AGS 2012 - Sat: Effective Care Transitions

Effective Care Transitions: the Call for Geriatric Leadership

Moderator: Sally L. Brooks, MD
This session will create the “business case" for Geriatric Medicine and Inter-disciplinary Teams by targeting resources in improving Care Transitions and decreasing avoidable re-hospitalizations. The call for action is now as Hospital and Healthcare Systems respond to the Affordable Care Act and Payers and Physician leaders prepare for an ACO future. Our Society membership created the foundation for these principles of right care, right time, and right place.

Successful Hospital-to-Home Care Management Programs for CHF Patients
Michael W. Rich, MD, AGSF, Washington University School of Medicine

• Summary and Conclusions
• Older adults account for the majority of hospitalizations for heart failure, MI, and pneumonia
• Despite multiple studies documenting the efficacy of multidisciplinary interventions for reducing readmissions, such interventions remain largely under-utilized and readmission rates remain unacceptably high
• Successful interventions must be patient-centered rather than disease-centered, and must include direct in-person interactions with patients and caregivers
• Given the demographics of these conditions (as well as many others) and the expertise of geriatricians in providing patient-centered multidisciplinary care, geriatricians are ideally positioned to take a leadership role in the design and implementation of effective care-transition strategies

The Urgency for Geriatric Care Leadership Given the Current Healthcare Trends and Environment
Sally L. Brooks, MD, AGSF, Kindred Healthcare

Building a Practice Model with Effective Care Transition Results
Jerome Wilborn, MD, IPC

• Understand ways that geriatrics healthcare professionals can offer added value to hospitals and health systems in our current payment environment, through improving transitional care
• Review a “systems” based approach to care coordination
• Discuss the business case for effective care transitions from community perspective

A Business Case for a Replicable Care Transitions Model
Kyle R. Allen, DO, AGSF, Riverside Health System

Slides
#8 Re-hospitalization Rates for Short-stay Nursing Facility Patients, by State
#9 Hospitalizations: Contributing Factors
#11 SNF Vs Hospital E/M Code Payments - 2010
#17 Early Readmission of Elderly Patients with Congestive Heart Failure
#32 Mor, et. al, using merged claims data, found that 23.5% of Medicare beneficiaries discharged from the hospital to a skilled nursing facility (SNF) were directly readmitted within 30 days at a cost to Medicare of $4.34 billion in 2006.