Transitions across Settings Workgroup

Dual Eligibles Planning Grant

Recommendations, January 2012

Co leads: Patricia Farnham, Sabrena Lea, Jennifer Cockerham

Workgroup Membership:

Evan AshkinUNC Dept. of Family Medicine ACCESSCare

Ada AtkinsonCommunity Care of Lower Cape Fear

Jeaneen BeckhamNorthern Piedmont Community Care

Robert BilbroCommunity Care of Wake & Johnston Counties

Denise BordemanAging and Disability Community Resource Connections-Mecklenburg County

Jessalyn BridgesCommunity Resource Center - Senior Services Inc

Judy BrungerThe Carolinas Center for Hospice & End of Life Care

Peter BrunnickHospice & Palliative Care Charlotte Region

Margaret BrunsonNorthern Piedmont Community Care

Kenny BurrowNorth Carolina Association of Long Term Care Facilities

CedarsTonyaArea Agency on Aging, Eastern Carolina Council

ChristopherFirst Health Home Care

Timothy DaalemanUniversity of North Carolina at Chapel Hill

Susan DavisCommunity Care of Wake & Johnston Counties

Peggy DorfmanNorth Carolina Medical Society/North Carolina Psychiatric Association

Patricia FieldsCommunity Care of Lower Cape Fear

Elizabeth GambleNorthwest Community Care Network

Miriam GodwinMoye Medical Center Eastern Carolina University

James GrahamNorth Carolina Program for All-inclusive Care for the Elderly (PACE)

Larry GreenblattNorthern Piedmont Community Care

Sandi Grey-Terry Community Care Partners of Northern Piedmont

Nikki GriffinNorth Carolina Association of County Directors of Social Services

Gregory GriggsNorth Carolina Academy of Family Physicians

Sam HedrickNorth Carolina Providers Council

Jill HintonEaster Seals UCP of NORTH CAROLINA& VA, Inc

Michael HowardNorth Carolina Division of Medical Assistance

Teresa JohnsonNorth Carolina Adult Day Services Association

Elizabeth JunakCraven County Health Department

Susan King-CopeNational Alliance on Mental Illness (NAMI) NC

Margaret KirkmanNorth Carolina Adult Foster Care Association

Kelly LivengoodNorthwest Community Care Network

Beth LopezCommunity Care Partners of Greater Mecklenburg

Laura MaynardNorth Carolina Hospital Association

Tammie McLeanCommunity Care of the Sandhills

John MorrisFour Seasons

Paul MorrowNorth Carolina Division of Medical Assistance

Dan MoscaGovernor's Advisory Council on Aging

Michael MoseleyWake Forest Baptist Health

Kevin NaleDisability Rights and Resources

Lydia NewmanCommunity Care of Lower Cape Fear

Lynne PerrinCommunity Health Partners

Gwen PhillipsChatham Orange Community Resources Corrections

Jennifer PoloCommunity Care Plan of Eastern Carolina

Marsha RingWestern Highlands Network

Kevin RobertsonNorth Carolina Department of Insurance

Michelle RosemanAll-inclusive Care for the Elderly (PACE)

Lorrie RothNorth Carolina Division of Aging and Adult Services

Erin RussellNorth Carolina Division of Vocational Rehabilitation

Janet SchanzenbachNorth Carolina Association of Long Term Care Facilities

Cynthia SextonNorth Carolina Statewide Independent Living Council

Chris SkowronekNorth Carolina Hospital Association

John S. Snow Iredell Health System

Scott TenbroeckGraduate Student

Patty UphamFirst Health Home Care

Polly WelshNorth Carolina Health Care Facilities Association

Amy WhitedNorth Carolina Medical Society

Neil WilliamsCommunity Care of North Carolina

Lou WilsonNorth Carolina Association of Long Term Care Facilities

Peggy BalakSaguaro Group LLC/ Triumph

Connor BrocketNorth Carolina Medical Society

Tim ClontzNorth Carolina PACE Association

Sandy GregoryNorth Carolina Baptist Aging Ministry

Don HerringWestern Highlands Network

Robin HuffmanNorth Carolina Psychiatric Association

Tyehimba Hunt-Harrison North Carolina Psychiatric Association and the North Carolina Council of Child and Adolescent Psychiatry.

Kathryn LanierNorth Carolina Division of Aging and Adult Services

Annette LauberNorth Carolina Assistive Technology Program

Pamela Lloyd-OgokeNorth Carolina Division of Vocational Rehabilitation

Ben MoneyNorth Carolina Community Health Center Association

Teresa PiezzoCommunity Care of North Carolina

Carson RoundsNorth Carolina Academy of Family Physicians

Louis SteinWestern Highlands Network

Kim SturkeyCommunity Care Partners of Greater Mecklenburg

Meeting Dates:

September 15th, Thursday

September 19th, Tuesday

September 30th, Friday

October 4th, Tuesday

October 14th, Friday

October 24th, Monday

November 8th, Tuesday

November 15th, Monday

November 28th, Tuesday

December 16th, Friday

January 10th, Tuesday

Charge of the Workgroup:

Identify opportunities and develop processes for increased collaboration and coordination among medical, behavioral health, and long term care facilities to improve transitions, divert unnecessary hospital and emergency department use, and integrate home- and community-based options.

  • Strengthen hospitals partnerships with CCNC and engage hospitalists and discharge planners in transitional care
  • Leverage and align efforts with other CMS funded transition and diversion initiatives
  • Coordinate efforts with and incorporate lessons learned from the Patient-centered Discharge Project Grant and related transition initiatives underway in NC
  • Explore community linkage and support bundling practices in other states
  • Align efforts with CCNC’s transitional care program and enhance efforts across provider settings

Final Recommendations for the Transitions Workgroup

This document reflects the synthesized recommendations of two task groups convened during the meetings of the Transitions Workgroup. These task groups were the Transitions Across Settings Group and the Transitions from Acute Care Group.

Over-Arching Policy Recommendations

The model developed and implemented should:

  • Position person/beneficiary using the services at the center of the transition process;
  • Result in support systems and service structures that encourage thoughtful, coordinated planning that mitigate the “3am” crisis call and reactionary decision-making by both service recipients and service providers;
  • Promote improved coordination among medical, behavioral health, long-term care, social, and community services and supports, accommodating effective preparation/ pre-planning that maximizes informed decision making and transition coordination;
  • Require prompt follow-up with beneficiary by receiving service providers after transition occurs;
  • Include education and training to prepare all members of the care transition team to be effective in their role in the transition process;
  • Use technology to facilitate and support successful transition from the acute care setting to the next care provider for recovery and/or palliative care.

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Detailed Recommendations / Additional Comments / Proposed Implementation Timeframe / Comments Related To The Implementation
Position person/beneficiary using the services at the center of the transition process
Support the person and caregivers with information needed to enable informed decision making / CCNC Care Manager in partnership with other community-based agencies are positioned to offer education to beneficiaries / Immediate / Coordinated transition planning is critical to successful
Build systems that promote continuity across settings, such as the presence of care coordinators to assist person and his/her family in navigating the service delivery systems and accessing appropriate services and supports / Phased in Approach / Challenge is lack of uniformity in service availability and capacity across the state
Result in support systems and service structures that encourage thoughtful, coordinated planning that mitigate the “3am” crisis call and reactionary decision-making by both service recipients and service providers;
Care Coordination Team (care coordinators who assist the person and his/her family in navigating services and accessing proper supports) come into the person’s life at the time an individual is enrolled or has access to his/her Medical Home staff if these coordinators are not already involved. (12/11) /
  • CCNC could potentially access information through Informatics System (currently access hospital data this way).
  • If involved early, will help ensure both medical and social needs met, which better leverages community resources and ensures medical needs are fully met before the transition occurs.
  • Could also have palliative care discussion
/ Immediate / Recommend that this be considered “standard practice” for all enrollees, but could prioritize those considered “high risk.”
Identify events that “trigger” access to the Care Coordination Team (12/11). / Possible “triggering” events:
  • discharge from hospital
  • multiple ED visits
  • upon request from SNF staff
  • upon request of resident
/ Immediate / Some of these “triggering” events already established.
Enrollment= potential savings
Care Coordination Team should be part of transition process before transition occurs (10/11) / Ensure continuity of care during transition process
Care coordination services distinct from nursing facility discharge planners, though the 2 work in collaboration:
  • discharge planners do not typically have full knowledge of community options
  • discharge planners not involved once person transitions into community setting
  • Planning for community life broader than planning to discharge safely from a facility
/ Immediate / Stronger coordination before the transition results in potential savings because of error reductions, etc.
  • Allows for faster scheduling of community-based medical appointments, less lag time; more oversight in follow-up.
  • More efficient care coordinators have better access to person, records and facility staff while the person is in the facility.
  • No major cost to CCNC care managers, main issue regulatory barrier
  • Medicaid billing structure already allows overlapping transition coordination for MFP participants and others

Improved training for hospital staff on “teach back” methods to improve patient understanding
  • Ensure that patient information and discharge instruction are offered at a low literacy levels
/ CCNC Care Mangers utilize the “teach back” method as well as Motivational Interviewing skills in communicating with patients in effort to convey clear, concise and easy to understand discharge instructions and self-management disease concepts. / Immediate / Expand training to hospital discharge staff
Promote improved coordination between medical, long-term care, behavioral health, social, and community services and supports, accommodating effective preparation/pre-planning in order to maximize informed decision making and transition coordination;
  • The Care Coordination Team should include both a medical care coordinator and a social support coordinator (12/11)
/
  • Medical care coordinators (i.e. CCNC care managers) and social support coordinators (i.e. CAP social workers, DVR-IL/CIL transition coordinators) have different skill sets and areas of expertise.
  • Coordinate community-based services and other public benefits through CRC
/ Immediate / Engagement of social coordinators better ensures access of natural supports and cost-effective community resources around housing, community involvement, employment, etc), which is more cost effective.
  • Social Support Coordinators could also be peers

Develop/adopt protocols to ensure medication reconciliation at every transition junction /
  • Med Reconciliation and Med Management should be viewed as the shared responsibility of all partners
  • Community Pharmacies may be untapped resource to assist community dwelling beneficiaries
/ Immediate
Develop/adopt a risk stratification tool to identity risk and assess patient capacity/motivation that is shared across care settings / A number of evidence-informed tools are already in use by various providers
Develop protocols to access and make referrals to behavioral health services when indicated
–Develop/adopt protocols for collaboration with community-based behavioral health programs / All CCNC Networks have a Behavioral Health Coordinator and a Psychiatrist as part of their interdisciplinary team.
Include behavior health screening in initial assessments / Immediate
  • Require prompt follow-up with beneficiary by receiving service providers after transition occurs;

Expanded use of tele-support for remote monitoring / A number of CCNC Networks already have this capacity / As needed / Successful models are incorporated in some CCNC networks
Include required home visit (for hospital to home d/c) within 72 hours of discharge depending on risk assessment / Some CCNC care mangers are already doing this / Immediate / Explore collaboration with other community partner who may already be in the home
  • Meals on Wheels volunteers
  • In-home Aides

  • Include education and training to prepare all members of the care transition team to be effective in their role in the transition process;

Education for the patient and family in preparing for “downstream events,” is not a one-time session but needs to be continual in order to prepare person and family. Encourage long-term care facility have planning conversation with resident and family on the prognosis of the patient and what they can expect in the coming weeks or days. (Developed 11/11; Revised 12/11) / CCNC networks have Palliative Care Champions to include a physician and an RN or SW care manager to help Primary Care Managers and Primary Care Physicians with local resources and communication techniques for leading end of life/palliative care discussions.
Defer to the Palliative Care Workgroup’s observations on this topic. / Immediate / Potentially no cost to SNF if partner with existing resources, like CCNC
Costs to CCNC mitigated by better outcomes as a result of stronger planning.
Support facilities and hospitals in training and education on:
  1. Macro Level: Resources available to aid in palliative care discussions and mechanisms for documenting these discussions
  2. Additional Training for Hospital discharge staff about community resources
  3. Include in the discharge discussion candid discussion about exceptions for recovery and/or palliative care
  4. Micro: Training auxiliary staff (including third shift) to understand and access these documents when supporting the resident in making decisions about care.
  5. Enhanced support/training for Hospitalists regarding options for reliable referrals to community resources that can be rapidly accessed
/ This recommendation stemmed from the observation that often late night facility staff will “err on the side of caution” by calling 911 instead of following palliative care directives. Often, this is because directives are not developed or are unknown to staff.
Possible documentation options:
“Five Wishes” or “MOST” form.
Consider adding as performance measure to Nursing Facility Medical Home “Tiered” Standards
Since the landscape of community services is ever-changing, identification of a community focal point that has accurate, up to date information about community based resource is optimal
Work with community-based organizations to indentify and fund critical services for rapid access mitigating the need for avoidable hospitalizations / Immediate: Securing Documentation
Midrange: Staff training, depending on capacities of nursing facility
Immediate / CRCs are trusted resources about the full range of Long term services and support in their communities.
Education for patient and family about hospitalities/discharge process up stream / CRCs are positioned in the community to collaborate with CCNC to help beneficiaries prepare for hospitalization through the “Options Counseling” function / Immediate
Information/Education to patient and care givers about chronic disease self-management, red flags that are signals to seek help before a crisis and options for care through medical home (urgent vs. emergent) / DAAS’ Evidenced based Chronic Disease Self Management program is available state wide / Immediate
Use technology to facilitate and support successful transition from the acute care setting to the next care provider for recovery and/or palliative care
Expanded use of tele-support for remote monitoring / A number of CCNC Network already have this capacity / As needed / Successful models are incorporated in some CCNC networks
Develop/Adopt protocols that allow current data to be shared across service delivery settings / CCNC has the capacity to share data through CMIS (Case Management Information System), the Informatics Report Site, Pharmacy Home, and Provider Portal / Immediate

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