On April 1, six Cal MediConnect plans in Los Angeles and Orange County began testing interventions aimed at reducing avoidable hospitalizations and other adverse events for nursing facility residents. Each plan first identified a cause or potential cause of high hospitalization rates and then devised a quality improvement strategy to address the issue. The plans will use the Plan-Do-Study-Act (PDSA) model to determine the effectiveness of their interventions and make changes to them as appropriate.
The pilot projects are summarized here, and more information will be shared as the results of their work is analyzed.
CareMore identified that the lack of coordinated follow-up after a beneficiary is discharged from a hospital to a nursing facility can cause higher rates of avoidable hospitalizations. In order to improve follow-up, CareMore will utilize nurse practitioners and case managers to improve care coordination by doing the following within 72 hours of hospital discharge: 1) conduct a post hospitalization visit; 2) complete medication reconciliation and review of systems; and 3) develop and implement a care plan with the beneficiary.
- Health Net
Health Net identified 10 Skilled Nursing Facilities (SNFs) with higher rates of avoidable hospitalizations. To reduce the rate of avoidable hospitalizations in these facilities, Health Net will perform a monthly review of unnecessary emergency department utilization and in-patient admissions for conditions that could be otherwise treated through ambulatory care. This claims and encounter data is being shared with nursing facility clinical teams to identify trends as well as opportunities for quality improvement, including preventing avoidable transitions to acute care hospitals.
Care1st is testing whether advance directives can decrease the rate of avoidable hospitalizations, which is currently 23% for long-term care residents recently released from hospitalization. Advance directives may be able to keep beneficiaries who would prefer palliative care out of the hospital by offering other care options if their health condition worsens.
Care1st’s intervention will focus on offering all beneficiaries residing in long term care facilities (LTCF) an advance directive. The beneficiary will receive education about the advance directive from a trained social worker. To evaluate the success of the intervention, Care1st will evaluate the number of LTCF members that prepared an advance directive and assess the admission and readmission rates corresponding to the period being measured.
Over the last 2 years, CalOptima has met with over 30 facilities to establish relationships and lay the groundwork for launching approaches to Treatment in Place (TIP), as a part of their comprehensive program to address the needs of members residing in nursing facilities. CalOptima plans to work with nursing staff to provide TIP services through education and training of staff at those facilities with the highest volume of CalOptima members and/or highest number of potentially avoidable hospitalizations.
Currently, CalOptima is in the process of “studying” (from the PDSA model) the findings from our meetings with the facilities and identifying the necessary resources to effectively implement the comprehensive LTC program. In addition, CalOptima staff have continued with regularly scheduled monthly visits to Long Term Care facilities and internal committees have been updating educational materials for facility staff training. Additional organizational efforts have focused on identifying the necessary components to support a more comprehensive approach to long-term care, specifically around avoidable admissions and more effective “treatment in place” services.
- L.A. Care
L.A. Care is running a series of meetings with two participating provider groups (PPGs) to identify and promote best practices to reduce avoidable ER and hospital admissions for nursing facility members. The two provider groups were selected because they are among the PPGs with the largest long-term care membership. Together, the plan and providers are working to facilitate early identification of indicators that may signal the need for clinical evaluation and potentially for treatment. The plan is to provide intervention tools to the facilities and groups (for example, the “Stop and Watch” early warning tool) so both clinical and non-clinical staff, as well as family members, can alert the appropriate individual of a potential change in clinical status. The plan is working with the groups to collect data to establish a baseline and track the impact of the interventions on avoidable ER and hospital admissions. L.A. Care is currently developing a communication strategy for the facilities as baseline rates are calculated.
Molina identified a low rate of pneumonia (IPD) vaccines (PCV-13) as a potential cause for avoidable hospitalizations. Based on hospitalization data, 41% of hospitalizations were directly associated with IPD-related diagnoses. As of February 2017, only 14% of the target population (50 Medi-Cal beneficiaries residing in select LA NFs) have received the vaccine. Molina’s goal is to increase that to 50% by December 31, 2017.
To address this issue, Molina will educate primary care providers, nursing facilities, and beneficiaries on the Centers for Disease Control and Prevention (CDC) recommendations and proper administration of the PCV-13. They will track vaccine administration through quarterly medical record review, using the following categories: offered-given, offered-refused, not offered.