Partnership for Patients: Reducing Readmissions and Hospital Acquired Conditions

1. Partnership for Patients: Reducing Readmissions and Hospital Acquired Conditions Dennis Wagner & Paul McGann, MD Co-Directors, Partnership for Patients US Department of Health & Human Services and Centers for Medicare & Medicaid Services AHRQ Annual Conference September 10, 2012

2. Questions to Run On • Why is the Partnership for Patients Different and How will it Make a Difference? • How can you benefit from the Partnership? • What actions and contributions might you, your organization, AHRQ’s network make? • What are your insights and advice about how CMS and AHRQ can be most helpful in achieving these bold aims? …we want your answers too

3. Breakthrough Aims of the Partnership for Patients 40% Reduction in Preventable Hospital Acquired Conditions • 1.8 Million Fewer Injuries • 60,000 Lives Saved 20% Reduction in 30-Day Readmissions • 1.6 Million Patients Recover Without Readmission Up to $35 Billion Dollars Saved

4. 3 Partnership for Patients Engines to Generate Better Health & Better Care at Lower Cost • CMS Innovation Center Investments, up to $1 billion • Technical Assistance to Hospitals (Hospital Engagement Networks) • Community Based Care Transitions Program • Programs and platforms of the Department of Health & Human Services – AHRQ, CDC, ACL, HRSA, CMS, ONC, OASH, IHS – VA and DoD • Programs and platforms of Partners: AMA, ABMS, AFL-CIO, AHA, NAPH, ANA, N4A, many more

5. If we always do what we’ve always done, we’ll always get what we’ve always got. Partnership for Patients is About All of Us Doing Things Differently We have unprecedented Federal action and coordination. We have an unprecedented CMMI Investment in taking proven practices to scale. We are calling for continued unprecedented action and alignment by CBOs, hospitals, clinicians, private partners and others.

6. 26 Hospital Engagement Networks (HENs)Achieving Results through 3,700+ Hospitals American Hospital Association Premier Healthcare Alliance VHA NC Hospital Assoc Intermountain HealthCare GA Hospital Assoc TX Hospital Assoc MN Hospital Assoc Healthcare Assoc of NY State IA Healthcare Collaborative PA Hospital Assoc WA Hospital Assoc DFWHC Foundation OH Hospital Assoc NJ Hospital Assoc Ascension Health TN Hospital Assoc MI Health & Hospital Assoc National Public Hospital & Health Institute LifePoint Hospitals, Inc Joint Commission Resources OCHSPS National Children’s Network Dignity Healthcare NV Hospital Assoc Carolinas Health Care UHC

7. Joint Commission Resources Reduces Heart Failure Readmissions: 3-Hospital System Pilot Hosp A Hosp B Hosp C System Baseline, Prior Year: Oct. 2009 – May 2010 NO intervention Oct. 2010 – May 2011 Intervention Oct. 2010 – May 2011 Readmissions/total cases Prior to Intervention: 159/515 Post Without Intervention :165/558 Post With Intervention: 36/184

8. AHA/HRET HEN First Focus Results: Early Elective Delivery (EED)

9. AHA/HRET EED Reduction Initiatives • In May 2012, the AHA Board of Trustees approved the position of supporting policies to eliminate early-term non medically necessary deliveries. • Physician engagement • Patient education • March of Dimes toolkit implementation • Implementation of hard stop policies. • Hospitals submitted Early Elective Delivery baseline and monitoring data to the HRET Comprehensive Data System.

10. AHA/HRET Reducing EED:State Activities Oklahoma • Partnered with the Oklahoma State Department of Health-Maternal Services, University of Oklahoma Health Sciences Center Office of Perinatal Quality Improvement, Oklahoma March of Dimes, and the Oklahoma Health Care Authority to implement an approach to institute scheduling process changes in birthing hospitals for scheduled cesareans and inductions, asking OB providers to distribute March of Dimes patient education materials and broadcasting a public service announcement on the risks of scheduling a baby’s birth before 39 weeks gestation. Florida • Worked with the Florida Perinatal Quality Collaborative (FPQC) and the Lawton and Rhea Chiles Center for Healthy Mothers and Babies at the University of South Florida. Hosted an EED kick-off webinar in July that provided the MoD toolkit, tips for engaging a hospital team, and resources available from the FPQC and FHA. FHA is promoting data submission to the HRET CDS, one-on-one coaching with OB hospitals, and development of OB/EED grand rounds. Louisiana • LHA partnered with the Louisiana Department of Health and Hospitals (LDHH) in a comprehensive birth outcomes initiative. Every birthing hospital, in 2011, pledged to adopt a comprehensive 39-week gestation delivery prohibition policy by the end of 2012. Partnered with the IHI Perinatal Collaborative efforts in which 22 hospital are enrolled and actively participating in the second phase of the collaborative.

11. The Community-Based Care Transitions Program (CCTP, ACA Section 3026) GOALS: Improve transitions of beneficiaries from the inpatient hospital setting to home or other care settings Improve quality of care Reduce readmissions for high risk beneficiaries Document measureable savings to the Medicare program For more information, visit: http://innovations.cms.gov/initiatives/Partnership-for-Patients/CCTP

12. 2010 Readmission Rates by Payer

13. The Community-Based Care Transitions Program (CCTP, ACA Section 3026) Now 47 Sites: CBOs with 200+ hospitals serving 185,500 beneficiaries in 21 states

14. Quality Improvement Organizations (QIOs) Work and Results on Partnership for Patients • 202 Communities Recruited • 179 Community Coalition Charters Signed • 89 Communities Submitting Applications to Care Transitions Funded Programs • 32 Communities Accepted into Funded Care Transitions  Programs • Recruited communities across the country include 661 Hospitals, 1584 Skilled Nursing Homes, 532 Home Health Agencies, 118 Dialysis Facilities, and 273 Hospices

15. PfP Readmissions Aim: A Network of Networks for Nationwide Results QIO-Recruited Communities, CCTP Sites, & ADRC Option D Grantees (as of July 31, 2012)

16. CCTP Sites, QIO-Recruited Communities, ADRC Grantees ZIP Code Level Readmissions per 1000 Medicare Beneficiaries (January 1, 2011 – December 31, 2011) 30-day Readmissions per 1000 beneficiaries

17. CCTP and QIO Care Transitions: The Approach Convene community partners to improve transitions across the continuum of care, including social and HCBS providers, hospitals, pharmacy, nursing homes, home health, primary care, other post-acute care providers Identify major drivers of readmissions and ideal target population through community-specific Root Cause Analysis Select interventions best suited to address those drivers and implement for target population identified as at high risk of readmission (in CCTP, with monthly payment for services) Use PDSA, rapid-cycle measurement for improvement (e.g., run charts), learning collaboratives and change packages to share successful practices, other continuous improvement tools to adjust target population and/or intervention strategy and improve along the way Partner with multiple payers if possible, to serve more patients and reduce more readmissions

18. Community-Based Care Transitions - Your QIO Can Help! • Community Coalition Formation • Community-specific Root Cause Analysis • Intervention Selection and Implementation • Assist with an Application for a Formal Care Transitions Program Access a comprehensive Toolkit, Learning Sessions, and locate your QIO care transitions contact at: http://cfmc.org/integratingcare under “Contact Us”

19. Readmissions ReductionKeys to Success Build on and spread success within and across networks, including CCTP, QIO, HEN, private efforts, and so on Hospitals team with the larger community Work closely with QIOs and align with state/local efforts Target patient-level interventions to highest risk patients Conduct a thorough Root Cause Analysis (RCA) to determine major readmissions drivers, not just top diagnoses Make greater patient engagement and enhanced role of family caregivers a core focus Choose your interventions based RCA findings Target High-Risk but Measure All-Cause Readmissions

20. Federal Partners and Programs Are Aligned & Generating Results on Partnership for Patients

21. AHRQ Alignment and Action on Partnership Aims • Led team that established the “Science Base” for PFP and developed national goals for reducing HACs and readmissions. • Worked with other agencies to establish methods and national baselines for the measured 2010 rates for HACs and readmissions that will be tracked through 2013. • Currently providing healthcare organizations with opportunities to implement proven tools and programs (e.g., CUSP for CLABSI, TeamSTEPPS® in partnership with DoD) and to join new projects (e.g., CUSP for CAUTI, for Safe Surgery and for Perinatal Safety). • A source for no-cost, stand-alone toolkits and guides, Webinars on available resources and implementation research findings, and related patient safety and quality improvement expertise.

22. AHRQ “CUSP for CLABSI” Project: Central Line-Associated Bloodstream Infections Reduced in Adult ICUs * CLABSI rate calculated as sum of infections divided by sum of line-days for all reporting ICUs 40% Reduction (1.91 CLABSIs per 1,000 line-days to 1.13) Notes: Data are for six cohorts that started collecting baseline data from May 2008 to April 2009. Q1 varies from May-Jul 2009 to Apr-Jun 2010. Q1 to Q4 covers all six cohorts; Q5 to Q8 covers three to five cohorts. Data are from 44 States, DC and PR; with a total of 1142 participating ICUs. We estimate that 27 percent of hospitals with an adult ICU in the nation are participating in CUSP for CLABSI. See: www.onthecuspstophai.org. The project is led by HRET, Johns Hopkins’ Armstrong Institute, and Michigan’s Keystone Center.

23. AHRQ-CMS Collaboration on PfP National Results Scorecard

24. PFP-Measured HACs (2010)

25. PFP-Measured HACs (2010)

26. Adverse Drug Events Measured in the PFP HACs • The 1.621M and 34 percent of HACs measured in the PFP 2010 totals are as follows: • ADE Associated with Digoxin (12,000) • ADE Associated with Insulin and Hypoglycemic Agents (930,000) • ADE Associated with IV Heparin (170,000) • ADE Associated with LMW Heparin and Factor Xa Inhibitor (340,000) • ADE Associated with Warfarin (170,000) • These ADE HACs are 57 percent hypoglycemic agents, 42 percent anticoagulants, and 1 percent Digoxin. • The most important missing ADE-type is probably opiate-related ADEs. • Not counted in the ADE category, but related to ADEs and counted in the “all-other” HACs category: • Contrast Nephropathy Associated with Catheter Angiography (230,000) • C. difficile Infection after Inpatient Antibiotics (87,000)

27. Counting the “40% of Preventable (44% of) HACs” Nationwide Goals for 2013

28. Health Resources and Services Administration (HRSA) • HRSA’s Patient Safety & Clinical Pharmacy Collaborative (PSPC) and CMS’s QIOs partnered to have teams in all 50 states working on preventing medication errors and facilitating care transitions • Outreach to small rural hospitals for their participation in PfP, with over 900 CAHs now engaged by the HENs. • Providing leadership to the Rural Affinity group with 20 of the HENs participating. • Convened representatives of rural hospitals and PfP HENs in a special 2-day working event for the HEN Rural Affinity Group.

29. ADRC Evidence Based Care Transition Program • ADRCs are implementing a variety of evidence based models: • Care Transitions Intervention® • Transitional Care Model • Project BOOST • Bridge • GRACE • Guided Care® • Current Status: • 93 ADRCs are partnering with 242 hospitals in 27states • 30 ADRCs are partnering with QIO’s • 74 ADRCs supported the transition of 10,314 consumers Source: ACL Semi Annual Report Data October 2010- March 2012

30. Success Story: Pennsylvania • Partnership between Delaware County ADRC and Crozer Keystone Health System • Mary Naylor Transitional Care Model • Partnership designed a team based approach: Hospital provides Nurse Assessor, ADRC provides Options Counselor • Original 2 year goal was to serve 235 participants • Served 355 participants within 13 months • ADRC Care Transition Program Readmission Rate = 7%* • 47% reduction from baseline • ACL investment of $400,000 yielded $3 Million in Savings* • State provided special funding to purchase supplies, equipment, and services for participants not covered by existing programs • Examples: Talking scale for a consumer with a visual impairment and CHF to monitor weight; Air Conditioner; Stair Rides • ADRC CT data was cited in successful CCTP application *Data provided by Crozer Keystone Health System

31. ACL Work on ACA Care Transitions • AoA (now ACL) National and Regional Leadership Engagement • Technical assistance to Aging Network on evidence-based care transitions interventions. • 12 webinars on practical implications for the Aging Network; 10,000+ Attended / 100,000+ Downloaded • Care Transitions Online Toolkit • CMS Community Based Care Transition Program (Section 3026/CCTP) • 47 CCTP sites • 86% lead CBO is in the Aging Network • 92% have at least one Aging Network Partner

32. Care Transitions Resource Development • Resource Development • Care Transitions Toolkit (41,000+ downloads from the AoA website) http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/Toolkit/index.aspx • ACL 2010 Evidence Based Care Transitions Program Webpage http://www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/index.aspx • ACL Affordable Care Act: Opportunities for the Aging Network Webpage http://www.aoa.gov/Aging_Statistics/Health_care_reform.aspx • ADRC Care Transition Technical Assistance Exchange Webpage http://www.adrc-tae.org/tiki-index.php?page=CareTransitions

33. Other Examples of Federal Alignment on Partnership Aims • National Quality Strategy • Assistant Secretary for Health – Office of Healthcare Quality • HAI Action Plan, State-Based Partner Meeting, Data Summit, Partnering to Heal Computer-based Simulation, Do the WAVE Consumer Campaign • Centers for Medicare and Medicaid Services • Medicare and Medicaid EHR Incentive Programs (with ONC) • ACA Sec. 3008 - Payment Adjustment for Hospital Acquired Conditions • ACA Sec. 3025 - Hospital Readmissions Reduction Program • QIO work to reduce readmissions, ADEs, HAIs • Medicare Hospital Inpatient Value-Based Purchasing Program • CMS Innovation Center Models, including ACOs and Bundled Payment

34. Other Examples of Federal Alignment on Partnership Aims • Centers for Disease Control and Prevention • NHSN Measurement System, State HAI Coordinators, Healthcare Infection Control Practices Advisory Committee • Department of Defense • TeamSTEPPS, Patient Safety Research Center • Office of the National Coordinator for HIT • Beacon Communities, Improving Care Transitions Through HIT Meaningful Use, Innovator Challenges

35. Partners Are Contributing to PfPin Major Ways • “Buying Value” initiative to align purchasing with PfP Aims by large employers, unions, NBGH and many others. • Johnson & Johnson incentives to employees discharged from hospitals who call for guidance on health care follow up. • Joint Commission is educating surveyors through a video and at the annual training course on the goals of the PfP • NAPH push to get public hospitals teaming with CBOs on Care Transitions to reduce 30 day readmissions. • AHA has launched a Readmissions Race across 1600 hospitals within 31 states to achieve significant reductions in 30 day readmissions by 12/31/2012.

36. How Can You Benefit? Be a part of the largest public or private sector investment in patient safety & readmissions reduction Access to real-time data and cutting-edge discoveries from hospitals and communities participating in the work of improvement Opportunity to see your research used in real-time to influence community –based care and/or drive patient and family engagement Become an important coordinator of care beyond hospital walls by establishing new cross-setting collaborations Ease the burden of HACs and re-hospitalization on patients and the community Build “communities of scale” by tapping into efforts already going on right in your backyard Other ways?

37. How Can You Benefit? Take 1 Minute Talk to Your Neighbor What are your answers?

38. How Can You Contribute? • Make sure your hospital or other care setting is a part of this important initiative • Connect with leaders in your hospital to be part of improvement work • Make HACs and readmissions your area of focus • Connect with the Partnership’s Network of Networks, starting with efforts already going on in your own backyard • Show us what works. We want to spread your proven practices! • What HIT tools better enable good patient safety and care transitions? • What gaps are there, and how can you help to fill them?

39. How Can You Contribute? Make a note….30 Seconds What is your answer to this question?

40. How Can CMS and AHRQ Help? • Work aggressively to bring proven practices to scale • Help to facilitate the connections among Partnership networks and results-getters • We want to broadcast your successes and results! • Have you submitted your QualityNet abstract? • Are you our next webinar keynote? • What more can CMS and AHRQ do to team with you and your networks and link you to other partners in the Partnership for Patients? • Other ways?

41. Sharing Insight, Possibility and Action AHRQ Annual Meeting My biggest insight about how my organization can benefit from the Partnership for Patients initiative is: ___________________________________ __________________________________________________________________. The possibilities I see for our organization to act on or contribute to the Partnership for Patients are: 1. 2. 3. My main advice to CMS and AHRQ about how they can be most helpful in achieving the bold aims of the Partnership:_____________________________ _________________________________________________________________. Name, Organization, Email:_______________________________________