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What are the objectives of the program?
Improved care coordination, Improved health outcomes, Reduced readmissions, Reduced avoidable utilization, Reduced spending
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Please provide a brief description of the program:
JHHCG Home Health Services aims to reduce the re-hospitalization rate for patients with CHF by two percentage points, as well as reduce the overall 60-Day Hospitalization rate by two percentage points in CY17 in comparison to CY16. Reducing hospitalizations has been a focus for over 4 years. While our agency has had much success in reducing acute care hospitalizations during this time period we are experiencing a stabilization in that downward trend. There is a great deal of pressure to improve our hospitalization rate now with the introduction of the CMS Quality of Care Star Rating and Home Health Value-Based Purchasing programs threatening our bottom line. Of the nearly 18% of our patients being hospitalized each month, 37% of them have a diagnosis involving their circulatory system (CHF, hypertension). JHHCG HHS aims to: Develop and ensure the implementation of best practices for managing CHF patients to improve patient outcomes & experience. Reduce and/or eliminate unnecessary variation in the process & approach to providing home care to patients with CHF.
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Is this program operated as part of HSCRC's Care Redesign Amendment?
No
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Which Center for Medicare and Medicaid Innovation (CMMI) category does (or would) the program fall under? Choose the best match.
Initiatives_to_Speed_the_Adoption_of_Best_Practices
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What are the major components of the program?
Care coordination/management, Patient assessment tools, Patient education/coaching/self-management, Multidisciplinary care teams, Patient care plans, Telehealth/connected patient technologies
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What types of organizations participate in the program?
Physicians office (primary care), Hospital/health system, Skilled nursing facility, Home health care, Non-clinical setting
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Which population(s) does the program target?
Medicare/older adults, Medicaid, Dual eligibles (Medicare-Medicaid enrollees)
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How many patients have participated in the program to date?
Approximately 475 CHF patients have been on service with JHHCG Home Health Services since the program's inception in January 2017.
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In what Maryland jurisdictions do participating patients reside?
Anne Arundel, Baltimore, Baltimore City, Harford, Howard
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Briefly describe the staffing resources required to operate the program:
Three hours per month of staff time was dedicated to this effort. The individuals involved included: Project Champion (Senior Director, Home Health Services): Kim Carl Project Leads (Clinical Managers): Tammy Taylor and Mike Markowski Project Facilitators (Quality Safety Managers): Karen Clayton and Melissa Higdon Project Team (Field Clinicians): Frances Bedford, Carla Bostic, Amelia Clarkson, Susie Crisp, Fil Delasalas, Sun Gin, Pat Grimes, Amanda Kohli, Stamatia Kokkinakos, Melissa Lantz-Garnish, Liddy Logan, Amanda Mitchell, Tammy Siedlecki, Robyn Smith, Stefanie Soler, Judy Umansky and Denise Wagner.
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Briefly describe the key initial steps to implementation:
A multi-disciplinary PI team was assembled to develop a standardized CHF clinical pathway Every CHF patient is evaluated for Remote Patient Monitoring (RPM) If RPM is not accepted/contraindicated, Johns Hopkins Home Care Group Home Health Services supplements the care plan with a Home Health Aide (HHA) for vital signs and weight on a routine basis Strongly encourage every CHF patient to accept Physical Therapy evaluation Evidence shows CHF patients benefit from PT Ensure at least one skilled discipline visit occurs each week Increase touch points thru the use of phone assessments
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Are incentive payments to health care providers part of the program?
False
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What are/were the expected results in improved outcomes, population health, and cost savings?
Improving the health of patients with a diagnosis involving their circulatory system (CHF, hypertension) and thereby reducing hospitalizations and saving costs.
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Have expected results for improving outcomes and population health been met?
Yes, expected results were achieved
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Please briefly explain your answer to Question 25, and describe any results for improved population health achieved to date:
Reducing hospitalizations has been a focus of Johns Hopkins Home Care Group (JHHCG) for over 4 years. While our agency has had much success in reducing acute care hospitalizations during this time period we are experiencing a stabilization in that downward trend. There is a great deal of pressure to improve our hospitalization rate now with the introduction of the CMS Quality of Care Star Rating and Home Health Value-Based Purchasing programs, as hospitalization rates are one metric contributing to eligibility for an incentive payment or penalty payment. Of the nearly 18% of our patients being hospitalized each month, 37% of them have a diagnosis involving their circulatory system (CHF, hypertension). JHHCG Home Health Services, aimed to reduced CHF related hospitalizations by 2 percentage points in calendar year 2017. In CY16, the CHF 60 day hospitalization rate was 33.46%. For CY17, the CHF 60 day hospitalization rate was 22.62%. In CY16, JHHCG was in the 90th percentile for Home Health Value Based Purchasing, which granted us a 1.57% incentive payment from CMS. In CY17, JHHCG is on track for being in the 90th percentile for Home Health Value Based Purchasing, which would make us eligible for an incentive payment up to 5% depending on the performance of other home health agencies in the state of Maryland. Final results for CY17 performance will be reported by CMS in August 2018. , Yes, expected results were achieved
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Please briefly explain your answer to Question 27, and describe any cost savings results achieved to date:
Have not completed full evaluation of the program currently attaining access to cost data
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Please provide URLs to any published evidence (e.g., peer-reviewed literature, white papers, etc.)
American Heart Association. 2014. Smoking and cardiovascular disease. Allen, L., Stevenson, L. W., Grady, K. L., Goldstein, N. E., Matlock, D. D., Arnold, R. M. Spertus, J. A. (2012). Decision making in advanced heart failure: A scientific statement from the American Heart Association. Circulation, 125(15), 1928-1952. Artinian, N. T., Fletcher, G. F., Mozaffarian, D., Kris-Etherton, P. (2010). Interventions to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults: A scientific statement from the American Heart Association. Circulation, 122(4), 406-441. Baker, L. C., Macaulay, D. S., Sorg, R. A., Diener, M. D., Johnson, S. J., & Birnbaum, H. G. (2013). Effects of Care Management and Telehealth: A Longitudinal Analysis Using Medicare Data. Journal of the American Geriatrics Society, 61(9), 1560-7. Baldonado, A., Rodriguez, L., Renfro, D., Sheridan, S. B., McElrath, M., & Chardos, J. (2013). A home telehealth heart failure management program for veterans through care transitions. Dimensions of Critical Care Nursing, 32(4), 162-5. Krames Guide. 2017. Living Well with Heart Failure. Maxim, A. (2017). Home Health Conditions of Participation: Charting a Course for Your Success. Kinnser Free Webinar Series: Home Health. Step-by-Step Guide. 2016. Patient Guide to Congestive Heart Failure. Visiting Nurses Association of America (VNAA). 2017. Heart Failure Blueprint. http://vnaablueprint.org/heart-failure/heart-failure.html