Aging and Disability Resource Centers and Care Transitions

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Aging and Disability Resource Centers and Care Transitions

Eligible Applicants4 Are statutorily defined as:− Acute Care Hospitals with high readmission rates inpartnership with an eligible community-based organization− Community-based organizations (CBOs) that provide caretransition servicesThere must always be a partnership between at least one acutecare hospital and one eligible CBOCritical access hospitals and specialty hospitals are excluded asfeeder hospitals but could be part of the larger communitycollaboration


Definition of CBO5Community-based organizations that provide care transitionservices across the continuum of care through arrangements withsubsection (d) hospitals Whose governing bodies include sufficient representation ofmultiple health care stakeholders, including consumers Must be a legal entity, i.e., have a taxpayer ID number - forexample, a 501(c)3) - so they can be paid for services theyprovide Must be physically located in the community it proposes to servePreference is for model with one CBO working with multipleacute care hospitals in a communityA self-contained or closed health system does not qualify asa CBO


Entities that may be a CBO6 Area Agencies on Aging Aging and Disability Resource Center (ADRCs) Federally Qualified Health Centers (FQHCs) A coalition representing a collaboration ofcommunity healthcare providers - if a legal entity isformed Some PAC providers may qualify- with evidencethat there is board representation that comes fromoutside of that provider entity.


Key Points7• CBOs will use care transition services to effectivelymanage transitions and report process and outcomemeasures on their results• Preference is for a model with one CBO working withmultiple acute care hospitals in a community• Applicants will be awarded 2 year agreements withcontinued participation dependent on achievingreductions in 30 day all cause readmission rates


Preferences8 Preference will be given to proposals that: Include participation in a program administered by theAoA to provide concurrent care transition interventionswith multiple hospitals and practitioners Provide services to medically-underserved populations,small communities and rural areas


Additional Considerations9 Consideration will be given to hospitals whose 30-dayreadmission rate on at least two of the three hospitalcompare measures (Acute Myocardial Infarction [AMI],Heart Failure [HF], Pneumonia [PNEU]) falls in the fourthquartile for its state You can find this data at:http://www.cms.gov/DemoProjectsEvalRpts/downloads/CCTP_FourthQuartileHospsbyState.pdf The data covers 30 day readmission rates for hospitalizationsthat occurred between July 2006 and June 2009


Previous Experience10 Description of previous experience implementing caretransitions interventions Includes evidence on the measurement strategies andoutcomes of this work Training completed in any of the evidence basedinterventions Description of other efforts to reduce readmissions May include discharge process redesign or the use ofelectronic health information systems and tools.


Common Application ErrorsThe applicant CBO does not meet the eligibilityrequirements to be a CBOUnclear documentation to support the applicant CBO meetsthe requirements of a CBO. Board members and their affiliations are not identifiedLack of a community specific RCAThe RCA is present, but the methodology for targeting highrisk beneficiaries and the selected interventions proposedare not tied back to the community specific RCA.Letters of support are missing from the applicationBudget


Budget Guidance12 CBOs will not be paid for discharge planningservices already required under the Social SecurityAct and stipulated in the CMS Conditions ofParticipation This is not a grant program CBOs may only include the direct service costs forthe provision of care transition services to high riskMedicare beneficiaries


Payment Methodology13 CBOs will be paid a per eligible discharge rate• Rate is determined by:the target population the proposed intervention(s) the anticipated patient volume the expected reduction in readmissions (cost savings)• Rate will not support ongoing disease management orchronic care management which generally require aPMPM fee


Common Budget Errors14 Propose a PMPM instead of a per eligibledischarge rate Use the average cost of a hospitaladmission/readmission ($9600) as a starting pointfor developing proposed rate Populate the budget worksheet with numbers andfail to provide narrative/justification for numberselsewhere


Common Budget Errors15 Build a budget like a grant and include costs fortraining, evaluation, office supplies and equipment,project directors, administrative support and so on Payments between providers for referrals Incentive payments to providers for good will andcooperation


For more CCTP informationThe program solicitation is available on the CCTP programwebpage athttp://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313The program will run for 5 years with the possibility ofexpansion beyond 2015Please direct questions to CareTransitions@cms.hhs.gov


Aging and Disability Resource Centers and CareTransitionsUsing Evidence-Based Interventions to Support a ComprehensivePerson-Centered SystemU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL aoainfo@aoa.gov | WEB www.aoa.gov


Home and Community Based Servicesand Hospital Readmissions• Some studies have found that between 40-50%of readmissions are linked to social problemsand lack of community resources• In a study evaluating the home foodenvironment of hospital-discharged olderadults, 1/3 of participants reported beingunable to both shop and prepare mealsProctor et al. (2000). Adequacy of Home Care and Hospital Readmission for Elderly Congestive Heart Failure Patients.Health and Social Work; 25(2): 87-96(10).Anyanqu, Ucheoma O., Sharkey, Joseph R., Jackson, Robert T. (2011) Home Food Environment of Older AdultsTransitioning From Hospital to Home. Journal of Nutrition in Gerontology and Geriatrics 30:105-121.U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV


Home and Community Based Servicesand Hospital Readmissions• Greater volume of attendant care,homemaking services and home-deliveredmeals is associated with lower risk of hospitaladmissionsXu, Huiping et al. (2010) Volume of Home-and Community-Based Medicaid Waiver Services and Risk of Hospital Admissions.Journal of American Geriatric SocietyU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV


CMS & AoA Vision for Aging andDisability Resource Centers• To have Aging and DisabilityResource Centers in everyInformation,Referral &Awarenesscommunity serving as highlyvisible and trusted placeswhere people of all incomesQuality Assuranceand ContinuousImprovementIndividualOptionsCounseling &Assistanceand ages can get informationon the full range of long termLiving in theCommunitysupport options and a singlepoint of entry for access topublic long term supportPerson CenteredCare TransitionsStreamlinedEligibilityDeterminations forPublic Programsprograms and benefits.


Strategies to Support Care TransitionsCommunity‐basedCare TransitionsProgram (Sec. 3026)2007 CMSRCSC PersonCenteredPlanning2008/2009 PersonCentered HDMProgram2010 16States EBCTModels2008 CMS QIO14 Care Transition Sites2003‐2006 AoA & CMS Framework Access to LTSS


ADRC Care Transitions Activity


AoA’s Evidence Based CareTransitions Grantees (16 states)• California• Colorado• Connecticut• Florida• Illinois• Indiana• Maine• Maryland• Massachusetts• New Hampshire• New York• Pennsylvania• Rhode Island• Tennessee• Texas• Washington7


2010 Evidence Based Care Transitions Grant ProgramModels Implemented by Grantees (16 States)Evidence Based ModelBOOSTBRIDGECTI℠GRACEGuided Care®TCMStates Implementing the ModelNew Hampshire (*also implementing CTI℠)IllinoisCalifornia, Colorado, Connecticut, Florida, Maine,Massachusetts, New Hampshire, New York,Rhode Island, Tennessee, Texas, WashingtonIndianaMarylandPennsylvaniaAoA 2010 Evidence Based Care Transitions Programhttp://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/index.aspx


Tech4Impact Diffusion Grants Program• Center for Technology and Aging• 2010 competitive funding opportunity for Option D ADRCEvidence Based Care Transitions Program grantees•Grant Awardees:•California•Indiana•Rhode Island•Texas•WashingtonCenter for Technology and Aging Tech4Impact Diffusion Grants Program: Summary of the Program and theAwardeeshttp://www.techandaging.org/Tech4Impact_Grants_Abstracts.pdf


Massachusetts Care Transitions Operating ModelSource: "Navigating Across Care Settings: Choices for Successful Transitions (NACS)"- Care TransitionsSample Flow Chart http://www.adrc-tae.org/tiki-index.php?page=allresources&catx=375&filter=grantee


Maine Care Transitions Operating ModelSMAA‐ADRC/ MMC‐PHO FlowchartSource: “Introducing: A Care Transitions Collaboration” ADRC Technical Assistance Exchangehttp://www.adrc-tae.org/tiki-index.php?page=allresources&catx=375&filter=grantee


No Wrong DoorSystemContinuous QualityImprovementPersonalinterviewDecisionSupportDevelopAction PlanManagementInformation SystemConnectTo ServicesParticipantIn Control&DirectingServicesTransportationCDSMP/EBDPHCBSNutritionHousing


AoA Care Transitions ToolkitChapter One: Getting StartedChapter Two: Taking Time to PlanChapter Three: Developing EffectivePartnerships with Health Care ProvidersChapter Four: Measuring for SuccessChapter Five: Building OrganizationalCapacityChapter Six: Implementation and Day-to-Day Operationshttp://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/Toolkit/index.aspxU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV


Additional ResourcesAoA 2010 Evidence Based Care Transitions Programhttp://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/index.aspxADRCs and Care Transitionshttp://www.adrc-tae.org/tiki-index.php?page=CareTransitionsCare Transitions Quality Improvement Organization Support Centerhttp://www.cfmc.org/caretransitions/Default.htmCare Transitions Quality Improvement Organization Support Center: CareTransitions Toolkithttp://www.cfmc.org/caretransitions/toolkit.htmU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV


Contact InformationCaroline RyanAging Services Program SpecialistOffice of Program Innovation andDemonstrationU.S. Administration on Agingcaroline.ryan@aoa.hhs.govU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV


The Role of Person Centered EvidenceBased Care Transitions in Maryland’sRebalancing InitiativesPerson Centered Hospital DischargeEvidence Based Wellness ProgramsEvidence Based Care TransitionsMoney Follows the PersonOptions CounselingU.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV


Contact InformationStephanie HullChief Long Term Services and Supports DivisionMaryland Department of Agingsah@ooa.state.md.us410-767-1107U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

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