, chronic pain, new colostomy due to sever ulcerative colitis, and recent dislocation of hip. 3rd admission

since December. On admission to Maxim Transition Assist, client had no follow up appointments scheduled with any doctors; also did not have a PCP. MTA worked with patient and the hospital to establish a PCP. CHW accompanied patient to first PCP appointment. MTA also set patient up with new pain clinic to help control her pain. Patient notified CHW that she was experiencing nausea, vomiting, and diarrhea and could not keep food down. CHW fed patient Gatorade and banana – she ate and felt better. At the same time CHW notified GI specialist After consulting with GI specialist CHW arranged appointment for the following day and accompanied patient notified GI specialist. After consulting with GI specialist, CHW arranged appointment for the following day and accompanied patient to GI appointment. CHW also set patient up with Mobility for transportation as well as food stamps. Two month post discharge, patient has not been back in the hospital.

• 90 year old female who was admitted with pneumonia. She lives alone and when CHW came to see her – her O2 cord was wrapped

around her walker. CHW untangled and explain how to walk with it. Patient refused to go to the PCP, so CHW made appointment and accompanied patient to the visit CHW found that the patient’s PCP was located in a building where the only parking was across the accompanied patient to the visit. CHW found that the patient s PCP was located in a building where the only parking was across the street; office was on third floor and included long walk to elevator. CHW arranged for the patient to get the patient to the appointment, despite the obstacles and then helped the patient pick‐up the prescription and find a PCP in a more convenient location.

• 82 year old female who had facial cellulitis due to eye shingles. Husband was confused and overwhelmed with care coordination and was

cancelling all of the patient’s appointments. CHW helped in coordinating every appointment, helped with pill box and medication

• calendar. Patient was drinking milk shakes; CHW convinced her to switch to protein shakes. Couple is extremely happy with the help
• calendar. Patient was drinking milk shakes; CHW convinced her to switch to protein shakes. Couple is extremely happy with the help

they received from MTA and patient was not re‐hospitalized.

• Male patient admitted with persistent infection due to groin abscess. He was hospitalized few times for it until he had surgery at the
• hospital. He was discharged home before the weekend. Patient's wife called to say that home health RN came in and she did not have

enough wound supplies until Monday. MTA staff contacted the wound clinic at SJMC, looked in patient’s chart, verified specific type of dressings needed. MTA staff assisted with additional dressings and relevant instructions from the hospital’s wound clinic, thereby g g p y preventing likely infection and readmission.

• 66 year old female patient with 5 hospitalizations in 6 month for COPD. CHW discovered that patient’s apartment was infested with
• mold. CHW worked on section 8 voucher to help patient move. Patient was also given Advair sample and later discovered that her

insurance did not cover the drug. CHW worked with insurance to get the prescription approved for coverage so that the patient could remain on Advair.