South Carolina Business Coalition on Health 6 th Annual Meeting May 8, 2012

1. South Carolina Care Transitions CollaborativeA South Carolina Partnership for Health InitiativeLaura Long, MD, MPHVice PresidentClinical Innovation and Population Health South Carolina Business Coalition on Health 6th Annual Meeting May 8, 2012

2. Goals for Today • Readmissions: Scope of the problem • South Carolina Partnership for Health • Review of common models for improving care transitions • Care Transitions Program • Project Boost • Project RED • STAAR • Hospital to Home • South Carolina Care Transitions Collaborative

3. Readmissions: The Problem • 18-20% of Medicare patients are readmitted within 30 days of discharge accounting for 15-18 billion in annual spend • 75% of these readmissions are potentially preventable • 33% of Medicare patients are readmitted within 90 days of discharge • Seven diagnoses make up 30% of Medicare readmissions Heart failure Myocardial infarction COPD CABG Pneumonia PTCA Other circulatory conditions • End stage renal disease has a 31.6% readmission rate • Readmissions have a 0.6 longer LOS than other patients in the same DRG Medicare Payment Advisory Commission (MedPac)

4. Readmission Rates/30 Days by Insurance Type Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, 2007

5. Readmission Rates/30 Days by Disease State Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, 2007

6. South Carolina Readmission Data • 519,846 hospitalizations in 2011 • 60,554 readmissions/30 days • 9.3% same hospital readmission rate, all patients • 11.7% any hospital readmission rate, all patients • 6,395 Medicare hospitalizations for ambulatory sensitive conditions. 15.9% were readmissions within 30 days. • Variations exists among counties with readmission rates/30 days ranging from 14.1% to 16.2%

7. Preventable Causes of Readmissions • Poor transitions between different providers and care settings • Poor quality of care • Poor care coordination at discharge • Lack of timely follow up with primary source of care following discharge • Lack of patient engagement/understanding of treatment care plan • Inability of patient and/or caregiver to provide adequate self management • Any combination of the above

8. Aligning with Federal Government Initiatives • CMS has multiple initiatives to encourage reduction of avoidable readmissions including: • The National Patient Safety Initiative-Saving Lives, Saving Money • A partnership between Medicare, Medicaid and private insurers to reduce patient injury and readmissions • Value-Based Purchasing • A 2012 health reform initiative using financial incentives to reduce avoidable readmissions for heart failure, heart attack and pneumonia • Care Transitions Program • Programs through the Quality Improvement Organizations to improve care coordination and reduce readmissions • Transparency Initiatives • Public reporting of 30 day risk standardized readmission rates for heart failure, heart attack and pneumonia.

9. South Carolina Partnership for Health • A unique collaboration of three local organizations whose missions strongly align with improving the competitiveness of the state through improving the health of South Carolinians.

10. South Carolina Partnership for Health Includes leadership by individuals at the highest levels in each of the founding organizations Jim Deyling, BlueCross President, is Chairman. Thornton Kirby, S.C. Hospital Association President, is Secretary. Jay Moskowitz, Health Sciences South Carolina President and CEO, is Treasurer Projects chosen based on ability to achieve “The Triple Aim” South Carolina can leverage the unique collaborative research base established through Health Sciences to validate projects undertaken by the Partnership First project targets reducing preventable readmissions for heart failure, heart attacks and pneumonia 10

11. The Triple Aim

12. Payers and Providers are Willing to Collaborate on Multiple LevelsWorking together, we can bend the cost curve Payment Model • Incentives aligned to encourage quality and measurable outcomes Care Delivery Redesign • Reconfiguration of care delivery to drive greater coordination, integration and cost consciousness Consumer Engagement and Incentives • Consumer incentives/ engagement initiatives to align consumer decisions with healthcare decisions

13. Models to Reduce Preventable Readmissions

14. Care Transitions Program • 4 week program developed by Dr. Eric Coleman. Focuses on patient self management and skill development using a transition coach. (www.caretransitions.org) • Specific tools include a personal health record and a medication discrepancy tool. (www.caretransitions.org/providertools.asp) • Developed the 15 item Care Transitions Measure(CTM) to assess quality of care transitions and patient centeredness • The CTM is designed for standardization and public reporting (www.caretransitions.org/CTMmain.asp)

15. Project BOOST(Better Outcomes for Older Adults through Safe Transitions) • Developed by the Society of Hospital Medicine • Provides mentoring, patient and family education resources, webinars and tools for improved flow of information between in and outpatient providers • Online resource room provides implementation guide, toolkits, etc at (www.hospitalmedicine.org/resourceroomredesign/RRcaretransitions/CThome/cfm)

16. Project RED(Re-Engineered Discharge) • Developed by a research group at Boston University Medical Center to promote safety and reduce readmission rates • The Project RED Intervention includes 11 discrete evidence based interventions which have been proven to reduce readmissions and improve patient satisfaction • The Project RED Checklist includes education on diagnosis, confirmation of the medication plan, and provision of a written discharge plan(www.bu.edu/fammed/projectred/index.html)

17. STAAR(State Action on Avoidable RE-hospitalizations) • A multi-state, multi-stakeholder initiative launched by IHI in 2009 • Goal is to reduce hospitalizations by working across organizational boundaries and by engaging payers, state and national stakeholders, patients and families, and caregivers • www.IHI.org/IHI/Programs/StrategicInitiatives/STateactiononavoidablerehospitalizationsSTAAR.htm

18. Hospital to Home (H2H): Excellence in Transitions • An initiative of the American College of Cardiology and the Institute of Healthcare Improvement • Focus is to reduce readmission and improve care transitions for cardiovascular patients • Specifically, by Dec 2012, reduce all cause readmission rates by 20%: • Heart failure • Heart attack • www.h2hquality.org/

19. Major Strategies to Reduce Avoidable Readmissions

20. Readmission rates for different conditions • By diagnosis and significant co-morbidities; correlate with severity • Readmission rates by practitioners • Look for patterns or anything unexpected • Readmission rates by readmission source • Look for rates by source(home, nursing home etc) and target most common source • Readmission rates by different time frames • 7,30,60 and 90 days. Shorter time frames suggest problems with hospital quality of care. Longer time frames suggest problems with follow up or patient’s understanding of self care.

21. Focus on specific patient populations • Conditions or patient populations with high readmission rates • Focus on stages of the care delivery process • Break down by reasons for readmission • Focus on hospital’s organizational strengths • Develop interventions starting with existing resources • Focus on hospital’s priority areas and current quality improvement initiatives • Align current initiatives and mandates

22. Getting the health care team on board to address the issue • Need active participation of health care providers. Must align hospital and physician incentives. Multi-disciplinary core team is helpful • Developing community connections to eliminate barriers to successful care transitions • Build partnerships with public/private community resources and providers to build continuity of care network including non-medical • Engage patients, families and caregivers • Consider patient advisory councils or advocacy groups to increase input. Consider teach back techniques to improve patient knowledge

23. Readmission rates for different conditions • Readmission rates by practitioner • Readmission rates by readmission source • Readmission rates over different time frames

24. South Carolina Care Transition Collaborative • Mission Statement: Provide South Carolina health organizations with the tools and resources that will allow patients to successfully transition from the hospital setting through the continuum of care. • Values: • Communication • Continuity • Commitment • Centered around patients and family

25. Program Components • Care transitions standardization, data collection, and benchmarking • Outcomes data (SC ORS) • Process measures (Local sites) • Skills training • Society for Hospital Medicine Training Sessions, Webinars • SC Collaborative generated content • Collaborative learning • Participation in Project BOOST community • Collaborative teleconferences and face to face meetings

26. Program Structure • Face to face conferences • Initial kick-off training • Annual collaborative meetings • Regional Meeting- Biannually • Live webinars • Pre-training session • 2 Webinars (topics TBA by curriculum committee) • Monthly collaborative calls • Content delivery • Review data collection • Highlight local best practices • Group discussion

27. Program Metrics: Hospital Engagement Contract • By the end of 2013, preventable complications during a transition from one care setting to another will decrease such that all hospital readmissions will be reduced by 20% compared to 2010. • Care Transition document completed and given to caregiver • All cause 30-day unadjusted readmission to same hospital • All cause 30-day Readmission (CS risk adjustment) • All cause OBS/ED visit within 30 days of Inpatient discharge • All cause unplanned readmission to any hospital within 30 days

28. Program Metrics: Proposed Measures for Collaborative • Length of Stay • Readmission Rate • Discharge Summary • Patient Satisfaction • Patient and Caregiver Understanding (CTM3)

29. Potential Webinar Topics • Project BOOST Overview- Introduction to BOOST resources • Process Mapping • Patient Education/Teach-Back • CTI intervention overview-emphasis on patient coaching, red flags

30. Potential Collaborative Content Topics • Patient Education (Teach-back and/or other concepts and techniques) • Generating high-quality discharge summaries • Discharge appointment scheduling • The 411 on discharge telephone calls • Community care transitions resources • Healthcare policy issues/update • Basics of chart abstraction/small-scale data gathering for QI • Collaborative readmission risk assessment • ED / Inpatient collaboration to avoid admissions/readmissions • Engaging community primary care providers • Successful care transitions strategies for heart failure patients • Successful care transitions strategies for AMI patients • Palliative Care

31. Collaborative Timeline 2012 • April, 2011- Announcement by Maureen Bisognano, IHI regarding formation of SC Partnership for Health at Patient Safety Symposium • April, 2012- Announcement by Maureen Bisognano, IHI, regarding launch and timeline of SC Care Transition Collaborative at Patient Safety Symposium • May 1, 2012- Contact hospitals identifying champions and teams • June 30, 2012-Webinar Reviewing current Data and discussing data collection and team participation • July 15th- Webinar-Root cause analysis of readmission / Process Mapping • August 2012- Decreasing Readmission Kick-off Training Key note speaker- BOOST/ Eric Coleman • September 2012- Webinar - How to use BOOST website and access portal • October 2012- Webinar- The 411 on Discharge phone calls • November 2012- Telephone conference-Medication Errors • December 2012- Telephone Conference---Palliative Care/ End of Life

32. Collaborative Timeline 2013 • January 2013- Regional meetings • February 2013- Webinar: Patient Education: Redesigning the process from Hospital to home • March 2013- Webinar: Where does the discharge paper work go?? • April 2013- Annual Symposium—Care Transitions- Community resources and involvement • May 2013- Telephone Conference-Enhanced Assessment of Post Discharge Needs- • June 2013- Reevaluation based on previous data points

33. Care Transitions Improvement Advisor • The Care Transitions Improvement Advisor will primarily focus on project management related to care transitions with defined groups of hospitals and other healthcare providers in South Carolina as set forth by the goals and strategies of the SC Partnership for Health Board. • Key responsibilities of this role include; • Strategic organizational support of the care transitions learning collaborative • Assessing and supporting the participating facilities’ ability to perform against key care transitions quality/performance goals • Providing consultation and coaching for relevant staff from these facilities • Supporting ongoing staff engagement with their action plans. • Serving as liaison between the SCPH Board and any individuals and organizations that are conducting care transition activities on behalf of SCPH.

34. References

35. Questions