Through an Administration for Community Living (ACL) No Wrong Door (NWD) Business Case grant, Indiana demonstrated that 1) person-centered counselors (PCCs) help individuals who need long term services and supports (LTSS) access home and community-based services (HCBS) and avoid institutional care in a nursing facility; and that 2) care transition coaches can help Indiana Aged and Disabled Medicaid Waiver (ADW) participants avoid hospital readmissions and associated potential negative impacts on functional status, thus improving their ability to remain in the community.

Findings: 

Indiana tracked healthcare utilization data on individuals from two counties (Allen County and Marion County). Results demonstrated that less than 1% of ADW participants that received PCC resided in a nursing facility at 90 days. Additionally, ADW participants that received care transition coaching had a 43% reduction in 30-day hospital readmission rate compared to ADW participants discharged from the  hospital to home in Allen County over the same time period.

Indiana disseminated business case results and technical assistance to the Aging and Disability Resource Centers (ADRCs) that led to expanded care coordination between ADRCs and hospitals. Based on project results, Indiana developed and implemented a statewide protocol for waiver care managers to provide and track care transitions support to Medicaid HCBS ADW participants. See the pitch deck they used to make the case to hospitals here (also attached to this post). The pitch deck for hospitals includes Indiana NWD system goals, project outcomes, readmission data, and a sample flyer for ADRCs to provide hospitals to explain the program.

Indiana was also successful in streamlining a referral process from hospitals to ADRCs for PCC and care transition support. A Standard of Practice/Care Transition Protocol/Process Flow was developed and implemented to guide ADW care managers in the provision and tracking of care transitions support to ADW participants. The process flow describes how waiver care managers and hospitals will coordinate together, including the sharing of emergency room, hospital, or skilled nursing facility (SNF) admission and discharge data. It also includes procedures for actions and instructions on recording the services into the tracking system, consistent with The National Committee for Quality Assurance’s standards for NCQA Accreditation of Case Management for LTSS. See the Standard of Practice/Care Transition Process Flow here (also attached to this post).

Indiana reported five critical components of engaging hospitals as partners.

1. Emphasis on social determinants of health (SDOH): Hospitals are very focused on SDOH and the impact on healthcare utilization and quality outcomes.  ADRCs were successful in helping hospitals understand how they serve as a critical link to SDOH.
2. Common populations of interest and expertise in serving these individuals: ADRCs successfully conveyed to hospitals that they serve populations that are a priority for hospitals.
3. ADRC point person identified for the hospital: Having a specified hospital liaison or point person can improve and streamline communication between the ADRC and the hospital.
4. Capitalizing on success: ADRCs promoted the 43% reduction in re-admission rate achieved through their business case pilot program, as mentioned above.
5. Standardized resources for business case launch: While local ADRCs could choose which hospitals to engage, the state made available a standard pitch deck and facilitated an initial meeting with hospital leadership to help kickoff the collaboration.

New Partnerships with Dual Eligible Special Needs Plans (D-SNPs):

Tracking outcomes on PCC and care transitions helped build awareness of the value of these NWD programs at both the state and local level. Project results facilitated new collaborations between ADRCs and Medicare Advantage D-SNPs, resulting in enhanced care coordination for ADW participants experiencing a hospital or SNF admission. A critical lesson learned was the importance of objective state and local data (and the systems to collect, compile and interpret the data). This data served the ADRC well when attempting to engage with hospitals and health systems to enhance care coordination opportunities and receive new referrals. The orientation for ADRCs and D-SNP slide deck provides an overview of the program, including an explanation of the target population, a definition of D-SNPs, procedures for hospital-to-home transitions, and the program’s outcomes (attached to this post). This is an excellent example of how states can facilitate D-SNP collaboration with local ADRCs, including sharing of information on hospital and skilled nursing facility admissions for at least one group of high-risk D-SNP beneficiaries.