pass - post acute support system

Agenda

Introduction to ILS

Care Transition

The ILS Post Acute Support System (PASS™ )

Benefits of PASS™

Questions & Answers


About ILS GroupIndependent Living Systems (ILS):

• Founded in 2001

• Health Care Management and Services Organization uses managed care concepts in the management of long-term care delivery, and focuses on the use of home and community based services as an alternative to institutional care.

• Services individuals in: MAPD / SNP plans (60,000), Capitated Medicaid LTC (2,000), Pediatric Medicaid plans (8,000), School & Community Nutrition (10,000)


ILS Group Principal Clients

Health Plans• Medicare Advantage &

Part D Plans• Dual Special Needs Plans• Chronic Special Needs Plans• Medicaid Plans

Hospitals• CMS Pilot Hospitals • Public Hospital Systems• Private Hospital Systems

Long-Term Care Diversion Program Plan & MCOs:• Florida Nursing Home

Diversion• New Mexico CoLTs• Tennessee CHOICES• PACE Programs

County / State Governmental Programs:• AAAs• ADRC / ARCs


The Problem…

19.6% of Medicare Patients nationally are readmitted within 30 days; 28.2% - 60 days, 34.0% 90 days.

The reasons (diagnoses) for readmissions were:• Heart Failure / Heart Attack• Pneumonia • COPD

The “factors” related to readmissions include: • Medications & Medication Management• Access to care / Lack of outpatient care• Lack of support systems & community services


Costly Readmission Rates


Correlation to Unbalanced use of HCBS Resources


The Solution – Care Transition

What is “Care Transition”?

The term “care transition” refers to the movement of patients through the continuum of care as their conditions and care needs change.

The ILS Post-Acute Support System (PASSTM) program focuses on the care transition between the institutional setting (Acute inpatient, Sub-Acute, Nursing Home) back to the home & community setting.


Post-Acute Support System PASS™

Based on Care Transition Intervention (CTISM) Program developed by Dr. Eric Coleman, University of Colorado.

Care Transition program designed to coordinate and manage the transition of individuals from the Acute Inpatient setting to the Home & Community Setting.

• PASS™ is not case management, discharge planning or home health.

• PASS™ is patient advocacy, education, communication and coordination.


PASS™ Value Proposition

Improve total care transition from inpatient to home

Facilitate communication between patient, caregiver & providers

Improve outcome (reduction in readmissions), provide consistency, reduce errors & unnecessary services (reduction in costs)

Patient advocacy, patient empowerment & patient education

Improved coordination of care and care transition

Improved overall health status and health education

Improved communication between patient, caregiver and providers

Reduced acute inpatient re-admissions and associated costs

Reduced overall health care costs and unnecessary expenses

Benefits / OutcomesObjectives


Post-Acute Support System

Driven by the PASS™ Coach and supported by Care Support Representatives and PASS™ system technology.

Interaction with patient:• Face-to-face during inpatient admission• Face-to-face at Home post discharge (48 – 72 hours)• Telephonic, day 2, 7, 14 & 30 post discharge

Enhanced components added to evidence-based foundation.


Targeted population:• Any individual admitted with one or more of the following

chronic conditions:

• AMI, CHF, COPD, PNE, etc

• Any individual with two (2) or more inpatient admissions within a 6 month period.

• Any individual already in a case management or disease management program.

Target populations are identified and developed during implementation.

Post-Acute Support System


PASS™ “Five Points”

Medication Self Management

Nutrition Management

Personal Health Record

PCP & Specialist Physician Follow-Up

Red Flags / Signs & Symptoms


Medication Self-Management

Goal: patient is knowledgeable about medications & has a medication management system.

Hospital Visit: discuss importance of knowing medications & ensure adherence / compliance.

Home Visit: reconcile pre & post hospitalization medication lists & correct any discrepancies.

Follow-up Calls: answer any remaining medication questions, provide support / resource, reinforce education.



Goal: patient is knowledgeable about nutritional status, meal planning & diet as it relates to chronic conditions.

Hospital Visit: initial nutrition & nutritional knowledge assessment.

Home Visit: nutrition education, meal planning & home-delivered meal package.

Follow-up Calls: reinforce education, answer any questions, provide support / resource.


Physician Follow-up Visits

Goal: patient schedules & completes follow-up visits with PCP / Specialists & is empowered to be an active participant in these interactions.

Hospital Visit: recommend PCP / Specialists follow-up visits.

Home Visit: emphasize importance of follow-up visits & need to provide PCP with recent hospitalization information. Practice & role-play questions for PCP.

Follow-up Calls: provide advocacy & support in getting appointment, if necessary.



Goal: patient is knowledgeable about indicators that suggest his/her condition is worsening & how to respond.

Hospital Visit: discuss signs & symptoms, red flags and drug reactions.

Home Visit: assess condition, reinforce hospital visit discussions.

Follow-up Calls: reinforce when / if PCP should be called, provide support / resource.


PASS™

Fully Integrated Care Transition


Medication Management


PCP & Specialist Physician Follow Up


Inpatient (Acute/Sub-Acute) Admissions:






Post Discharge - Home (48-72 hrs):






Follow-up Calls 2, 7, 14, 30 days Post Discharge:

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PASS™ Information System

Secure HIPAA compliant, web-based, real-time system providing:• Patient Tracking: tracks client through the various interactions

and components for each episode.• Electronic PHR: maintains an electronic record of the client’s

PHR including history & medications.• Data Collection: allows for data collection to provide feedback

on admissions, discharge transitions and readmissions.• Care Plan Management: tracks interventions identified for a

clients care plan and additional services coordinated including transportation, home physician visits, telemedicine, etc.

• Reporting: designed to provide standard and Ad-hoc reporting.


PASS™ MCO Implementation:Factors to Consider

Business Model Presentation• Presentation of intervention (PASS™)• Presentation of incentives:

• Financial: cost savings exceeds cost of intervention• Quality of Care: improved coordination of care and member

satisfaction/retention• Pilot Program Opportunities – (6-8 month)

• ROI Program (savings ROI ranges from 2:1 to 4:1)

Data Analysis• Evaluation of claims data to determine trends, variables and

factors behind readmissions – this determines high risk “targets”• Hospitals, Diagnoses, Physician Encounters, Benefits

• Determination of full cost of readmission (admission)


Hospital Relationship Building• Introduction of intervention in target facilities. Issues to

consider:• In-network facility vs Non-network facility• Facility’s national readmission rates

Coordination of Care & Post Episode Services• Follow-up Physician coordination• Health plan contacts for coordination of identified

services:• Case Managers, Vendors, Network Services

• Coordination / Referrals for community based services


PASS™ MCO Implementation:Factors to Consider

PASS™ MCO Implementation

Challenges & Barriers Solutions That WorkData Analysis • Obtaining data from MCO.

• Developing formulas for readmission rate (baseline) & factors

• Standardized file formats.• Data Analysis support

from established data sources.

Hospital Relationships

• Developing relationships (through MCO relationships) with facilities

• Present intervention as opportunity to improve performance and efficiency for hospital.

Hospital Process

• Difficulty identifying patients• Developing workflows with

hospital staff

• Present opportunities for intervention to “assist” hospital staff.


PASS™ MCO Implementation

Challenges & Barriers Solutions That WorkProcess Clarification & Coordination

• Confusing Care Transition with Case Management, Concurrent Review, Discharge Planning or Home Health

• Standardized process delineation.

• PASS Coach opportunities to provide support to these processes

Member Acceptance

• Lack of member understanding of service.

• MCO communication to member for education – added benefit.

• Consent processPhysician Acceptance

• Lack of physician understanding

• MCO communication to physician for education.

• Consistent communication


Hospital Perspectives Facing significant revenue reductions because of potential

readmission payment reforms:• Hospital Planning – most hospitals with a significant Medicare census

have initiated an effort to deal with this issue• Dedicated Resources– care transition coaching cannot become an

additional duty of discharge planners or case managers.• Evidenced Based Model -better to use model with proven results.

Program needs formalized protocols and procedures, IT support, etc.• Opportunity for Marketing – program can become concierge service,

nutrition program and meals on discharge can differentiate hospital, post discharge follow up can bond patient to hospital and its other services. Program improves communication between hospital and staff MDs.

• Reporting and Evaluation - Data tracking and ongoing evaluation of program is key!


PASS™ “Best Case” Implementation

Client 1:500 Bed Private Hospital &

Physician Practices

Client 2:1000 MA MSO & Medical

Center (At Risk)

Client 3:2000 MA Member Health Plan

(County Coverage)

Admitsto Hospital

Pilot to manage specific MC admits based on Dx, & previous case management

Manage admits for designated Dx to designated hospitals

Manage admits for designated Dx to all

hospitals in the County


Questions?

For more information:Jeffrey T. King, RN, MBA - [email protected]

Josefina Carbonell - [email protected]

Independent Living Systems5201 Blue Lagoon Drive, Suite 270Miami, FL 33126www.ilshealth.com / (305)262-1292


pass - post acute support system

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