Transitional Care and Preventing Readmissions in San Francisco - - PowerPoint PPT Presentation

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Transitional Care and Preventing Readmissions in San Francisco 24th Annual Medical Surgical Conference April 10, 2014 South San Francisco Conference Center San Francisco Transitional Care Program Carrie Wong, MSW, MPH, LCSW Director of Long

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Transitional Care and Preventing Readmissions in San Francisco

24th Annual Medical Surgical Conference April 10, 2014 South San Francisco Conference Center

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San Francisco Transitional Care Program

Carrie Wong, MSW, MPH, LCSW Director of Long Term Care Operations San Francisco Department of Aging and Adult Services Carrie.Wong@sfgov.org

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Abstract

Community-based Care Transition Programs have been used to reduce costs by preventing unnecessary hospital readmissions, and improving the quality of care and the overall patient experience. The San Francisco Transitional Care Program is a unique partnership of government, hospitals, and community-based organizations with innovative approach to a seamless delivery of services from within hospital walls to the community, to secure better health outcomes, and to reduce healthcare costs without adverse human costs.

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Learning Objectives

To understand the context for Medicare Innovations,

transitional care, and health care delivery

To understand how the complexity of socioeconomic factors,

health literacy, and support systems affect health outcomes

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Agenda

Why is transitional care important?
Background
Program Description
Challenges
Readmission Outcomes
Questions?

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Why is Transitional Care important?

Making it personal…

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Background

Almost one out of every five Medicare patients

(approximately 2.6 million seniors) discharged from a hospital is readmitted within 30 days

Total cost is over $26 billion every year
Multiple factors along the care continuum that impact

readmissions.

Centers for Medicare and Medicaid Services created

Community-based Care Transitions Program to encourage communities to work together to improve quality, reduce cost, and improve patient experience.

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The Community-based Care Transitions Program (CCTP)

Created by Section 3026 of the Affordable Care Act
Launched in 2011
Test models for improving care transitions from the hospital

to other settings and reducing readmissions for high-risk Medicare beneficiaries.

Also a part of the Partnership for Patients which is a

nationwide public-private partnership that aims

to reduce preventative errors in hospitals by 40% and
reduce hospital readmissions by 20%

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Goals of the CCTP

To improve transitions of

beneficiaries from the inpatient hospital setting to

ther care settings
To improve quality of care,

to reduce readmissions for high risk beneficiaries

To document measurable

savings to the Medicare program

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CCTP Participants

102 participants nationwide
California has 11 CCTP Teams
Northern California
San Francisco
Sonoma
Marin
Southern California
Anaheim
Glendale
Los Angeles
Reseda
San Diego
San Fernando
Ventura

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San Francisco Transitional Care Program

A formal partnership that includes the Department of

Aging & Adult Services, NCPHS/SF Senior Center and multiple community-based organizations and hospitals to: Help eligible older adults and adults with disabilities to transition safely from hospital to home Reduce unnecessary acute hospital readmissions

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Target Population

Older adults (age 60 or older)
Adults with disabilities (age 18 to 59)
Cognitive impairment
Little or no formal or informal supports and/or lives alone
Chronic illness and/or more than three medical co-morbidities
Two or more readmissions within the last 6 months
Difficulty managing medications and/or taking 8 or more routine

medications

Needs assistance with 2 or more activities of daily living
Demonstrated need for service/resource to avoid readmissions

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Eligibility Criteria

Payor source:

MediCare fee-for-service and MediCare/MediCal (eventual expansion to uninsured and MediCal only)

Seniors age 60 & older or adults with disabilities age 18-59
A resident of San Francisco
In stable housing
Referred by hospital during acute medical hospitalization
Client, family or friends are able to benefit from coaching or care

coordination services

Willing to accept services

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Infrastructure

Collaboration of county, 8 hospitals, and 8

community-based organizations to address a citywide issue

Specialized committees to guide program

aspects -- Governance, Steering, Finance

Centralized Intake System at Dept of Aging

and Adult Services for information and referrals for SFTCP and other county services such as IHSS, APS, HDM, CLF, and I&R

Web-based electronic client database for data

management and reporting

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Main Roles

Hospital Liaison with DAAS Intake
Assist hospital staff/units with program information and referrals
Initiate patient intervention during initial hospital visit
Collectively cover all 7 hospital campuses every weekday
Transitional Care Specialist
Provide transitional care services in the 5 focus areas
Complete home visits and appropriate follow up
Arrange for service packages (transportation, meals, or

homecare)

Stabilize and refer to long term resources
Complete Patient Activation Survey

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Program Staff

Program Manager
Intake Coordinator
Clinical Supervisor
11 Transitional Specialists
Language Capacity
Cantonese
Mandarin
Toisanese
Japanese
Russian
Spanish
Tagalog
Vietnamese

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The Intervention

Coaching and care coordination model
Transitional care services provided between 4-6 weeks after an acute

hospitalization

Hospital visit 24 hours prior to discharge
Home visit within 3 days after discharge
Additional home visits if needed
Phone calls
Service packages of meals, home care, and transportation
Referrals to case management and other services as needed after

transitional care services are completed

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Client Areas of Focus

 Set a recovery goal  Understand one's health issues and role of medications  Recognize symptoms and have a plan of action if they occur  Develop “My Wellness Plan” – a tool to organize health information  Secure/prepare for the first PCP appointment including questions and concerns  Establish services/resources with emphasis on nutrition, transportation, care at home

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Program-to-Date Outcomes

1346 clients referred
1317 clients enrolled initially
1192 clients completed the intervention
89.5% or 1079 clients successfully transitioned home
10.5% or 113 clients were rehospitalized

*Preliminary data between December 2012 – November 2013

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38% Coaching only
13% Care coordination only
48% Both coaching and care coordination

*Preliminary data from April 2013 to November 2013

Types of Services Provided –

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100% of clients used My Wellness Plan
87% of clients were able to manage medication
90% of clients went to their first doctor appointment
76% of clients knew their own health “red flags”
54% of clients needed and accessed additional community

based services *Preliminary data from April 2013 to August 2013

5 Focus Areas at Case Completion

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Readmissions for SFTCP Clients

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Readmissions

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Referrals vs Enrollments

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Ongoing Challenges

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Contact

Carrie Wong, MSW, MPH, LCSW Director of Long Term Care Operations San Francisco Department of Aging and Adult Services Carrie.Wong@sfgov.org