Long-Term Care Discussion GroupMay 24, 2012

National Commission for Quality Long-Term Care

» Co-Chairs– Former Senator Bob Kerrey– Former Speaker Newt

Gingrich– 21 Commissioners

» Quality» Workforce» Technology » Finance

• Funded by Leading Age, AHCA, Alliance for Quality Nursing Home Care

Mathematica Policy ResearchA Strategic Plan for LTQA

» Potential for LTQA to make a difference by –– Facilitating dialogue and

partnerships among all provider groups that serve people needing LTSS and help break down the silos

– Bringing consumers and family caregivers together the LTSS providers and government agencies

– Making stronger links between quality measurement goals and evidence based practices

– Collaborating with other quality improvement organizations on common priorities and goals

» Launched January 30th – Brookings Institution

» 30 member Board appointed – – Inagural Executive Committee

• Mary Naylor – Chair• Carol Raphael – Vice-Chair• Gail Hunt – Secretary• Larry Minnix – Treasurer• Mark McClellan – At large

» Developed Statement of Principles

Mission StatementTo improve the effectiveness and efficiency

of care and the quality of life of people receiving long-term services and supports by

fostering person- and family-centered quality measurement and advancing

innovative best practices.

Strategic Agenda (2010-2012)

Care transitions; impact on people’s health and QoL; effects on potentially avoidable hospitalizations, re-hospitalizations and total health care costs.

Quality Measurement

Key Strategy: Address a national health challenge, TRANSITIONS IN CARE, affecting people receiving LTSS in order to produce demonstrable improvement in quality and cost reductions

Person- and family-centered, effective transitional care practices

Quality Improvement

Information and policies that advance high quality, person- and family-centered transitional care

Outreach/Public Awareness

Members

Members

GRANTS

» The SCAN Foundation

» The Commonwealth Fund

» AHRQ- The Agency for Healthcare Research and Quality

Quality Measurement Workgroup Report

» Achieved consensus on domains for measurement of transitional care in LTSS– Person/Family Centered Care– Transitional Care Processes– Performance Outcomes

» Identified and recommended set of 12 transitional care measures

» Identified gaps in measurement relevant to transitional care which represent areas for measure development and/or research

Gaps in Transitional Care Measurement

» Person and family-centeredness (beyond clinical outcomes)

» Process and outcome measures for older adults with cognitive impairment and those receiving palliative care

» Transitional care management across episodes of care

» Discharge readiness and social support» Preventive care » Access to, cost and cost-effectiveness of

transitional care» Disparities and measures reflective of unique

subpopulations» Performance of measure “bundle”

12

Next Steps

» These consensus-based recommendations synchronize and align with the work of NQF and Measures Application Partnership’s (MAP) roles in recommending measures to CMS

» Initial testing of this set of measures can begin through additional LTQA programs including the launch of the Innovative Communities Initiative

» Further research is needed to develop and test measures that address LTSS priorities

13

White Paper on Preventable Hospitalizations» Although the decision to go to the hospital is

often made in LTSS settings, there are no available validated measures to help long-term care organizations determine what is a preventable hospitalization. 

» The paper includes seven recommendations for the LTQA to pursue. These include:– Defining preventable hospitalizations in

general instead of by setting.– Defining as precisely as possible the

population receiving LTSS.– Beginning a process to develop appropriate

measures or measure-based procedures to identify potentially preventable hospitalizations in the LTQA population.

– Advocating for studies of measures.– Advocating with CMS for rigorous

monitoring of programs designed to reduce preventable hospitalizations.

– Expanding education for clinicians who trigger hospitalizations.

– Advocating for expanded implementation of existing tools for reducing preventable hospitalizations.

Work In Review

» Advancing Effective Care Transitions Among Older Adults Receiving Long-Term Services and Supports– Selected ACA Provisions—Impact on Transitions

Among Older Adults Receiving LTSS• Readmissions - Section 3025• Bundled payments – Section 3023• CCTP - Section 3026

» Two webinars This work is funded by The Commonwealth Fund

In Development

» White Paper - Achieving Higher Value Person-Centered LTSS Through Statewide Payment and Delivery System Reform – Why do states need to ‘fix’ LTSS?– A vision for higher value, person-centered LTSS – Challenges in achieving higher value, person-

centered LTSS– Description of statewide approaches and analysis

of each in addressing core values and features of higher value, person-centered LTSS

– Policy recommendations

» Two webinarsThis work is funded by The Commonwealth Fund

How do communities navigate this transition?

?Nursing Home

Assisted Living

Rehabilitation

Continuing Care Retirement Community

Home

County Council/

Department on Aging

Area Agency

on Aging

Cooperative

ExtensionMental Health Provide

rCommunity Resource Connection

Home Health Care

Senior Center

Adult Day ServicesFaith

Community

County Social

Services

Community-Based Approach

» Communities across the US are beginning to consider transitions of care as a community –based challenge that requires shared ownership and close collaboration across settings.

» (Institute for Healthcare Improvement)

Innovative Communities – Why?

“Without the involvement of long-term services and supports, ACO’s or other new collaborative models of service delivery will not be able to achieve

sustained quality improvements and reduced costs.”

-Mark McClellan, MD, Ph.DCAST ChairDirector, Engelberg Center for Health Care ReformLeonard D. Schaeffer Chair in Health Policy StudiesBrookings Institution, Washington DC

Innovative Communities - Why?

“…LTQA is convinced that the most important health reform victories will take place at the local level, in cities and towns… A broad range of community stakeholders…is needed to help older people and people with disabilities remain healthy and independent…”

- “Innovative Communities: Breaking Down Barriers for the Good of Consumers and their Family Caregivers.” p.3

Innovative Communities Summit

Philosophical Principles“Large-scale social change requires broad

cross-sector coordination, yet the social sector remains focused on the isolated intervention of individual organizations.”

-John Kania, Mark Kramer, “Collective Impact,” Stanford Social Innovation Review, Winter, 2011, p.36

Innovative Communities SummitKania and Kramer*

Five Conditions of Collective Success*

» Common Agenda Shared vision for change. Common

understanding of the problem. Joint approach to solution.

» Shared Measurement Systems Agreement for success measures.

Consistent data collection and indicators. Group accountability. Shared learning for success and failure.

Innovative Communities SummitKania and Kramer*

Five Conditions of Collective Success*

» Mutually Reinforcing Activities Each party plays their unique role. Coordination of efforts.

Mutual support.

» Continuous Communications Trusting relationships. Common motivation regardless of

sector. Regular meetings. Best solutions instead of self-interest.

» Backbone Support Organization Separate organization of stakeholders. Coordination of

leadership talent.

December 2010 Innovative Communities Summit

» Participants in the inaugural meeting worked together to create a common vision for a more collaborative future for those who provide and those who receive care and services.

» That vision, as outlined in our first report, called for:

– Empowerment of consumers through a customized, coordinated life-care plan that is person-centered and developed with the involvement of family.

– Development of community teams made up of equal partners and led by an independent and invested leadership.

» To help make this vision a reality, participants in the 1st Innovative Communities Summit encouraged LTQA to: – Serve as a repository for information that could help local

stakeholders create and support Innovative Communities at the local level.

– Serve as a cheerleader for Innovative Communities by coaching fledgling communities and convening regular meetings to encourage sharing of ideas and best practices.

– Help Innovative Communities identify federal and state sources of funding and offer them advice on ways to access that funding.

June 2011 Innovative Communities Summit

» Summit participants represented – 20 Innovative Communities– 20 federal agencies – 15 state and local governments – 5 foundations– 7 consumers– 32 providers – 14 health-care purchasers and payers – 16 academicians

» Leaders explored how LTQA can support Innovative Communities and how these communities can work together to improve care transitions and reduce unnecessary rehospitalizations.

» 11 presenters facilitated panels and small-group discussions. Presenters represented three major categories of stakeholders:

– Innovative Communities– National & State Support Programs– Private Foundations

The Health Care Innovation Challenge

» Innovative Communities Initiative (ICI)– Engage 300 communities in an outcomes-

oriented Collaborative Action Network (CAN)• Measured Component

– 3 Domains – Change Management; Action-Oriented Improvement Skills; Best Practices/Enabling Technologies to –• Reduce ED/Hospital use for target population

– Request - $24,526,425• Save Medicare $78 M – net savings of $53M – ROI of

2.19

3rd Innovative Communities Summit

SO WHAT’S NEXT?

Don Berwick Brought ‘Triple Aim’ to CMS

» Better Care for Individuals– Described by 6 dimensions listed in the IOM’s “Crossing

the Quality Chasm” report -• Safety, Effectiveness, Patient-Centeredness,

Timeliness, Efficiency, Equity» Better Health for Populations

– Through attacking “the upstream causes of so much of our ill health”

» Reducing Per-Capita Costs

CMS Vision of Post-Acute Care

» “ The person-centered post-acute system of the future will:– Optimize choice and control of services;– Ensure that placement decisions are based on patient

needs;– Provide coordinated, high quality care with seamless

transition between settings; – Reward excellence by reflecting performance on quality

measures in payment;– Recognize the critical role of family care giving; and – Utilize health information technology

The Affordable Care Act

Long-Term Care Spending in the US

Share of total spending, 2006

Medicaid43%

Medicare18%

Private insurance7%

Out-of-pocket28%

Other4%

Source: Avalere Health, the SCAN Foundation.

By 2030, more than 1/3 of the entire budget will be devoted to Medicare and Medicaid

Source: The Center for American Progress. The Math is Clear: Reducing Our Long-Term Federal Budget Deficit Mean Enhancing Health Care Reform

Payment & Delivery System Reforms to Support a High Performance Health Care

System» Accountable Care Organizations: Broad responsibility

for quality and cost of patient care, rewards for quality, shared savings

» Primary Care and Medical Homes: Expansion of current Medicare demonstration, new Medicare pilots, Medicaid initiatives

» Value-based purchasing» More transparency on quality and cost» Prevention, health promotion, patient safety, hospital-

acquired infections, quality» Center for Medicare and Medicaid Innovation

» Source: The Commonwealth Fund, The New Wave of Innovation: How the Health Care System is Reforming, (New York: Columbia Journalism Review, November, 2011).

Health Care Table

Hospitals

Government

Insurance

Pharma

Business

Physicians

Nurses

Labor

Special Interests

LTSS

Improved effectiveness and efficiency of care and the quality of

life of people receiving LTSS

Advance best practices at the

community level

Promote better care and

outcomes while reducing costs

Raise the visibility of

LTSS as part of the Health Care

Spectrum

Doug Pacedpace@leadingage.org

202-508-9454

Abbey Ammermanaammerman@leadingage.org

202-508-9474

www.ltqa.org