Health Innovation Highlights: December 20, 2018

Full Edition

FROM THE CENTER & OUR PARTNERS

Friday, Dec. 21: Center Webinar on Hospital Community Health Needs Assessments

Please join Center Senior Advisor Jessica Curtis and a panel of experts Friday, Dec. 21, 2-3 p.m. Eastern, for “Tips, Tricks and Trends for Building Effective Partnerships through Hospital Community Benefit: Making the Most of the Next Hospital CHNA Cycle.” In this webinar, hospital and consumer experts will share tips and tools to help community groups, advocates, and hospital staff navigate the Community Health Needs Assessment (CHNA) process in ways that add value for everyone, seeding the ground for future collaboration. 

Right now, non-profit hospitals across the nation are conducting the latest round of CHNAs. Due every three years, the CHNA can shine a powerful spotlight on health issues and inequities at the local and regional level. Findings revealed by the CHNA process can pave the way for long-term collaborations on health care access, food security, environmental health, and other social and economic health drivers. How should hospitals be working with public health and community partners in the CHNA? How might community partners maximize their involvement given limited resources? And most importantly, how can all partners ensure that the CHNA process--and the programs that get implemented as a result--lift up their communities' priorities and advance equity?

We've asked our panel to tackle these questions and more.  Please register here and join us for the webinar!

Your New “Go-To” Guide on Screening for Social Needs

Recognizing the growing consensus that addressing the social determinants of health is key to improving health outcomes, the Center has released a new resource on incorporating screening for social needs into the fabric of the health system. Highlighting best practices from Kansas, Michigan, North Carolina, Ohio and Tennessee, this resource focuses on the policy levers advocates should look to in seeking to incorporate social determinants screening into the health system, how to select a screening tool and how to use the data gathered from the tool. Advocates will find this short, practical resource useful in their social determinants advocacy.

Center’s “Care That Works” Series Highlights Pennsylvania’s ElderPAC Program

Innovations in how to best care for people with complex health and social needs are happening across the country. Our “Care That Works” series seeks to examine and elevate these successful programs and share the stories of the people they serve. This is the fourth brief in our series.

The fourth brief in our series reports on “Elder Partnership for All-Inclusive Care (ElderPAC),” a home-based primary care program that was developed and implemented in Philadelphia more than 20 years ago by the University of Pennsylvania Health System in partnership with the Philadelphia Corporation for Aging. Its purpose is to deliver a comprehensive blend of medical care and home and community-based services (HCBS) to frail older adults with multiple complex chronic conditions and functional impairments in their homes. Participants are either Medicare-Medicaid enrollees or those in the Pennsylvania Options program (a non-Medicaid HCBS program funded through the Aging Block Grant). All participants have been evaluated to be eligible for nursing facility level of care.

This brief describes the program and summarizes some of its very promising results. Two five-year evaluations between 1998-2009 showed a 40-50 percent reduction in Medicare costs, 20 additional months of survival in the community compared to matched home and community-based care controls and a four-fold decrease in months participants spent in nursing homes, resulting in 23 percent lower Medicaid costs.

The brief provides many more details, and also shares the story of Ms. Emma Gray, an ElderPAC participant.  

Center Pens Blog on Latest Duals Demonstration Evaluations

In its latest blog post, the Center’s Senior Policy Analyst Leena Sharma offers our quick take on the recently-released evaluations by the Medicare-Medicaid Coordination Office on the dual eligible demonstration projects. While a deeper analysis is forthcoming, Sharma shares five key takeaways from the reports from California, Illinois, Ohio and Washington:

  1. Care coordination is a fundamental component of the demonstrations, but much more needs to be done to improve this function
  2. Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results indicate that enrollees were generally satisfied with their experience with their plan
  3. There are promising indicators of decreased utilization on inpatient admissions and in skilled nursing facility admissions
  4. Cost savings, while significant for two states, are only for Medicare; as there is no Medicaid data yet
  5. Enrollment into the demonstrations is a challenge across the board

For more details on each, check out our blog!

Coming in Early 2019: Center Educational Video Series, “Re-envisioning Care for Persons With Involved Disabilities”

To support clinicians and health system leaders in understanding and adopting principles of person-centered care, the Center has worked with Dr. Robert Master and other clinician and consumer leaders to produce a series of short educational videos. The health care system frequently falls short when it comes to the care of people with complex needs, particularly people with involved disabilities. We need a different approach, one that is built on a partnership between consumers and clinicians, and that reimagines what care would look like if it were truly person-centered.

An initial series of four video modules will be available in early 2019. Each video runs for approximately 10 minutes and is designed for asynchronous learning that fits into the learner’s schedule. Please visit our series page to watch a preview and register to be notified when these videos are available. 

Pennsylvania Center Partner Appointed to Statewide Home Care Advisory Group

Erin Ninehouser, Consumer Engagement Manager for PHAN (Pennsylvania Health Access Network), has been appointed by Pennsylvania Gov. Tom Wolf to a statewide advisory group that will work with the state’s Department of Human Services to discuss strategies for improving the quality of home care in the commonwealth. A significant focus of the advisory group will be to provide the home care work force with a voice in improving their working conditions. Ms. Ninehouser has been working with older adults and disabled individuals in Pennsylvania impacted by the state’s new LTSS (long-term services and supports) managed care program, Community Health Choices, and is an expert on the needs of this population.

NOTEWORTHY NEWS & RESOURCES

If Upheld, Texas v. Azar Case Would Eliminate MMCO and CMMI

Last week, a federal district court judge in Texas ruled the entirety of the Affordable Care Act unconstitutional. The law remains in place, but this ruling poses a significant threat to nearly everyone in the United States, particularly populations with complex health and social needs. Not only did the Affordable Care Act expand coverage to 20 million consumers and provide important protections for people with pre-existing conditions, it also included many provisions to advance health care innovation. For example, both the Center for Medicare & Medicaid Innovation (CMMI) and the Medicare-Medicaid Coordination Office (MMCO) were created by the ACA. These offices have important roles in improving care for vulnerable Medicare and Medicaid beneficiaries. The Financial Alignment Initiative (FAI), for example, was created and is administered by MMCO, and CMMI has rolled out programs that are working to emphasize better coordination of care. The ruling is expected to be appealed.

CMS Offers States New Ways to Better Serve Medicare-Medicaid Enrollees

In a newly-released letter to State Medicaid Directors, CMS is offering ten new opportunities to better serve the Medicare-Medicaid enrollees in their state. The opportunities--which include those that integrate care, improve access to Medicare data and reduce administrative burden—are listed below:

  1. State contracting with Dual Eligible Special Needs Plans (D-SNPs)
  2. Default enrollment into a D-SNP
  3. Passive enrollment into Medicare health or drug plans
  4. Integrating care through The Programs of All-Inclusive Care for the Elderly (PACE)
  5. Reducing barriers to accessing Medicare data
  6. Allowing states to use Medicare data for program integrity purposes
  7. More frequent filing of state “MMA files”
  8. More frequent exchange of “State buy-in” file data
  9. Creating Medicare Part A “buy-in” agreements
  10. Opportunities to simplify eligibility and enrollment

Two New Reports on ACOS

This month brought two new reports on Accountable Care Organizations (ACOs). The first, from a six-foundation collaborative working together to improve care for people with complex health and social needs, looks at responses to the fourth wave of the National Survey of ACOs. Specifically, the survey responses were analyzed to assess the extent to which ACOs have adopted approaches with special relevance for complex populations. Findings suggest that ACOs have increased their efforts to target populations with complex care needs but that opportunities for improvement remain. Few ACOs report having labor-intensive interventions related to patient engagement, one-on-one care transitions and integration of physical and behavioral health.

A second report, commissioned by the National Association of ACOs, looks at the savings estimates associated with the Medicare Shared Savings Program (MSSP) Performance Year 2016. This report concludes that ACOs are saving the federal government money, a finding that counters CMS' suggestion that ACOs in the MSSP aren't performing well. The report shows an estimated $2.66 billion in savings from 2013 to 2016. Net savings are calculated at $665.8 million after accounting for incentive payments made by and to the program.

HHS Seeking Public Input on Improving Care Coordination and “Reducing Regulatory Burden of HIPAA”

The U.S. Department of Health and Human Services (HHS) announced on Dec. 12 that it is seeking public input on how the Health Insurance Portability and Accountability Act (HIPAA) Rule could be modified to better promote coordinated, value-based care. In its press release, HHS states, “In addressing the opioid crisis, we’ve heard stories about how the Privacy Rule can get in the way of patients and families getting the help they need. We’ve also heard how the Rule may impede other forms of care coordination that can drive value.” However, advocates working in the substance use treatment sphere are concerned that while increased coordination of care may have merit, patient privacy and the release to unauthorized parties of sensitive information must be balanced to prevent stigmatization. Public comments are due by Feb. 12, 2019.

ELDERCARE VOICES

When Person-Centered Services Stop at My Mother's Nursing Home Door: Views from a Daughter and Champion of Person-Centered Care

Lori Simon-Rusinowitz, MPH, Ph.D.

What can a daughter do when her mother's reality – a nursing home with no person-centered care in sight – presents a stark contrast to her own work devoted to making person-centered services available to all? This service model means asking what is important to people and honoring their preferences. 

It would be hard for any daughter to see her strong mom lose her independence and be in a setting that doesn't ask about her preferences or honor them. It is especially difficult for me. Early in my career, I aimed to infuse person-centeredness in care for my parents' generation. It soon became clear that my colleagues and I need to help our fellow baby boomers and the generations that follow.

My mother’s physical limitations and severe pain led to her needing 24/7 care. Despite our shared desire to avoid the move to a nursing home, my mom and I (a long-distance caregiver) were out of alternatives. Once she was in a facility, it was easy for me to view her care limitations and the need for change through a policy lens. A worker shortage, low wages, limited worker training and inadequate staffing requirements were intertwined with care limitations and the absence of person-centered services.

I've never before written about nursing homes nor my personal experiences as a caregiver. I'm doing so now to highlight the need for person-centered services in this setting. I hope that shining a bright light on nursing homes, for an audience dedicated to enhancing the consumer's voice, will spur a much-needed culture change.   

Culture Change in Nursing Homes: Limited Movement Toward Person-Centered Services

A culture change movement, including consumer advocacy, legal, legislative and policy efforts, has sought to establish person-centered services in nursing homes for over 30 years. This change would include resident-directed care, close relationships between residents, family and staff, and staff empowerment to meet residents’ needs. What would this look like? Residents would decide when they get up and when they go to bed, what they wear and what they eat, in contrast to a “one size fits all” routine. The Green House model, with home-like open kitchens, private bedrooms and staff who are engaged with residents, exemplifies these principles.    

Yet traditional nursing homes still dominate. A 2013 survey found that only 13 percent of 2,164 directors of nursing said they had “completely changed the way the (nursing home) cared for residents,” although many others had begun making changes in this direction. However, in a significant step toward person-centered services in nursing homes, the Centers for Medicare and Medicaid Services (CMS) enacted a 2016 regulation (483.21) requiring comprehensive person-centered care planning.

My Mother's Experience

My mom’s situation illustrates the impact of overwhelmed and under-trained workers. Person-centered care takes time, adequate staffing and training. It is unlikely to happen with understaffing, where even basic needs of residents may not be met. Getting to the bathroom and changing soiled diapers quickly are necessary to maintain a person’s dignity and health. Yet, I spend a lot of time calling from 500 miles away to ask that someone take my mother to the bathroom after she has been waiting too long.

Busy staff couldn’t even take time to introduce my mom to her new roommate when she arrived. The two women, who would live a few feet from each other, deserved an introduction that affirmed each person’s dignity and worth.

My mother has always dressed well, and still cares about her appearance. Rushed aides don't often find the clothes she wants to wear, instead choosing mismatched items and leaving clothes on the floor. These actions do not honor her preferences or convey respect.

How Can We Expand Person-Centeredness for Nursing Home Residents?

While nursing home experts know more about these problems than I do, I humbly offer some suggestions to help advance nursing home culture change.

Get Outraged and Make Change Happen

Remember the posters that said “If You’re Not Outraged, You’re Not Paying Attention?” We need to convey outrage so that the right people pay attention. Without change now, generations of older adults will face the same unacceptable conditions. Let’s we adult children of aging parents take advantage of our numbers, participate in consumer advocacy, and insist that nursing homes do better.

Get Curious – Why So Little Emphasis on Consumer and Family Satisfaction in Nursing Homes?

Families and residents have been unhappy with nursing homes for many years. Other businesses know consumer satisfaction is essential for success, yet nursing home owners undervalue this principle. The authors of a 2014 study about the CMS five-star nursing home rating system recommended that CMS add consumer information for a complete picture. A person-centered culture must solicit and act upon consumer perspectives and feedback.

Get Policy- and Business-Wise

The CMS regulation requiring person-centered care planning in nursing homes (Reg.483.21) is a critical step toward achieving culture change. A 2018 article reported that the power of partnerships between aging service advocates and geriatric clinicians may be instructive about achieving this requirement’s potential. In partnering to expand person-centered care, they could improve resident satisfaction and quality of life (according to a 2017 study of 11,752 residents in 320 Kansas nursing homes) and also help facilities’ bottom lines. More satisfied residents could lower resident turnover and address quality challenges due to high staff turnover. 

While I would love culture change to happen quickly enough to come through my mother’s nursing home door, this is highly unlikely. However, she and I would both be thrilled if this discussion sparks fresh ideas, new partnerships and action that opens the door a bit wider to welcome person-centered care into more nursing homes.  

Lori Simon-Rusinowitz, MPH, PhD, is a faculty member at the University of Maryland, School of Public Health in the Department of Health Services Administration and Center on Aging. She was the research director for a national demonstration and evaluation that compared consumer-directed and traditional approaches to providing personal care services for elderly and younger people with disabilities. She continued this role for a national replication project and resource center addressing consumer-directed care. She has been a long-distance caregiver for eight years.

STATE HIGHLIGHTS

Colorado

Denver, Colorado is joining other cities across the nation in creating new streams of revenue to address disparities in mental health services and access by levying a 0.25 percent sales tax to fund mental health treatment. Last year, Colorado experienced a record number of suicides and overdoses, and is currently ranked 25th in the nation on spending for mental health treatment, according to mental health advocacy experts. The goal of the new revenue is to focus on clinical treatment and therapy, rather than relying on the criminal justice system to respond to incidents on an individual basis. Officials say the funds will build a new mental health treatment center in Denver, but will also go toward schools, addiction centers and first responders to help better integrate mental health and substance use-specific treatments within existing systems and address the root causes of mental health issues before a crisis.

Idaho

The Center for Health Care Strategies has issued a report on Idaho’s Medicare Medicaid Coordinated Plan (MMCP), detailing some early successes and potential actions for other states. In 2014, Idaho launched its MMCP to provide services and supports, including Medicare Parts A, B, and D, most Medicaid benefits, LTSS, medical transport, and supplemental services, to the state’s nearly 30,000 dually eligible individuals. Some of the program successes outlined in the report include meaningful stakeholder engagement in the process, coordinated outreach for the program across a wide swath of networks and the establishment of a foundation for a broader MLTSS program in the state. Lessons identified for other states to consider include the importance of using local care coordinators who live in the same communities as enrollees and developing both internal expertise on Medicare and external (private insurer) expertise in Medicaid programs to ensure better coordination.

Minnesota

Health clinics in Minnesota are controlling medical spending cost growth by being more intentional about procedures and referrals. The total costs for privately insured consumers rose just 2 percent last year, as did pharmaceuticals spending, while spending for outpatient hospital services declined by one percent – after rising by 7.3 percent in the previous year.  Using primary care providers as “traffic cops” for the health care system, clinics discouraged and reduced the number of unnecessary procedures and referred patients to lower-cost medications and laboratory services. There remains a wide variation between clinics in the success of these measures, but that variation is due mostly to differences in price setting, rather than in population or procedural differences, according to Minnesota Community Measurement, the non-profit policy and research center who produced the findings

Ohio

A summary of Ohio’s Medicare-Medicaid capitated financial alignment model demonstration is now available through The Center for Health Care Strategies. This model, called MyCare Ohio, is the second largest capitated demonstration in the country, serving more than 80,000 enrollees, and was developed to maximize the potential for Medicare-Medicaid integration in the state. The MyCare Ohio model includes eligibility and enrollment supports, coordinated care management provisions and an emphasis on substantive community partnerships among its primary components. In its 2018 evaluation report, MyCare Ohio boasted the highest “opt-in” rate of any financial alignment demonstration in the nation, with around 70 percent of eligible Ohioans choosing to enroll. Additionally, MyCare Ohio’s focus on value-added service plans and moving enrollees from institutional care settings to community-based care has resulted in lower costs and higher enrollee satisfaction than the traditional fee-for-service Medicaid models. While the initial transition timeline of three months was unrealistic and Ohio has plenty of work to do to increase stakeholder engagement, this model’s implementation has been largely successful thus far.