It Takes a Village Community-Based Care Transitions Improvement

1. It Takes a VillageCommunity-Based Care Transitions Improvement Jane Brock, MD, MSPH Colorado Foundation for Medical Care December 8, 2011 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 • Introduction: Common Pool Resource Management • Lessons from the Care Transitions Theme • Drivers of Readmission, or why reducing hospital readmissions is a community engagement project • Developing a community project in care transitions • ‘Collective Impact’ as a framework for managing the project • A collection of insights

4. The Tragedy of the Commons “The… problem has no technical solution; it requires a fundamental extension of morality.” Garret Hardin Science, New Series, Vol. 162 (3859): 1243-8, 1968.

6. “Polycentric Local Management”

7. What does this have to do with healthcare?

8. What does this have to do with healthcare?

9. What does this have to do with healthcare? • A history of collective action to serve a visible group of people… • Common mission/vision • Local control • Place Identity

10. http://content.healthaffairs.org/content/29/9/1678.full.html

11. Common-Pool Resource Management http://en.wikipedia.org/wiki/Common-pool_resource

12. can it be replicated?Lessons from the care transitions Theme The real world as opposed to ‘clearly defined borders’

13. 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

14. Results

15. It’s not a hospital project

16. It’s a Community Problem HHA SNF

17. HHA SNF

18. 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

19. Social Network Analytic techniques for displaying the provider network

20. Developing a community project to reduce hospital readmissions

21. RCA Drivers • Data • Medical record review • Process assessment

22. 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

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

24. 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

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

26. Intervention Packages

27. Building Community Infrastructure

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

29. 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

30. I think it’s an elephant!

31. Backbone ‘agency’ • Common agenda • Common measures • Structured collaboration

32. 3 important things we learned:

33. 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 blahblah, blah blah. Any questions? 1. Patient activation trumps all

35. PATIENT ACTIVATION

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

37. 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 37

38. The PAM is very helpful to guide interventions

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

40. 3. Ask the community to help • “Brought to you by your Community Partners”

41. Community Organizing Techniques • Tie participation to values • Include personal narratives • Intentionally develop other leaders • Intentionally develop relationships • Develop flexible tactics

42. Examples

43. 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

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

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

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