Promising Models of Care Coordination for Beneficiaries with Chronic Illnesses

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Promising Models of Nurture Recipients with Incessant Ailments. Cheryl Schraeder, RN, PhD, FAAN UIC School of Nursing Patricia Volland, MSW, MBA New York Foundation of Solution Robyn Brilliant, Mama, LCSW Surge College Medicinal Center Maturing In America 2011. Outline.

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Promising Models of Care Coordination for Beneficiaries with Chronic Illnesses Cheryl Schraeder, RN, PhD, FAAN UIC College of Nursing Patricia Volland, MSW, MBA New York Academy of Medicine Robyn Golden, MA, LCSW Rush University Medical Center Aging In America 2011

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Overview Define mind coordination Identify demonstrated care coordination/administration intercessions for recipients with perpetual ailment Transitional Care Comprehensive Care Coordination Medicare/Duals Medicaid Describe scratch recognizing highlights Describe interior and outer assessment

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What is Care Coordination? N3C characterizes mind coordination as: " A man focused, appraisal based, interdisciplinary way to deal with incorporating medicinal services and social bolster benefits in a financially savvy way in which an individual's needs and inclinations are evaluated, an extensive care plan is produced, and administrations are overseen and observed by a confirmation based process which regularly includes an assigned lead mind organizer."

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What is the Problem? Most social insurance dollars are spent on a little rate of recipients Those with complex unending conditions Causes of high usage and costs: Deviations from confirmation based care Poor correspondence among essential suppliers, authorities, wellbeing and group suppliers, patients, and families Failure to catch issues early Failure to address psychosocial issues Lack of facilitated, longitudinal administration Ineffective transitional administration

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What is Effective Care Coordination? Intercession with thorough confirmation that: Improves recipient results Reduces add up to medicinal services consumptions for partaking recipients Improved fulfillment or clinical pointers not adequate Net reserve funds require lessened hospitalizations

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Promising Interventions Most proof shows effects are inconsistent However, encouraging consideration coordination and care administration mediations are developing Transitional care intercessions Care Transitions Intervention (Coleman) Transitional Care Model (Naylor) Enhanced Discharge Planning Program – RUSH (Perry) Comprehensive Care Management - Medicare/Duals Guided Care ( Boult ) GRACE ( Counsell ) Care Management Plus (Dorr) MCCD: Best Practice Sites (Brown) Comprehensive Care Management – Medicaid/Duals Integrated Care Management (Douglas) Community Based Chronic Care Management ( Lessler ) Hospital to Home (Raven) Health Care Management Program ( Reconnu & Herndon)

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Transitional Care: Components These projects: Engage patients with endless diseases while hospitalized Follow patients seriously post-release Teach/mentor patients about drugs, self-care, and side effect acknowledgment and administration Remind and urge patients to keep catch up doctor arrangements Approaches to accomplishing these objectives vary crosswise over projects

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Transitional Care: Three Promising Models Care Transitions Intervention (Coleman) Patient-focused intercession intended to enhance quality and contain costs for patients with complex care needs as they move crosswise over care settings Transitional Care Intervention (Naylor) Patient-focused intercession intended to enhance personal satisfaction, quiet fulfillment, and diminish doctor's facility readmissions and cost for elderly patients hospitalized with CHF Enhanced Discharge Planning Program (RUSH) Telephone-conveyed social work-based transitional care demonstrate (doctor's facility to home) intended to advance patient wellbeing and fulfillment, enhance personal satisfaction, and decrease preventable re-hospitalizations and ED visits.

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Transitional Care: Target Populations Care Transitions Intervention (Coleman) Included: Patients dc'd from clinic with specific findings; 30-day Medicare readmissions for HF, MI, PNE; extra hazard calculation for readmission drawn from regulatory information Excluded: Dementia with no parental figure, essential psychiatric determination, with maniacal components, dynamic medication or liquor utilize Transitional Care Intervention (Naylor) Included: 65+ CHF persistent admitted to specific doctor's facilities and living inside 60 miles of assigned doctor's facility Excluded: ESRD, non-English speaking Enhanced Discharge Planning Program (RUSH) Included: 65+ returning home after release with 7+ solutions and 1 extra hazard consider including living alone, past affirmation, no/unsteady emotionally supportive network, other psychosocial issue Excluded: Transplant

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Transitional Care: Staffing Care Transitions Intervention (Coleman) APN, RN, social laborer, or word related advisor 1 mind facilitator for each 40 patients Duration : 30 days taking after hospitalization Transitional Care Intervention (Naylor) Advanced Practice Nurses (3) 1 mind organizer for every 39 patients Duration : 3 months taking after file hospitalization Enhanced Discharge Planning Program (RUSH) Master's readied social laborer with involvement in wellbeing and maturing 1 mind organizer for each 48 patients Duration : Up to 30 days, normal 8 days

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Transitional Care: Intervention Care Transitions Intervention (Coleman) Home visit post release, three follow-up calls Based on 4 columns: drug administration, quiet focused record, essential care and authority development, learning of warnings Transitional Care Intervention (Naylor) Hospital visit and home visits of fluctuating recurrence Comprehensive appraisal in doctor's facility, characterizing need needs and administrations Ongoing promotion, training, and correspondence to guarantee plan of care Enhanced Discharge Planning Program (RUSH) Pre-evaluation through therapeutic graph survey to decide potential needs Telephonic biopsychosocial appraisal and care coordination to balance out circumstance, guarantee medicinal and home wellbeing development, and connect with group based specialist co-ops

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Transitional Care: Evidence Care Transitions Intervention (Coleman) Intervention patients had Lower re-hospitalization rates at 90 days: For any reason (17% versus 23%) For introductory condition (5% versus 10%) Lowered healing facility costs 19% more than 180 days ($2,058 versus $2,546) Transitional Care Intervention (Naylor) Intervention patients had: 54 % less re-hospitalizations per persistent following 12 months (1.18 versus 1.79) 10.5% abatement in re-hospitalization rate (44.9% versus 55.4%) 39% lower mean aggregate expenses ($7,636 versus $12,481 Enhanced Discharge Planning Program (RUSH) Intervention patients had a lower 30 day post release death rate contrasted with the typical care aggregate (2.2% versus 5.3%)

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Comprehensive Care Coordination: Components These projects: Implement confirm based rules for care administration Conduct an exhaustive evaluation Collaboratively create and execute an arrangement of care Teach/mentor patients about legitimate self-mind, medicines, how to speak with suppliers Monitor patients' indications, prosperity and adherence between office visits Advise patients on the most proficient method to converse with and when to see their doctor Apprise patients' doctor and different suppliers of imperative side effects or changes Arrange for required wellbeing related bolster administrations Coordinate correspondence among doctors, wellbeing/group suppliers and patient/family Approaches to accomplishing these objectives contrast crosswise over projects

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Comprehensive CC - Medicare/Duals: Four Promising Models Guided Care: Boult A model of extensive human services gave by attendant doctor groups to patients with a few unending conditions GRACE: Counsell A model to enhance the nature of administer to low salary seniors by the longitudinal reconciliation of geriatric and essential care benefits over the progression of Care Management Plus (CMP): Dorr Patient-focused mediation intended to decrease mortality and doctor's facility affirmations for elderly patients of essential care doctors Medicare Coordinated Care: Brown Provide mind coordination administrations to high hazard Medicare recipients with numerous constant conditions to enhance quality and diminish add up to cost of care

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Comprehensive CC - Medicare/Duals: Target Population Guided Care ( Boult ) Included: Older patients (65+) at high danger of utilizing wellbeing administrations amid the next year, as assessed by Hierarchical Condition Category (HCC) prescient model ( scores of 1.2 or higher ) Excluded: Low HCC scores GRACE ( Counsell ) Included: 65+, set up patient of a site essential care clinician, pay under 200% government destitution Excluded: Residence in nursing home, accepting dialysis, extreme hearing misfortune, English dialect hindrance, no entrance to phone, serious subjective debilitation without an accessible guardian CMP (Dorr) Included: Older incessantly sick patients (65+) of essential care doctors served by Intermountain Health Care, an expansive health awareness framework in Utah, with various comorbidites and recipients of Medicare Part B for no less than 11 months preceding enlistment Excluded: Patient declined to partake MCCD Best Practice Sites (Brown) Included: Medicare recipients with endless obstructive aspiratory sickness (COPD), congestive heart disappointment (CHF) or coronary conduit ailment (CAD) and in any event on hospitalization in the earlier year and any of the 12 ceaseless conditions and at least two hospitalizations in the earlier two years Excluded: Enrolled in hospice, dwell in nursing home or have end organize renal infection (ESRD)

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Comprehensive CC - Medicare/Duals: Staffing Guided Care ( Boult ) Registered attendant situated in essential care work on working with 3-5 doctors 1 mind organizer (CC) per 50-60 patients GRACE ( Counsell ) An APN and social specialist in a joint effort with PCP and a geriatric interdisciplinary group drove by a geriatrician 1 CC/social laborer (SW) per 100-125 patients CMP (Dorr) All care directors are RNs , generalists , situated in essential care centers 1 mind facilitator for every 350-500 patients MCCD Best Practice Sites (Brown) Registered medical caretakers prepared in far reaching care coordination Wash U: 1 CC for every 85-95 patients HQP: 1 CC for each 75-85 patients M