It Takes a Village Community-Based Care Transitions Improvement

1. It Takes a VillageCommunity-Based Care Transitions Improvement Marian Boxer, RN Colorado Foundation for Medical Care February 22, 2012 This material was prepared by CFMC (PM-4010-031 CO 2011), the Medicare Quality Improvement Organization for Colorado, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

2. Objectives • Reducing Readmissions • 4 Important things we learned from the Care Transitions Theme • Where to start – Drivers and Settings • New /Current opportunities

4. A Variety of Opportunities Walkers: just starting to think about care transitions & reducing readmissions Community-Based Care Transitions Program (CCTP) QIO Support Joggers: currently involved in efforts to improve care transitions & reduce readmissions Marathoners: have a permanent structure in place to improve care transitions & reduce readmissions (Accountable Care Organizations)

5. 14 QIOs with 14 Target Communities • AL: Tuscaloosa • CO: Northwest Denver • FL: Miami • GA: Metro Atlanta East • IN: Evansville • LA: Baton Rouge • MI: Greater Lansing area • NE: Omaha • NJ: Southwestern NJ • NY: Upper capital • PA: Western PA • RI: Providence • TX: Harlingen HRR • WA: Whatcom county

6. Results

7. 1. It’s not a hospital project

8. It’s a Community Problem HHA SNF

9. Whyare people readmitted? Provider-Patient interface Unmanaged condition worsening Use of suboptimal medication regimens Return to an emergency department Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers No Community infrastructure for achieving common goals

10. CMS’ Table of Interventions Available at: www.cfmc.org/caretransitions

11. What’s he saying? I sure hope my wife is getting this.. No I’m good to go. Whatever you say is what we’ll do Doctor Blah blah blah, blah blah. Any questions? 2. Patient activation trumps all

13. PATIENT ACTIVATION

14. The CMS Discharge Planning Checklist • http://www.medicare.gov/Publications/Pubs/pdf/11376.pdf

15. The Patient Activation Measurewww.insigniahealth.com Sample Questions: #1: “When all is said and done, I am the person who is responsible for taking care of my health.” #12: “I am confident I can figure out solutions when new problems arise with my health” The PAM is scored on a 100 point continuum. Most patients score between 35 and 80 Knowledge, skills and confidence PATIENT ACTIVATION 15

16. The PAM is very helpful to guide interventions

17. 3. Local adaptation is inevitable • Adapt gold standard models • Do not adapt others’ adaptations

18. 4. Ask the community to help • “Brought to you by your Community Partners”

19. To Organize a Community.. • Tie participation to values • Include personal narratives • Develop flexible tactics

20. Identify the community Determine drivers of readmission Select intervention strategies Develop a ‘backbone’ agency Developing a community project to reduce hospital readmissions

21. I think it’s an elephant!

22. The ‘Zip Code Overlap’ Community Definition FFS Medicare beneficiaries living in zip codes of interest Target Population FFS beneficiaries discharged from hospitals of interest Community identity supports both social and economic sustainability

23. Social Network Analytic techniques for displaying the provider network

24. Building Community Infrastructure

25. RCA Drivers • Data • Medical record review • Process assessment • Drivers + Settings = Interventions

26. Intervention Packages

27. RCA Drivers • Data • Medical record review • Process assessment • Drivers + Settings = Interventions • Backbone ‘agency’

28. Examples

29. Provider Pair:HHAs and hospital pharmacy (NY) Butterfield, Stegel, Tartaglia. Improving outcomes through re-engineering care transitions: The New York Experience. Remington Report May/June 2010. MULTI-PROVIDER INTERVENTIONS

30. Lateral Cluster: 30day hospital readmission rate from SNFs in Harlingen http://www.cfmc.org/caretransitions/files/Feb24_2011%20Learning%20Session_FINAL.pdf

31. Partnering for coached discharges:Improved activation (Co) PATIENT ACTIVATION

32. The HHS National Quality Strategy(http://www.healthcare.gov/center/reports/quality03212011a.html) • Three-Part Aim • Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe. • Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care. • Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

33. Goals: • Improve quality of care for Medicare beneficiaries as they transition between healthcare settings • Reduce 30-day hospital readmission rates by 20% over 3 years for the nation • QIO technical assistance for all communities:

34. Zip Code Overlap • Social Network Display • Community coalition formation • Root cause analysis • Intervention selection • Statewide Learning Networks • Assistance with CCTP applications • Quarterly data feedback if not in CCTP Technical Assistance • CCTP payment (http://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313) • PAM, CTM, HCAHPS support • Collaborative Learning • Connection with best practices • Quarterly monitoring data • Shared savings • ? Other TA

36. The Care Transitions Toolkit: • Getting Started • Participants • Community Engagement • Root Cause Analysis • Interventions • Measurement http://www.cfmc.org/caretransitions/toolkit.htm

37. Care Transitions Statewide Learning in Action Network Care Transitions Learning in Action Network  Quarterly Statewide sessions (3 calls & 1 in-person meeting) Mechanism by which large scale improvement is fostered, studied, adapted and rapidly spread regardless of the change methodology, tools, or time-bounded initiative used to achieve the aim Action oriented Real time learning/problem solving (Community Development) Transparent, flexible, interchangeable, purposeful

38. Community-Based Care Transitions Program:ACA Section 3026 • To pay for improved transitions of care for Mcare beneficiaries from the inpatient hospital setting to home or other care settings • Improve quality of care • Reduce readmissions for high risk beneficiaries • Document measureable savings to the Medicare program $500 Million

40. “It’s clear that somebody has to do something and it’s incredibly pathetic that it has to be us” Jerry Garcia