The Community Care Transitions Program Affecting Positive Health Outcomes in Older Adults

Goal(s) and objectives of practice Goal 1: To improve transitions of older adult patients from the inpatient hospital setting to other care settings. Objective 1. Conduct a face-to-face home visit with the patient and/or patient caregiver to provide the Care Transitions Intervention Model within 72 hours of hospital discharge. Objective 2. Conduct 3 follow up phone contacts with patient within 30 days of initial home visit to ensure completion of doctor's appointments and patient follow through on health self-maintenance goals. Goal 2: To improve quality of care for older adult patients' post-discharge from the hospital to support successful aging in place. Objective 1. Provide the patient with a dynamic Personal Health Record at the face-to-face home visit to document, monitor, and perform health self-manage strategies to prevent hospital readmission. Objective 2. Conduct a needs assessment with the patient and their caregivers at the home visit for any community resources and supports eliminate any barriers to social determinants. Goal 3: To reduce 30-day readmissions for patients identified as high risk. Objective 1. Make referrals to partnering agencies within 24 – 48 hours of needs assessment at patient home visits. Objective 2. Provide follow up for 60 days with patient and their caregiver to ensure resource linkage and reaching self-management milestones. Objective 3. Reduce the and maintain a readmission rate below established baselines for the patient population enrolled in Community Care Transitions Program. What did you do to achieve the goals and objectives? Steps taken to implement the program Step 1. Planning the Project Hospital readmissions within 30 days of discharge have been identified as a major cost-driver for Medicare. In response, the Center for Medicare and Medicaid in 2013 began imposing financial penalties on hospitals with high 30-day readmission rates for Medicare beneficiaries. HHD started exploring opportunities to work with several hospitals in the Greater Houston area to provide hospital care transitions assistance. The model selected for this project was a patient activation” model, intended to engage, educate and activate” the patient (or caregiver) in their recovery. Research has found that this approach reduces hospital readmissions by 25 to 30%. Interventions used include Care Transitions. HHD-HCAAA primary goal was establish a partnership with a hospital system to reduce avoidable readmissions over a 30-day period for patients meeting the following criteria: Age 60 and over With a primary or secondary diagnosis of Congestive Heart Failure (CHF) and Residing in any of the Regional Healthcare Partnership Region 3 Counties Step 2. Collaborative Partner Selection HHD-HCAAA researched health systems that serviced populations most at-risk for readmissions to include the following: 1) Dual-eligible patients (Medicare + Medicaid); 2) Minority Populations; and 3) Low-income populations that are disproportionately impacted by social determinants of health. HHD Harris County Area Agency on Aging (HCAAA) initiated a collaboration with 5 hospitals in the Methodist Hospital system to present to implement the Community Care Transitions Program (CCTP) under Hospital Readmissions Reduction Program in Fall 2013 to present. Based on the work from CCTP, HCAAA, under the auspices of Houston Health Department developed a hospital readmissions reduction program through the Delivery System Reform Incentive Performance Program/1115 Waiver Program. In Fall 2013, care transitions assistance was extended to patients at three additional hospitals (Methodist Willowbrook, Methodist San Jacinto, and Methodist Sugar Land) in the Houston area and continues to this day. In Spring 2015, CCTP established a partnership with Methodist Medical Center. Step 3. Recruitment A communication and referral system were developed between HHD-HCAAA and the health system leadership including the Chief Operating Officer and Chief Nursing Officer. Physicians, nurses, social workers, case managers and other professionals were educated about the CCTP program and encouraged to refer patients with CHF who meet the outlined criteria to the program. Once patients are identified, they are contacted by the CCTP team and offered program enrollment. Through this referral mechanism, the team identifies potentially eligible and appropriate patients while the patient is still hospitalized. This step allows time to establish rapport and assess individual patient needs. Patients are identified and referred by hospital staff including nurses, case managers and social workers. They identify the most high-risk patients during daily rounds and refer them to the designated Transitions Coach on staff at the hospital. Some referrals come directly from physicians who believe patients should enroll and participate in this program as part of ‘best practices.' Step 4. Training Transition Coaches received training in the Coleman Model with the expectation to maintain model fidelity when assisting patients. This model requires the Transitions Coach to successfully utilize motivational interviewing techniques to encourage patients to become their own best advocates when it comes to their health. Patients are expected to use a Personal Health Record to document their personal information including name, address, primary care physician information, medications, dosage, purpose, personal goal, and questions for the physician(s) at the follow-up appointment. A week-long, intensive training prepared the Transitions Coaches to visit the patients in the hospital room, present the Care Transitions model and enroll the patients in the Care Transitions program upon release from the hospital or other in-patient facilities. The training also prepared the Coaches to follow-up with the patient for 30 days until successful program completion. A key to patients successfully completing the program is the implementation of Teach Back. Teach Back tools assist the Transitions Coaches with increasing patients' health literacy, so they are able to make better informed, more appropriate health choices and to increase the likelihood for following treatment plans. CTI program staff attended a two-day orientation at their assigned hospital site. The orientation consisted of the hospital's safety policies, confidentiality agreement, signature identification and badging, and access to Electronic Health Records. CTI program staff are also received web-based training on access and navigation on the data management system for client records implemented by HHD. Any criteria for who was selected to receive the practice (if applicable)? Older adult patients (age 60 and over) categorized as high risk with a hospital admission and a primary or secondary diagnosis of CHF were those who are selected to receive the intervention. The patients also had to reside in the following counties: Austin, Calhoun, Chambers, Colorado, Fort Bend, Harris, Matagorda, Waller, and Wharton. What was the timeframe for the practice? Project Year 1— November 2013 – September 2014 Hire and train HHD staff on Care Transitions Intervention. Develop the plan for the HHD Community Care Transitions Program. Produce a comprehensive manual of operating procedures including clinical protocols, staffing plan, and job descriptions. Install and test data management systems. Establish partnerships with 3 community hospitals; Houston Methodist West, Methodist Baytown, Houston Methodist Willowbrook. CCTP Transitions Coaches completed the two-day orientation provided by the hospital system. Establish baseline number of individuals receiving the intervention and program readmission rate. Attend monthly meetings with Directors of Case Management to review outcomes and discuss best practices, challenges, and lessons learned. Complete monthly activity report for number of readmissions within 30 days for clients enrolled and completed the program. Project Year 2— October 2014 – September 2015 Establish partnerships with 2 additional community hospitals; Houston Methodist Hospital and Methodist Baytown Hospital. Expand program staff by hiring Team Lead and two Transition Coaches Increase the proportion of people receiving the intervention by 5% over baseline. Reduce the 30-day readmission rate by 10% below baseline. Complete monthly activity report for number of readmissions within 30 days for clients enrolled and completed the program. Attend monthly meetings with Directors of Case Management to review outcomes and discuss best practices, challenges, and lessons learned. Project Year 3— October 2015 – September 2016 Increase the proportion of people receiving the intervention by 10% over baseline. Reduce the 30-day readmission rate by 15% below baseline. Complete monthly activity report for number of readmissions within 30 days for clients enrolled and completed the program. Complete annual project report to include project implementation, project outputs and outcomes, accomplishments, challenges, and lessons learned. Attend monthly meetings with Directors of Case Management to review outcomes and discuss best practices, challenges, and lessons learned. Project Year 4— October 2016 – September 2017 Increase the proportion of people receiving the intervention by 10% over baseline. Reduce the 30-day readmission rate by 15% below baseline. Complete monthly activity report for number of readmissions within 30 days for clients enrolled and completed the program. Complete annual project report to include project implementation, quality improvement activities, progress on core components, project outputs and outcomes, and sustainability. Attend monthly meetings with Directors of Case Management to review outcomes and discuss best practices, challenges, and lessons learned. Project Year 5—September 2017 – October 2018 Achieve same baseline goals as previous project year. Engage in sustainability activities such as meeting with partnership hospital system to explore funding opportunities for providing the CTI intervention. What was their role in the planning and implementation process? The planning process was undertaken by the Director's Office at HHD, Harris County Area Agency on Aging (HCAAA), and the leadership of Houston Methodist Hospital system. The stakeholders involved in the planning and implementation process were the Chief Executive Officers and Directors of Case Management of five community hospital sites within the Houston Methodist Hospital system. The stakeholders were involved in the review and execution of the Memorandum of Agreement and Business Associate Agreement between HHD, HCAAA, and each community hospital site. The stakeholder's role in the planning process consisted of providing the CTI staff with the following: On-site orientation to the hospital system's policies and procedures Training and read-only access to the patient population Electronic Medical Records (EMR) Work space and computers at the hospital site Photo ID badges and email accounts What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s) The Methodist Hospital system and HHD-HCAAA continue to communicate via monthly teleconference calls. The calls provide an opportunity for discussion of the program best practices, challenges, and lessons learned. The participants in the teleconference meeting are the Care Transitions team, hospital administrative staff, physicians, pharmacists and other clinical staff. The calls are productive providing insightful dialogue and action steps to increase patient enrollments. During the calls, the Methodist Hospital System has shared updates regarding clinical support services and resources for patients such as phone numbers to connect and assist patients with scheduling medical appointments, medication consultation, and medical supplies. The Care Transition team has shared updates and positive outcomes associated with health maintenance to prevent 30-day readmissions. Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Otherwise, provide an estimate of start-up costs/ budget breakdown. Direct Costs were: -Personnel Services: Salary Base Pay: $244,921.57 Bilingual Pay: $548.97 Termination Pay: $218.81 FICA: $18,188.43 Health Insurance: $39,342.39 Basic Life Insurance: $137.00 Long Term Disability: $458.90 Workers Comp: $1,374.66 -Supplies: Office Supplies: $43.33 Food Supplies: $6,000.00 Recreational Supplies: $605.00 Miscellaneous Parts & Supplies: $9,751.38 Inventory Sales: $187.50 -Other Services and Charges: Temporary Personnel Services: $25,671.64 Print Shop: $5,328.00 Printing & Reprod Sv: $2,945.00 Education & Training: $42,536.00 Travel – Training Related: $3,313.01 Travel – Non-Training Related: $6,455.61 Voice Services – Wireless: $27.49 Office Equipment Rental: $8,912.52 Miscellaneous Other Services: $2,631.00 KRONOS Service Charge: $1.84 -Non-Capital Purchases: $2,657.86 Total Expenses: $483,651.00

What did you find out? To what extent were your objectives achieved? Please re-state your objectives. HHD-HCAAA demonstrated successful achievement of the goals and objectives the program was designed and implement to meet. With the partnership between HHD, CCTP and the Methodist Hospital System coupled with the collaboration with HCAAA and Aging and Disability Resource Center (ADRC). The impact was far beyond what was initially expected. Goal(s) and objectives of practice Goal 1: To improve transitions of older adult patients from the inpatient hospital setting to other care settings. Objective 1. Conduct a face-to-face home visit with the patient and/or patient caregiver to provide the Care Transitions Intervention Model within 72 hours of hospital discharge. Objective 2. Conduct 3 follow up phone contacts with patient within 30 days of initial home visit to ensure completion of doctor's appointments and patient follow through on health self-maintenance goals. Goal 2: To improve quality of care for older adult patient post-discharges from the hospital to support successful aging in place. Objective 1. Provide the patient with a dynamic Personal Health Record at the face-to-face home visit to document, monitor, and perform health self-manage strategies to prevent hospital readmission. Objective 2. Conduct a needs assessment with the patient and their caregivers at the home visit for any community resources and supports eliminate any barriers to social determinants. Goal 3: To reduce 30-day readmissions for patients identified as high risk. Objective 1. Make referrals to partnering agencies within 24 48 hours of needs assessment at patient home visits. Objective 2. Provide follow up for 60 days with patient and their caregiver to ensure resource linkage and reaching self-management milestones. Objective 3. Reduce the and maintain a readmission rate below established baselines for the patient population enrolled in Community Care Transitions Program. All objectives were successfully completed. Did you evaluate your practice? Yes, the project was evaluated at several points: during the training, during HHD leadership and CCTP staff meetings, during monthly meetings between CCTP manager team and Methodist Hospital Directors of Case Management, and at the end of each project year to assess completion of the goals and objectives. List any primary data sources, who collected the data, and how (if applicable) CCTP staff utilize ClientTrack, a web-based data management system has been implemented system-wide to track patient demographics, enrollment and engagement activity. HHD Staff Analyst provide the CCTP staff with a Quality Performance Improvement (QPI) data collection report each month that consists of total number of patient enrollments (month and year-to-date), number and type of 30-day readmissions, insurance/payer source, patient age, gender, and if the patient is low income status CCTP Transition Coaches have been provided read-only access to the hospital Electronic Health Record (EHR) system to obtain all necessary health related demographics. CCTP staff utilize excel spreadsheets created by the CCTP Program Manager as back-up documentation to track all patient referrals and other pertinent demographic information. List any secondary data sources used (if applicable) N/A The evaluation was performed at several points along the project. During each project year, the effectiveness of the intervention was evaluated according to target goals established for total number patients enrolled and reduction in readmission rate. The evaluation occurred weekly via auditing of referral and enrollment activities, monthly via data collection reports, semi-annually and annually via narrative reports. The evaluation was conducted by the project team lead on a weekly basis. The team lead audited patient referrals, 30-day readmissions, and enrollments entered in ClientTrack and excel spreadsheets by the Transition Coaches. The project team lead reviews the QPI report and weekly audits for accuracy and goal achievement. The team lead conducts visits to each hospital site once a month to review caseloads with the Transition Coaches. During the hospital visit with the Transition Coach, the project team lead meets with the Director of Case Management to discuss and review program outcomes and best practices. The Transition Coaches receive patient referrals via the hospital data management system, which generates a daily census list. The patient census list is filtered to meet the eligibility requirements established for project target population. Year 1 The project enrolled a total of 373 patients during DY3 and established a baseline readmission rate of 18.18%. Year 2 Increase caseload enrollment to 40 patients per month, achieve a project completion total of 480 patients, and reduce readmission rates by 10% below baseline. An average of forty (40) patients per month were enrolled, a total of 502 patients enrolled for the year, and the program readmission rate was 12%. Year 3 Increase caseload enrollment to 50 patients per month, achieve a project completion total of 600 patients, and reduce readmission rates by 15% below baseline. An average of fifty (50) patients per month was achieved, 608 total patients were enrolled, and the readmission rate was 13%. Year 4 Maintain caseload size to 50 patients per month with a projected enrollment and project completion total of 600 patients. Fifty patients per month average was met, a total of 611 patients enrolled, and a readmission rate of 11% Year 5 Maintain caseload size to 50 patients per month with a projected enrollment and project completion of 600 patients. Fifty patients per month average was met, a total of 618 patients enrolled, and a readmission rate of 13%. Describe how results were analyzed. The patient enrollment and readmission data were reviewed each week to ensure the target monthly enrollment goal is being met. The 30-day readmissions are reviewed to determine if the cause is due to congestive heart failure (CHF related) or another condition (All-Cause). The QPI data collection calculates the monthly and year-to-date target goals for enrollment and readmission rate. Were any modifications made to the practice as a result of the data findings? No

Lessons learned in relation to practice Several lessons were learned during this project, including: More patients without formal caregivers or support systems opted to participate in the intervention. Patients who had multiple medical appointments felt overwhelmed by the Transitions Coach home visit by the and opted out of the intervention. Over the 5 years of the project's, sixty-eight percent (68%) of the patient population received ancillary community resources via the partnerships with HCAAA and ADRC. Access to resources attributed to the reduction in the 30-day readmission rate. There were some challenges with assisting uninsured patients and those ineligible for Medicare with obtaining medical coverage once they were released from the hospital. Those who reached the age of eligibility for Medicare were referred to speak with a Benefits Counselor with HCAAA or Houston-Galveston Area Council (HGAC) depending on the county of residence. For those under the age of 65, these patients were referred to HHD multi-service centers for eligibility screening to determine appropriate insurance options including health plans offered through the Affordable Care Act. Lessons learned in relation to partner collaboration (if applicable) The Directors of Case Management for each hospital site and the Care Transitions team engaged in brainstorming ways to increase patient enrollment and address precursors to readmissions via monthly teleconference calls and meetings. The brainstorming provided an opportunity for discussion of the project best practices, challenges, and lessons learned. The Directors of Case Management shared updates regarding clinical support services and resources for patients such as phone numbers to connect and assist patients with scheduling medical appointments, medication consultation, and medical supplies. By addressing the barrier of transportation, HHD-HCAAA through a partnership with Harris County Rides provided transportation so patients were able to attend their medical appointment(s) and pick up their prescriptions from their pharmacy. The follow-up doctor's appointment is a critical component to the patient's hospital discharge plan and have an impact on whether the patient readmits to the hospital. Did you do a cost/benefit analysis? If so, describe. Methodology: The analysis used 36 months as the evaluation period to calculate per member per month (PMPM) savings and costs. The evaluation period was aligned with Delivery System Reform Incentive Performance (DSRIP) Year 3, 4 and 5 of program implementation. Patients enrolled in DSRIP Year 6 were undergoing interventions when the analysis was conducted, so the data was not included. In the first year of implementation, it took CCTP approximately 10 months to enroll the clients and implement the intervention to full load of at-risk population. The program focuses efforts on older patients (age 60 and over) categorized as high risk with a primary or secondary diagnosis of Congested Heart Failure (CHF). The project served about 1,500 patients between DY3 and DY5, so the average quantifiable patient impact was about 500 patients per year. Since the tool took ramp-up time into consideration when calculating the total intervention group and the tool did not allow increase in yearly enrollment, 525 was used as the average annual size of eligible population in order to make the total of the intervention group matched with the total QPI served by the program. Program Cost: The cost for intervention group members entailed the amount spent on inpatient care, emergency department, outpatient care, home-based care, Laboratory and Pharmacy. The average cost for hospital admission, Emergent Department visit, and home-based care for 60 years and older CHF patients were provided by Methodist Physicians' Alliance for Quality program. The laboratory and pharmacy cost were pulled from Texas Inpatient Public User Data Files, and only hospital stays for senior CHF patients admitted to Methodist systems were included in the data pull. The ROI Forecasting Calculator also asked for the cost for outpatient and other cost, but the data was not available at the time of evaluation. The average costs were based on two years of record, and the biennium data was not reliable to reflect trend in health care expenditures. The overall cost per hospital admission for the targeted population was $51,595, and the average cost PMPM was $4,300. The Finance Department in Houston Health Department (HHD) provided the investment occurred for CCTP between DY3 and DY5, including personnel, training and operations, office operations, technology and equipment, and other indirect cost. The HHD fiscal year is different from the DSRIP year, but the data can be used as a valid estimation of the overall cost. The total expenditure on implementation of Care Transition Program was nearly $1.4 million, and the program cost per intervention member was estimated to be $2,700. Program Savings: The ROI Forecasting Calculator applied the analytical results and computed the total savings by comparing the projected expenditures if the CCTP intervention did not take place to the reported spending on inpatient care for the intervention group. Based on the size of the intervention group, the change in the percentage of 30-day readmission to hospitals, and the cost of inpatient care, the total savings brought by CCTP was approximately $3 million between DY3 and DY5. The savings per intervention member was estimated to be $6,500 per intervention member. Is there sufficient stakeholder commitment to sustain the practice? Yes. Describe sustainability plans. HHD-HCAAA is in communication with current and prospective partners to enhance the current project by adding new patient types and additional health conditions. Proposed enhancements include: New patient types Medicare fee-for-service Dual-eligible All ages Additional health conditions Acute Myocardial Infarction/heart attack (AMI) Pneumonia Chronic Obstructive Pulmonary Disease (COPD) Coronary Artery Bypass Graft (CABG) Total Hip and/or Total Knee To sustain the project, the addition of new patient types and additional health conditions will open a pathway to reimbursement for transitional and chronic case management services. References 1. Innovation.cms.gov. (2018). [online] Available at: https://innovation.cms.gov/Files/fact-sheet/CCTP-Fact-Sheet.pdf [Accessed 3 Dec. 2018]. 2. Eric B. Coleman, MD, MPH, E. (n.d.). The Care Transitions Program® - Transitional Care & Intervention. [online] The Care Transitions Program. Available at: https://caretransitions.org/ [Accessed 3 Dec. 2018]. 3. Innovation.cms.gov. (n.d.). Community-based Care Transitions Program | Center for Medicare & Medicaid Innovation. [online] Available at: https://innovation.cms.gov/initiatives/CCTP/ [Accessed 3 Dec. 2018]. 4. Eric B. Coleman, MD, MPH, E. (n.d.). Care Transitions Model. [online] Johnahartford.org. Available at: https://www.johnahartford.org/ar2007/pdf/Hart07_CARE_TRANSITIONS_MODEL.pdf [Accessed 3 Dec. 2018].

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