Community-Based Approach to Reducing Readmissions

1. Community-Based Approach to Reducing Readmissions Dana Schmitz, MS Program ManagerTMF Quality Innovation Network

2. TMF QIN-QIO Regional Partners TMF has subcontracted with strong, experienced quality improvement partners to provide expert technical assistance and quality improvement support for participating providers across the region. • Arkansas Foundation for Medical Care • Primaris (Missouri) • QIPRO and Ponce Medical School Foundation (Puerto Rico) • TMF Health Quality Institute (Texas and Oklahoma)

3. Join the TMF QIN-QIO Website http://www.tmfqin.org • Provides targeted technical assistance and engages providers and stakeholders in improvement initiatives through numerous Learning and Action Networks (LANs). • The networks serve as information hubs to monitor data, engage relevant organizations, facilitate learning and sharing of best practices, reduce disparities and elevate the voice of the patient.

4. LANs Join any of the following TMFQIN.org networks and you can sign up to receive email notifications to stay current on announcements, emerging content, events and discussions in the online forums. Behavioral Health Cardiovascular Health and Million Hearts Health for Life – Everyone with Diabetes Counts Healthcare-Associated Infections Immunizations Meaningful Use Medication Safety Nursing Home Quality Improvement Patient and Family Quality Improvement Initiative Readmissions Value-Based Improvement and Outcomes

5. Readmission Landscape 2.6 million Seniors are readmitted annually at a cost of $26 billion every year • Increasingly complex patient population: • Two-thirds of Medicare beneficiaries 65 years or older have 2 or more chronic conditions; 15% have 6 or more • Medicare population is living longer with chronic disease, using more health care services and more likely to be hospitalized, with greater resources required per episode

6. Financial Pressures New payment models incentivize value (outcomes) over volume: MACRA: MIPS, APMs https://qpp.cms.gov/ VBP (MSPB) ACO Episodic Bundled Payment Readmission Reduction Program Transparency of Quality Outcome Measures: Hospital Compare, Nursing Home Compare, Physician Compare; Hospital, NH & HH Star Ratings

7. Meeting the Challenge Utilization of best practices and evidence-based tools Some Common Strategies: • Medication Reconciliation • Post-discharge appointments • Post-discharge phone calls • Teach back interventions • Risk Stratification

8. Evidence-based Models for High Quality Care Transitions for Older Adults & Caregivers • “BOOST” (Better Outcomes for Older Adults Through Safe Transitions) http://www.hospitalmedicine.org/BOOST/ • Identify high risk, discharge checklist, teachback, med rec, standardized communication, 72 hr f/u • “Project RED” (Re-Engineered Discharge) https://www.bu.edu/fammed/projectred • Enhanced hospital discharge planning, pt. education, telephone support • “Care Transition Program” http://www.caretransitions.org • Transition coach; Trained volunteers; Empowered patients and caregivers • “BPIP” (Best Practices Intervention Packages): Fundamentals of Reducing Hospitalizations http://www.homehealthquality.org/Education/Best-Practices.aspx

9. “Transitional Care Model” http://www.transitionalcare.info/home • APN coordinates care during and after discharge, pt. self-management • Home, SNF, and clinic visits • “INTERACT” (Interventions to Reduce Acute Care Transfers) http://interact2.net • Communication Tools, Care Paths, Advance Care Planning Tools, and QI tools for nursing homes and SNFs • “Bridge Model” http://www.transitionalcare.org/the-bridge-model • Social Worker-led coordination with hospital, community & aging network • “POLST” (or “MOLST”) (Physician (or Medical) Orders For life Sustaining Treatment) http://polst.org/ • Advance care planning

10. Drivers of Rehospitalization • Patient Activation • Standard, known Processes • Transfer of Information

11. Interventions by Driver: Low Patient Activation

12. Interventions by Driver: Lack of Standard, Known Process

13. Interventions by Driver: Inadequate Transfer of Information

14. Interventions Addressing Multiple Drivers

15. Community-Based Approach to Readmission Reductions • Collaboration supports better communication and Coordination of Care across providers. • Community-based initiatives can address population health and target chronic disease prevention/management. • Greater sustainability and support • Synergies instead of silos/maximize impact

16. Successful Strategies • Leadership support • Utilize community data to drive change • Build a foundation of trust in the community • Collaboration across the care continuum • Robust communication and continuity of information

17. Collaboration • What am I already tracking to measure my progress, quality and efficiency? • What other level of care am I working with? • How can we share information? • How can we share in progress?

18. Coalition Charter • States Mission and Vision • Shared Goals and Purpose • Set norms and participation expectations • Collaboration across levels of care as well as peer to peer • Patient-centered • Allows providers access to community data in which to benchmark performance

19. Data

22. Missouri

24. Local Initiatives: • You are the experts in your local community • Passionate Community and Healthcare leaders: parallel activities, connecting the dots • QIN-QIO as convener and support oflocal initiatives to improve care transitions • Align goals/efforts to maximize quality measures across the continuum of care • Community engagement across providers that impacts patient outcomes

25. Where to Start: • Identify high priority care coordination issues in the local environment and prioritize areas of focus (RCA, Community Health Needs Assessment, etc) • Facilitate discussion across care providers, stakeholders & patients to establish shared goals and vision • Peer-to-peer sharing • Identify/Implement best practices and tools • Evaluate current metrics for ongoing process improvement • Monitor progress to goals (data/metrics)

26. Acronyms • QIN-QIO: Quality Innovation Network-Quality Improvement Organization • MACRA: Medicare Access and CHIP Reauthorization Act of 2015 • MIPS: Merit-based Incentive Payment System • APMs: Advanced Alternative Payment Models • VBP: Value-based Purchasing • MSPB: Medicare Spending Per Beneficiary • ACO: Accountable Care Organization • IMPACT Act: Improving Medicare Post-Acute Care Transformation Act of 2014 • CAHPS: Consumer Assessment of Healthcare Providers and Systems

27. Contact Information: Dana Schmitz, MS Program Manager TMF Quality Innovation Network 800-735-6776 dana.schmitz@area-B.hcqis.org This material was prepared by TMF Health Quality Institute, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 11SOW-QINQIO-CX-16-75