It Takes a Village: Community Engagement for Care Transitions

1. It Takes A Village: Community Engagement across the Health Care Continuum to Improve Care Transitions & Reduce Readmissions Alicia Goroski, MPH Colorado Foundation for Medical Care Integrating Care for Populations and Communities National Coordinating Center www.cfmc.org/integratingcare This material was prepared by CFMC, 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. PM-4010-035 2013

2. Objectives for Today’s Session Participants will: • Hear how a community-based approach to reducing readmissions is effective • Engage, motivate and sustain the work • National strategies and best practices • Determine how to incorporate community organizing strategies into readmissions reduction work • Why the solution to readmissions is community collective action and organizing • Why the solution to community action is you

3. Content Development • 8th SOW: • Transitions of Care Pilot • VALUE • 9th SOW • Care Transitions Theme • 10thSOW • Integrating Care for Populations & Communities • Community-Based Care Transitions Program

4. It Worked!! http://jama.jamanetwork.com/article.aspx?articleid=1558278

5. 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. Interim Quarterly Results

7. Numerator and Denominator Quarterly

8. Rehospitalization Trends, Intervention and Comparison Communities -5.7% (p<.001) -2.1% (p=.08) P=.03 (difference)

9. Hospitalization Trends, Intervention and Comparison Communities -5.7% (p<.001) -3.1% (p<.001) P=.01 (difference)

10. Statistical process control • Assesses variation in an outcome presumed to be related to system functioning • A change worth investigating: • Reduced variation (increased control) • Significant change in the value of the outcome Process control limits = 3sd from the mean variation during ‘baseline’ ‘Significant’:8 points in a row above/below the mean with at least one point in the ‘during intervention’ time period OR A single point above/below the process control limit in the ‘during intervention’ time period

11. Community Results

12. Control Charts – an innovative way to measure progress in healthcare

14. The Improvement continues….

15. What’s important about this publication? • Intervention communities avoided twice as many rehospitalizations (1 hospitalization for every 1000 Medicare beneficiaries) and hospitalizations (5 for every 1000 beneficiaries) as comparison communities • Improvement for whole communities is a promising strategy • Providers engaged based on relevance • QIOs in the role of convener/supporter • Included community and social services • Unadjusted geographic population data allows easy data display/sharing

16. WhatElse was Important? • Allowing flexibility leverages local resources/context • Shewhart control charts published in a major peer-reviewed journal • Rehospitalizations/1000 and hospitalizations/1000 metrics proved useful for improvement work

17. Collective Impact as a framework • Why the solution to readmissions (care transitions quality improvement) is community collective action • Why the solution to community collective action is you • Within your ‘industry’ • Within a greater community Collective Impact. Stanford Social Innovation Review, Winter 2011. http://www.ssireview.org/pdf/2011_WI_Feature_Kania.pdf

18. 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.

19. “Polycentric Local Management”

20. What does this have to do with healthcare?

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

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

23. Readmissions - not just a hospital problem

24. It’s a Community Problem HHA SNF

25. 5 conditions of collective success • Common agenda • Standard measurement system • Mutually reinforcing activities • Continuous communication • Backbone support organizations Collective Impact. Stanford Social Innovation Review, Winter 2011. http://www.ssireview.org/pdf/2011_WI_Feature_Kania.pdf Channeling change: Making collective impact work http://www.fsg.org/Portals/0/Uploads/Documents/PDF/Channeling_Change_SSIR.pdf?cpgn=WP%20DL%20-%20Channeling%20Change

26. So what does it take? • A few champions • Belief in the goal over attribution • Simple measures of progress towards the goal • Relationship building

27. Tools to help foster success:Community Organizing Techniques • Tie participation to values • Include public narratives • Intentionally develop other leaders • Intentionally develop relationships • Develop flexible tactics

28. Public Narrative Strong commitment to the relationships Thanks to Marshall Ganz, NOI, OfH and others

29. En

30. Creating shared relational commitment Interests Interests Resources Resources Relationship as InterestCommon Interests New Interests Commitment Commitment New Resources Common Resources Relationship as Resource

31. Creating shared structure

32. Organizing in Healthcare • NW Denver Sustainability Campaign • National Health Service in GB • Organizing for Health • Operation Safe Surgery, SC • Healthy South Carolina • QIO 10th SOW • CCTP Partners

33. Public Narrative - example

34. QIO Accomplishments as of January 31, 2013

35. QIO 10th SOW • National Map with 400+ QIO Communities

36. National Coalition of QIO-recruited Communities Early Progress 6.8%

37. National Coalition of QIO-recruited Communities Early Progress 9.1%

39. Texas Data • Highestnumber of recruited communities • Highest number of community coalition charters • 3rdhighest number of engaged communities • 3rdhighest number of accepted CCTP applications • 16thin admissions reduction • 27thin readmissions reduction

41. Select Interim Improvement!!!10/1/10-3/31/11 compared to 10/1/11-3/31/12

42. Lufkin, Texas

43. Lufkin, Texas

44. Follow-up Appointments Scheduled for CHF Patients

45. Follow-up Appointments for CHF, AMI, PNE Patients

46. 30-day Readmission for HF Patients

47. 8.9%* 5.3%* *10.1.10-3.31.11 compared to 10.1.11-3.31.12

48. AcknowledgementsWe welcome your suggestions for improving this guide further for future training sessions. We also welcome you to use it and adapt it for your own training needs, subject to the restrictions below.Many of these materials have been developed by Kate Hilton, Janet Groat, Erin McFee, Sarah Kopse-Schulberg, Chris Lawrence-Pietroni, Liz Pallatto, Joy Cushman, Devon Anderson, Jake Waxman, Hope Wood, Ella Auchincloss, New Organizing Institute staff, and many others. Restrictions of UseThis information is provided to you pursuant to the following terms and conditions of use. Your acceptance of the work constitutes your acceptance of these terms:You may reproduce and distribute the work to others for free, but you may not sell the work to others.You may not remove the legends from the work that provide attribution as to source (i.e., “originally adapted from the works of Marshall Ganz of Harvard University”).You may modify the work, provided that the attribution legends remain on the guide, and provided further that you send any significant modifications or updates to marshall_ganz@harvard.edu or Marshall Ganz, Hauser Center, Harvard Kennedy School, 79 JFK Street, Cambridge, MA 02138You hereby grant an irrevocable, royalty-free license to Marshall Ganz and his successors, heirs, licensees and assigns, to reproduce, distribute and modify the work as modified by you.You shall include a copy of these restrictions with all copies of the guide that you distribute and you shall inform everyone to whom you distribute the guide that they are subject to the restrictions and obligations set forth herein.

49. Questions agoroski@cfmc.org www.cfmc.org/integratingcare