The STAAR Initiative: A quality effort at the heart of system redesign

1. The STAAR Initiative: A quality effort at the heart of system redesign Amy E. Boutwell, MD MPP Director of Health Policy Strategy Co-Principal Investigator, STAAR Initiative Institute for Healthcare Improvement

2. Overall Summary • Rehospitalizations are frequent ,costly and many are avoidable; • Successful pilots, local programs and research studies demonstrate that rehospitalization rates can be reduced; • Individual successes exist where financial incentives are aligned; • Improving transitions state-wide requires action beyond the level of the individual provider; systemic barriers must be addressed; • Public sector leadership is a powerful asset in a state-wide effort to improve care coordination across settings and over time.

3. Many Complementary Approaches C A Home Hospital A B Skilled Nursing A D A: Improve transition out of the hospital and into the next setting of care B: Enhanced care by coaches, clinicians in the month(s) following hospitalization C: Proactive care to avoid ED/hospitalization (including “medical home”) D: Improve care in Skilled Nursing Facilities to avoid hospitalization

4. General Principles of Successful Efforts • Measure hospital or community-based rehospitalization rates • Examine current performance; set an aim for improvement • Identify patients at high risk of rehospitalization • Population based on overall utilization (medically or socially complex) • Population based on disease state (heart failure) • Provide enhanced support at times of transition • Self-management coaching and support • Supplemental clinical management services (ANP, remote monitoring) • Ensure close follow up after discharge • Improve communication between providers

5. Improving transitions is part of a comprehensive strategy to promote appropriate utilization of health care

6. What can be done, and how? There exist a wealth of approaches to reduce unnecessary readmissions that have been locally successful Which are high leverage? Which can go to scale? Success requires engaging clinicians, providers across organizational and service delivery types, patients, payers, and policy makers How to align incentives? How to catalyze coordinated effort?

8. STAAR InitiativeSTate Action on Avoidable Rehospitalizations Purpose • Improve quality, patient experience, and reduce avoidable utilization through a multi-stakeholder initiative to reduce rehospitalizations. Methods • Engage state-level leadership and state-wide process improvement . Aims • Improve patient/family satisfaction with care transitions. • Reduce all-cause 30-day rehospitalization rates by 30 percent. Settings • Massachusetts, Michigan, Washington.

9. The state is the unit of intervention

10. STAAR InitiativeSTateAction on Avoidable Rehospitalizations • Approach of the STAAR Initiative: • Provide technical assistance to front-line teams of providersworking to improve the transition out of the hospital, the reception into the next setting of care with the specific aim of reducing avoidable rehospitalizations and improving patient satisfaction with care • AND • Create a state-based, multi-stakeholder initiative to concurrently address the systemic barriers to improving care transitions, care coordination over time (policies, regulations, accreditation standards, etc)

11. STAAR InitiativeSTateAction on Avoidable Rehospitalizations • Improve the transition out of the hospital • Cross-continuum teams • Collaborative learning • State-based mentoring and quality improvement infrastructure • Support state-level, multi-stakeholder initiatives to address the systemic barriers • State leadership- coordinating, aligning, convening • State-level data and measurement • Financial impact of reducing readmissions • Engaging payers to reduce barriers • Working across the continuum • Other leadership, policy, regulatory levers

12. STAAR Collaborative:Optimize the transition for all patients

13. STAAR InitiativeSTate Action on Avoidable Rehospitalizations • Measure all-cause 30day readmission rate • Form a cross-continuum team • Cross-continuum team reviews longitudinal, cross-setting story of 5 recently readmitted patients

14. STAAR Initiative Key Changes • Enhanced Assessment of Patients:why does the patient/caregiver/SNF/outpatient provider think caused readmit? • Enhanced Teaching and Learning:change focus from what providers tell patients to what patients/caregivers learn • Real-time Communication:timely, clinically meaning information exchange with opportunity for clarification • Timely Post Acute Care Follow-Up:clinical contact (call, home health visit, office visit) within 48h or 5 days depending on risk

15. STAAR Collaborative

16. Support State Level Multi-Stakeholder Coalitions to Develop State Strategy and Address Systemic Barriers

17. STAAR State Level Strategy Hospital-level Improve the transition out of the hospital for allpatients* Measure and track 30-day readmission rates* Understand the financial implications of reducing rehospitalizations* Community-level Engage organizations across continuum to collaborate on improving care, partner with non-clinical community based services, address lack of IT connectivity, clarify who “owns” coordination, engage patient advocates* Ensure post-acute providers are able to detect and manage clinical changes, develop common communication and education tools* State-level Develop state-level population based rehospitalization data* Convene all payer discussions to explore coordinated action* Link with efforts to expand coverage, engage patients, improve HIT infrastructure, establish medical homes, contain costs, etc.* Establish state strategy, use regulatory levers* * Elements of the STAAR Initiative

18. Michigan STAAR Steering Committee CEO, Area Agency on Aging 1-B Director, Office of Services for the Aging, MDCH Chief Nurse Executive, MDCH  Bureau Director, Medicaid Program Operations and QA  Policy Advisor, Office of Governor Jennifer Granholm Gerontologist, University of Michigan Director of Health Policy Strategy, IHI Executive Director, Citizens for Better Care  President, Michigan MICAH  President & CEO, Aging Services of MI  President & CEO, HCAM  Michigan Chapter , American College of Cardiology Executive Director, MAHP  Executive Director, MSMS  Michigan Osteopathic Association Michigan Hospice & Palliative Care  Senior VP & CMO, BCBSM  VP Strategic Initiatives, MPRO  Senior VP Patient Safety and Quality, MHA President and Chief Executive Officer, MPRO Executive Director, MHHA

19. Michigan STAAR Portfolio of Projects

20. Massachusetts STAAR Portfolio of Projects • Care Transitions Forum • State Strategic Plan on Care Transitions • Division of Health Care Finance and Policy PPR Committee • HCQCC Expert Panel on Performance Measurement • Quality inspectors trained in elements of a good transition • Standard transfer forms between all settings of care • Hospital requirement to form patient/family advisory councils • MOLST (Medical Orders for Life Sustaining Treatment) • INTERACT (Interventions to Reduce Acute Care Transfers) • Medical home demonstrations; new applications coordinate training on principles of optimal transitions with STAAR • ASAPs join cross continuum teams

21. Massachusetts STAAR Cross Continuum Map

22. Address Systemic Barriers

23. STAAR State Leadership, Strategy, Policy

24. Lessons on State Level Engagement • State-based approach allows: • Common framing of issue, common language • Inventory complementary efforts across state • Aligning efforts encourages, elevates, sustains action • State strategy to systematically work through • No surprises- transparent intent and plan • Leverage regulatory, licensure, other policy levers

25. STAAR InitiativeSTateAction on Avoidable Rehospitalizations Resources: • STAAR How-to Guide: Creating an Ideal Transition Home • STAAR Guide for Field Testing: Creating an Ideal Transition to the Office Practice • STAAR Guide for Field Testing: Creating an Ideal Transition to a Skilled Nursing Facility • Applying Early Evidence and Experience in Front-Line Process Improvements to Develop a State-Based Strategy: The STAAR Initiative • The STAAR Initiative: A Survey of the Published Evidence • The STAAR Initiative: A Compendium of 15 Promising Interventions • The STAAR Initiative: A Tool for State Policy Makers • STAAR Issue Brief: The Financial Impact of Readmissions on Hospitals • STAAR Issue Brief: Engaging Payers • STAAR Issue Brief: Working Together in a Cross-Continuum Team • STAAR Issue Brief: Measuring Rehospitalizations at the State Level Available at www.ihi.org/STAAR

26. Thank you Amy E. Boutwell, MD MPP Director of Health Policy Strategy Co-Principal Investigator, STAAR Initiative Institute for Healthcare Improvement aboutwell@ihi.org