Challenges and Opportunities: Lessons from the STAAR Initiative

1. These presenters have nothing to disclose May 29, 2013 Challenges and Opportunities: Lessons from the STAAR Initiative

2. Disclosures The presenters have no conflicts of interest to declare and do not have any relevant financial relationships with any commercial interests

3. Objective Describe factors that influence the implementation of front-line quality efforts

4. We Will: • Apply lessons from the four-year STAAR Initiative • Identify factors that enable and constrain the implementation of front-line improvements • Hear how the Portage Health System sought to transform care transitions within and across care settings

6. IHI’s Approach Alternative or Supplemental Care for High-Risk Patients Transition to Community Care Settings Transition from Hospital to Home or other Care Setting Patient and Family Engagement Cross-Continuum Team Collaboration

7. Lessons from STAAR: Challenges • Multiple competing demands and improvement fatigue • Weaker evidence based for scalable and sustainable solutions • Lack of financial alignment • EMR and HIT challenges to obtain and input data that is actionable for improvement

8. Portage health 36 Bed Acute Care Hospital Located in the Upper Peninsula Approximately 700 employees Many Primary Care Providers in the community are Portage Health employees Most of our cross-continuum team is within Portage Health

9. History Began working with the STAAR initiative in 2009 The team was led by a social worker who also works as a discharge planning coordinator There were many accomplishments throughout their work: Warm handovers upon discharge Follow up appts made prior to discharge Whiteboards Post discharge phone calls made on all patients I was introduced to this initiative in Feb, 2012 At this point, the team meetings had fizzled out and needed a revival We had a team in place (internally), but many were not completely engaged due to competing demands The one item that we still needed to tackle was teach back, and that became our focus

10. Barriers Resources Time Staff *Multiple initiatives all competing for limited resources Limitations within our EMR

11. Factors that Accelerated Progress Support from Executive Leadership Appointing a Coordinator dedicated to this initiative Align initiatives where possible (example: PCMH) Getting the right people on your team Get the message out (reporting at QPS, 3 section meetings) Staff/Management engagement

12. How We got them engaged Trial and Error Depended on who I was working with *Inpatient Unit: teach back *Home Health: have their own pay for performance measures that can be improved by care transitions work *Outpatient Clinic: teach back is part of their PCMH criteria, initiative ties into PCMH model *Physicians: frequent reporting and requesting their feedback, saw progress being made, wanted to be involved with the SNF issues *Emergency Department: realized they missed out on valuable feedback from the SNFs when we invited them to our meeting *SNFs: Didn’t take much!

13. Engagement cont. Did not come easy at first- felt very slow moving Multiple factors going on simultaneously- Continually reporting out on progress made Talking to physicians, front line staff- getting feedback Trying to find that one issue that they identified with to hook them in Finally getting a project implemented (Risk Assessment)- started gaining momentum Coordinated a meeting with SNFs- everyone really started getting interested

14. Eventually evolved to where we are today: Opened communication lines with SNFs Staff are initiating work on their own without my lead Staff (including physicians) know that I am the “go to” person and seek me out to bring up issues that need work

15. Key Lessons Learned Don’t give up! Listen to staff- be non-threatening Be flexible Use executive leadership when needed Don’t focus too much on the numbers, but rather the great work that is being done

16. Lessons from STAAR: Opportunities • Change the mindset • Redefine the team • Remember to focus on what you are NOT going to do • Start with an n of 1 • Honor the expertise of the front-lines • Use data to identify, drive and sustain improvement • Celebrate the “wins” big and small

17. The Carrots • Community-based Care Transitions Program • Hospital Engagement Networks • Nursing Home Initiative • Care Coordination Benefits

18. Community-based Care Transitions Program • $500 million available over 5 years • Awarded to community based organizations (CBO’s) partnering with acute and post-acute care organizations to provide care transitions services to Medicare beneficiaries • CBO’s paid an all-inclusive rate once per eligible discharge within a 180 period • 102 awards granted thus far http://innovation.cms.gov/initiatives/CCTP/

19. Hospital Engagement Networks • 26 contracts awarded nationwide for a total of $218 million • Awardees include hospital systems, hospital associations, and national organizations such as the American Hospital Association and the Joint Commission • HEN’s must support hospitals in efforts to reduce avoidable rehospitalizations by 20% and a series of 9 Hospital Acquired Conditions by 40% by the end of 2013 • $10 million also awarded for content development, beneficiary engagement and evaluation http://partnershipforpatients.cms.gov/about-the-partnership/hospital-engagement-networks/thehospitalengagementnetworks.html

20. Nursing Home Initiative • 7 organizations (“enhanced care & coordination providers”) partnering with nursing facilities to reduce avoidable rehospitalization rates • Focus is on residents enrolled in Medicare and Medicaid http://innovation.cms.gov/initiatives/rahnfr/

21. Care Coordination Benefit CMS 2013 Physician Fee Schedule includes two new CPT codes for Transitions Care Management (99495 and 99496) http://www.hospitalmedicine.org/AM/Images/Advocacy_Image/pdf/FAQ-CPT_Transitional_Care_Management_Final.pdf

22. Questions?

23. Contact Information Heather Gagnon, RN Quality Management Specialist Portage Health (e) hgagnon@portagehealth.org (p) 906.483.1497 Saranya Loehrer, MD, MPH Director Institute for Healthcare Improvement (e) sloehrer@ihi.org (p) 617.301.4832