Health reformCreates new Care Models and Opportunities for Social Work W. June Simmons, CEO Partners in Care Foundation April 2nd, 2014 Society for Social Work Leaders in Healthcare
We Thank Our Funders Our work in this area is made possible through the generous support of: John A. Hartford Foundation Archstone Foundation And Administration for Community Living
Partners in Care FoundationWho We Are Partners in Care is a transforming presence, an innovator and an advocate to shape the future of health care We address social and environmental determinants of health to broaden the impact of medicine We have a two-fold approach, creating and using evidence-based models for: provider/system practice change and enhance patient self-management Changing the shape of health care through new community partnerships and innovations
Objectives Participants will be able to: • Describe key Affordable Care Act issues impacting social work/long term supports and services practice • Recognize key target populations for social work intervention • Describe central social work strategies and interventions in this changing environment
Ecological Social Work Practice Framework: A Perfect Fit for Health Reform Enduring Social Work Framework State & National Policy Community Resources & Partnerships Institutional Practices Other Caregivers Patient/Family
The Expanded Chronic Care Model: Integrating Population Health Promotion
Gallant MP. The influence of social support on chronic illness self-management: a review and directions for research. Health Educ Behav. 2003;30(2):170-95.; DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol. 2004;23(2):207-18.; Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health. 2002;92(5):758-68.; American Public Health Association. The hidden health costs of transportation. http://www.apha.org/NR/rdonlyres/A8FAB489-BE92-4F37-BD5D-5954935D55C9/0/APHAHiddenHealthCosts_Long.pdf. Published February 2010. Accessed January 10, 2012.; Centers for Disease Control and Prevention. CDC health disparities and inequalities report – U.S. 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.; Robert Wood Johnson Foundation. Overcoming obstacles to health care. www.commissiononhealth.org/PDF/ObstaclesToHealth-Highlights.pdf. Published February 2008. Accessed January 10, 2012.; Shi L, Singh D. The Nation’s Health. 8th ed. Sudbury, MA: Jones and Bartlett Learning, LLC; 2011. Social Factors and Health Outcomes Societal-level social determinants have individual-level impact
The Affordable Care Act: A New Opportunity for Social Work Robyn Golden, LCSW Director, Health and Aging Rush University Medical Center Chicago, Illinois
ACA, Social Work, and Care Coordination • ACA provisions create opportunity for new social work roles • Avenues to sustainable care coordination by social workers increasingly available • Provisions include • Changing incentives • Changing payment structures • Moving away from fee-for-service
Health Care’s Blind Side • 2011 Robert Wood Johnson Foundation surveyof 1,000 primary care physicians • 85% feel social needs directly contribute to poor health • 4 out of 5 not confident can meet social needs, hurting their ability to provide quality care • Rx for social needs, if they existed, would be 1 in 7 Rx’s written • Psychosocial issues treated as physical concerns • Social work operates in this blind side
Moving toward the Second Curve First Curve Second Curve Option on the Health Exchange Direct Contracts with Employers Traditional Fee-for-Service Payment System Medicare Advantage Plan Readmission Rate Penalties Accountable Care Organizations Population Health Per Capita Payment System Bundled Payment Pilots Adapted from Ian Morrison
Bundled Payments • Bundled payment pilot began 01/31/2013 • Single Medicare payment to cover all services for an episode of care to be distributed among care providers: • Acute hospital services • Physicians’ services • Care coordination & transitional care services • Post-acute services • Home health care • Skilled nursing facility services • Inpatient rehabilitation services • Pilot testing four variations on bundling model over 3 years to assess efficacy
Medical Homes • Change in outpatient care delivery toward coordinated, chronic care, including the following supportive services: • Care coordination • Case management • Health promotion • Transitional care • Patient and family support • Referral to community services • Additional funding available for coordination through greater reimbursement
Accountable Care Organizations • Medicare Shared Savings Program (3022) creates incentive for the establishment of Accountable Care Organizations (ACOs) • Networks of physicians and other providers • Integrated, cooperative services designed to foster collective accountability • Share savings resulting from the ACO’s coordinated care • Reduced Medicare expenditures • Improved beneficiary health outcomes • No consensus on vital components of an ACO • Will have to address social issues to see true cost savings • Opportunity for social work to achieve savings and quality improvement
The CMS Innovation Center (CMMI) • Test innovative payment and service delivery models • To reduce program expenditures • To preserve or enhance the quality of care furnished to Medicare and Medicaid beneficiaries • Preference given to models that improve health care coordination, quality, & efficiency • Authority to expand any model • Funding of $1 billion per year for 10 years • Released through ongoing Funding Opportunity Announcements • Targeted distribution within priority areas • Budget neutrality requirement waived during testing
Thrive Under Reform • Key elements to making the ACA successful • Engaging patients • Prevention and wellness • Not transactions but a journey • Transparency of performance • Focus on burden of treatment, not illness • Cost and quality in the same breath • Where does social work fit?
Changing Times – New Opportunities • Following patients across the continuum • Connecting sites of care within sectors • Connecting providers of care across sectors • Articulating the value of social work • Persistence is required
Social Work and Mental Health • Social workers can be a valuable member of the mental health team • Care manager • Therapist • Advocate and educator of the healthcare team • BRIGHTEN: Bridging Resources of an Interdisciplinary Geriatric Health Team via Electronic Networking • Team-based approach to mental health in primary care • Along with the social workers, the team is comprised of: • Patient • Geropsychologist • Geropsychiatrist • Physical Therapist • Occupational Therapist • Nutritionist • Chaplain • Pharmacist • Primary Care Physician
Social Workers and Interdisciplinary Teams in Practice • Social workers are both valuable contributors to a team and effective leaders • This can be seen in successful models utilizing social workers as team coordinators • Social Work and Mental Health • BRIGHTEN: Virtual interdisciplinary program integrating mental health into primary care • Social Work and Transitional Care • Bridge Model: Transitional care model provided by MSW’s from a biopsychosocial perspective • Social Work and Patient Centered Medical Homes (PCMH) • Ambulatory Integration of the Medical and Social (AIMS Model): Primary-care based care coordination
Targeting Home & Community-Based Services in Active Population Health Management Examples: Hospice & home palliative care Examples: SNF diversion, Respite Care, Home Modifications, home monitoring, daily meals, assisted transportation Examples: Coaching & Patient Activation, Home-delivered Meals; Referral to Self-Management Classes Examples : Stanford Healthier Living; Diabetes Self-Management; Matter of Balance Examples: Activity programs & education @ senior center
Targeted Patient Population Management with Increasing Disease/Disability Home Palliative Care Hot Spotters! Post Acute and Long Term Supports and Services Evidence Based Self-Management, Home Assessment and HomeMeds
Avoidable Readmissions Penalty • Incentive to improve care transitions & reduce avoidable readmissions • Lost reimbursement to drive performance improvement • Penalty for each hospital based on risk-adjusted actual 30-day readmission rate compared to expected readmission rate • Reduced Medicare DRG payments by 1%, rising to 3% in 2015 • 3 target conditions starting in FY 2012, expanding to 7 in FY 2015 • Hospital-specific readmission rates posted on Hospital Compare website for public viewing • Expand to skilled nursing homes & Home Health agencies
Community Based Care Transitions Program (3026) • Provides funding to hospitals & community-based entities that furnish evidence-based transition services to Medicare beneficiaries at high risk for readmission • Preference for medically underserved areas, small communities, rural areas & AoA programs • Services must include at least one of 5 interventions • Arranging post-discharge services • Providing self-management support (or caregivers support) • Conducting medication management review • 5 year program started in 2011
Bridge Model: Primary Goals Addressed by Social Work 3 guiding tasks to reach the goal of preventing avoidable adverse events post-discharge: • Ensure patients receive appropriate services in their home post-discharge • Connect patients to their physician for follow-up appointments • Support caregivers to reduce stress and burden
Social Work and Transitional Care: Bridge Model • Bridge social worker serves as primary care coordinator • Manages care coordination tasks • Facilitates inclusion of other team members • Additional team members vary by client • Inpatient case manager & attending physician • Primary care physician • Pharmacist, therapists, other medical providers • Home health care provider • Community service provider
Social Work and Patient Centered Medical Homes (PCMH) • Role for social workers in augmenting the patient’s primary care encounter • Address gaps in care resulting from insufficient time, staff, resources • Provide compensatory support to meet patients’ medical and psychosocial problems • Assess patients’ psychosocial considerations and their impact on medical status • Educate providers how to support patient self-management • This resource is central to PCMH success • True improvement in care, health, and cost cannot be done without addressing the factors that impede patients’ medical care plan adherence • Ambulatory Integration of the Medical and Social (AIMS) Model at Rush
Outcomes of Social Work Involvement and Leadership • These three examples demonstrate success as a result of social work involvement • BRIGHTEN: Lower PHQ-9 scores & depression scores • Bridge: Increased communication with physicians & keeping medical appointments; Decreased mortality • PCMH Social Work: Increased well-being; decreased stress; more time for medical issues at next appointment • However, social work evidence not extensive: ongoing challenge for field
Getting to the Table • What can social work education programs do to get social work to the table? • Find cross-institutional ways to collaborate • Learn to communicate and market social work • Frame social work from other perspectives • Speak the language of other professions • Vary the message to fit the mission of the team • Find ways to partner with other disciplines • Example: Delegating tasks to community health workers so social worker can focus on skilled activities
Future of IPEP and Geriatric Social Work • We must prove the value of social work • Make clear business case • Show return on investment from social work involvement • Clarify how social work helps to meet the Triple Aim of better care, better health, lower cost • Frame within social determinant of health language and not just make it a guild issue • Not social workers can do it better • Social workers can do it, too • Comparative effectiveness research to show outcomes of not having social worker involved
The Imperative • Critical to incorporate: • The social determinants of health • Prevention • Care coordination • It takes a village • Need a team to meet the needs of increasingly complex, older patient population • Responsibility cannot solely reside with the physician • To meet this imperative, we must innovate
1% spend 21% 5% spend 50% The Upstream Approach: What would happen if we were to spend more addressing social & environmental causes of poor health?
Most of Costliest 5% have Functional Limitations http://www.cahpf.org/docuserfiles/georgetown_trnsfrming_care.pdf
Concentration of Risk • Functional Limitation • Dementia • Frailty • Serious illness(es)
Dementia and Total Spend • 2010: $215 billion/yr • By comparison: heart disease $102 billion; cancer $77 billion • 2040 estimates> $375 billion/yr Source: Hurd MD et al. NEJM 2013;368:1326-34.
Dementia Drives Utilization Prospective Cohort of Community dwelling older adults Source: Callahan et al. JAGS 2012;60:813-20.
In case you are not already worried…The Future of Dementia Hospitalizations and Long Term Services+Supports 10 fold growth in dementia related hospitalizations projected between 2000 and 2050 to >7 million. Zilberberg and Tija. Arch Int Med 2011;171:1850. 3 fold increase in need for formal LTSS between now and 2050, from 9 to 27 million. Lynn and Satyarthi. Arch Int Med 2011;171:1852.
Because of the Concentration of Risk and Spending, Home and Community Care Principles and Practices are Central to Improving Quality and Reducing Cost
Surprise! Home and Community Based Services are High Value • Improves quality: Staying home is concordant with people’s goals. • Reduces spending: Based on 25 State reports, costs of Home and Community Based LTC Services less than 1/3rd the cost of Nursing Home care.
This is Our Expertise • Highest risk, highest cost population is ours: functional limitation, frailty, cognitive impairment +/- serious illness • We need a fully integrated service line that also addresses keeping people out of the top 5%
Home and Community Based Services – a Specialty Practice Expertise • Evidence-based approaches underlie all our work • In-Home assessment and supports, long and short term – waivers/ Care Transitions • Caregiver skills and support
Predisposition 30% Behavioral Patterns 40% Social Circumstances 15% Health Care 10% Environmental Exposure 5% Determinants of Health & Contribution to Premature Death Source: Stephen A. Schroeder, MD. We Can Do Better. NEJM 357:12
Scope of the Problem • 1.7 million Americans die of a chronic disease each year • Chronic diseases affect the quality of life for 90 million Americans • 87% of persons aged 65 and over have at least 1 chronic condition; 67% have 2 or more • 99% of Medicare spending is on behalf of beneficiaries with at least one chronic condition
Projected “Boomers” Health in 2030 • More than 6 of every 10 will be managing more than one chronic condition • 14 million (1 out of 4) will be living with diabetes • >21 million (1 out of 3) will be considered obese • Their health care will cost Medicare 34% more than others • 26 million (1 out of 2) will have arthritis • Knee replacement surgeries will increase 800% by 2030 Source:“ When I’m 64: How Boomers Will Change Health Care ”, American Hospital Association, May 2007