Keeping Patients Healthy and Safe After Discharge

1. Keeping Patients Healthy and Safe After Discharge Hospital NamePresenter Title

2. Because there really isNo Place Like Home

3. (Hospital Name) A committed participant in the No Place Like Home Campaign

4. The No Place Like Home Campaign Works across the continuum of care to reduce avoidable hospital readmissions in Arizona. Seeks commitment from all hospitals in Arizona. Engages other care providers in our community who work with patients post-discharge.

5. Statewide Triple Aim Goals • Population Health • Prevent 4,000 avoidable readmissions within 30 days of discharge. • Reduce the overall readmission rate by 20 percent from the 2010 baseline by June 30, 2013. • Care Experience • Help patients and their families spend 16,000 more nights in their own beds instead of in the hospital. • Improve the responses to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions related to hospital discharge. • Affordability of Care • Save an estimated $30 million for Medicare patients (with similar savings for commercially insured patients).

6. Broad Community Support Campaign Supporting Partners’ Role Provide resources and support to develop and implement specific aspects of the Campaign. • Health Services Advisory Group, Inc., (HSAG) • HSAG will manage the day-to-day operational aspects of the Campaign by providing staffing and resources to support participants. • Arizona Partnership Implementing Patient Safety (APIPS) • Arizona Department of Health Services (ADHS) • Arizona Hospital and Healthcare Association (AzHHA)

7. Broad Community Support (cont’d) Campaign Community Partners’ Role Endorse and actively support the Campaign. • These partners represent a growing list of providers, state health agencies, health plans, home health agencies, nursing homes, patient advocacy groups, and other community organizations.

8. The Right Thing to Do Most of us have likely had a loved one who returned to the hospital soon after discharge. This causes anxiety, unrest, and burden on patients and their families. Patients and their families prefer to remain in their homes and be surrounded by the things that bring them comfort. We have a great opportunity to prevent avoidable readmissions and ensure our loved ones enjoy better health at home.

9. Our Hospitals Need to Improve • Nearly one in five Medicare patients discharged from hospitals in Arizona is readmitted within 30 days. • Many of these readmissions are avoidable. • 13 states had lower readmissions rates than Arizona—we can do better!

10. A Care Delivery System Approach Many hospital readmissions are the result of a fragmented healthcare system. Addressing this fragmentation across the care continuum will reduce avoidable readmissions and improve overall care delivery.

11. Helps Make Healthcare Affordable The estimated average cost of a readmission ranges from $8,000 to $13,000. We have an opportunity to save tens of millions of dollars in Arizona—helping more people afford healthcare. National Priorities Partnership Compact Action Brief, “Preventing Hospital Readmissions: A $25 Billion Opportunity.”

12. Potential Financial Penalties • Hospitals with higher than expected risk-adjusted, 30-day readmission performance can incur penalties up to 1 percent of their total inpatient Medicare payments beginning in fiscal year 2013 (i.e., starting October 1, 2012). The penalty increases by 1 percent each year after that, before being capped at 3 percent for fiscal year 2015. • The Centers for Medicare & Medicaid Services (CMS) will evaluate the prior year’s readmissions data, effectively starting the clock ticking on October 1, 2011.

13. Potential Financial Gains The Affordable Care Act creates a hospital readmissions reduction program to help hospitals smooth transitions for patients and reward hospitals that are successful in reducing avoidable readmissions.

14. Timing Is Right • Key focus of CMS and its projects • Quality Improvement Organizations’ Care Transition Project (seeks to improve the patient’s continuum of care after hospital discharge and reduce avoidable hospital readmissions) • Partnerships for Patients Program • Community-Based Care Transitions Program The Campaign can make Arizona a national leader by supporting these federal initiatives.

15. No Place Like Home Goals We are committed to reduce our overall readmissions by 20 percent from our 2010 baseline. This equates to (Insert your hospital’s specific reduction goal—XX) fewer readmissions by June 30, 2013. This means reducing readmissions by X per month through the end of next year.

16. What We’ve Committed To • Meeting our specific readmission reduction goals. • Conducting an organizational assessment of our readmissions. • Committing to improve performance in key areas identified through the organizational assessment. • Sharing our organizational assessment results and readmissions data with HSAG. • Agreeing to publicly disclose participation in the No Place Like Home Campaign to show our support.

17. Support for Our Hospital A resource consultant is available to us throughout the Campaign. This consultant will assist us in identifying the areas to focus on that have the greatest opportunity for reducing readmissions.

18. Support for Our Hospital (cont’d) Best-practice toolkits Face-to-face sessions Webinars Conference calls Peer coaching Data reporting “Innovator” approach

19. Support for Our Hospital (cont’d) • Technical assistance on developing an action plan to reduce avoidable readmissions • Access to recognized experts in the five focus areas • Comprehensive discharge planning, medication management, patient and family engagement, transition care support, transition communications • Opportunities to network and collaborate with other hospital teams

20. Progress Will Be Measured We will collect data on a variety of process measures as we do improvement work. We will routinely assess admission and readmission rates.

21. Campaign Rollout • Our initiative starts now. • Our hospital No Place Like Home Team has been formed to lead this effort. • List team lead, physician champion, and other team players. • Targeted hospital engagement begins January/February 2012. • Improvement and monitoring work continues through June 30, 2013.

22. We Need Everyone’s Support Our active participation in the No Place Like Home Campaign to achieve our goals is: Right for our hospital. Right for our community. Right for our state. Most importantly, right for our patients and loved ones.

23. Thank you for doing your part to keep everyone healthy and safe after discharge.

24. For More Information (Add your key internal No Place Like Home Campaign contacts’ information here) name name www.noplacelikehomeaz.com

25. This material was adapted by Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Arizona, under contract with the Centers for Medicare & Medicaid Services, an agency of the U. S. Department of Health and Human Services, from material originally prepared by the RARE Campaign. The contents presented do not necessarily reflect CMS policy. Publication No. AZ-10SOW-8.0-012312-01