Progress in the MA STAAR Collaborative and Working Across the Continuum

1. Progress in the MA STAAR Collaborative and Working Across the Continuum Pat Rutherford Rebecca Steinfield (The presenters have nothing to disclose) MA STAAR Collaborative Learning Session October 11, 2011

2. Session Objectives Participants will be able to: • Describe the case for creating a more patient-centered transition from the hospital to post-acute care • Describe IHI/CMWF strategies and identify key interventions promoted in the MA STAAR Collaborative to reduce avoidable rehospitalizations • Share an overview of the MA STAAR Collaborative progress to-date

5. Systems of Care “The quality of patients’ experience is the “north star” for systems of care.” –Don Berwick

6. Rebecca’s Story Rebecca Bryson lives in Whatcom County, WA and she suffers from diabetes, cardiomyopathy, congestive heart failure, and a number of other significant complications; during the worst of her health crises, she saw 14 doctors and took 42 medications. In addition to the challenges of understanding her conditions and the treatments they required, she was burdened by the job of coordinating communication among all her providers, passing information to each one after every admission, appointment, and medication change. http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral/ImprovementStories/PursuingPerfectionReportfromWhatcomCountyWashingtononPatientCenteredCare.htm

7. Rebecca’s Story Rebecca said if she were to dream up a tool that would be truly helpful, it would be something that would help her keep her care team all on the same page. Bryson described typical medical records as being “location or process centered, not patient-centered.” She also describes how difficult it can be for patients to navigate a large health care system. Rebecca summarizes her experience in this way – “Patients are in the worst kind of maze, one filled with hazards, barriers, and burdens.” http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral/ImprovementStories/PursuingPerfectionReportfromWhatcomCountyWashingtononPatientCenteredCare.htm

8. “North Star” in STAAR? Whose experience of care is the “north star” for your system of care?

9. Strategic Questions for Executive Leaders • Is reducing the hospital’s readmission rate a strategic priority for the executive leaders at your hospital? Why? • Do you know your hospital’s 30-day readmission rate? • What is your understanding of the problem? • Have you assessed the financial implications of reducing readmissions? Of potential decreases in reimbursement? • Have you declared your improvement goals? • Do you have the capability to make improvements? • How will you provide oversight for the collaborative, learn from the work and spread successes?

10. What can be done, and how? There exist a growing number of approaches to reduce 30-day readmissions that have been successful locally Which are high leverage? Which are scalable? 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?

11. STAAR Initiative: Two Concurrent Strategies • Provide technical assistance to front-line teams of providersworking to improve the transition out of the hospital and into the next care setting • Actively engage hospitals and their community partners in co-designing processes to improve transitions • Provide coaching by content experts and facilitate collaborative learning with the goals of creating exemplary cross continuum models in each state and identifying high-leverage changes in each care setting • Develop quality improvement expertise and content experts to mentor others • Create and support state-based, multi-stakeholder initiativesto concurrently examine and address the systemic barriers to improving care transitions, care coordination over time. • State leadership, steering committees, key allies, aligning initiatives • Technical assistance to “staff” challenges in framing the issue, designing strategy, scanning for developments in best practice/policy • Specific focus areas: understanding the financial impact of success, aligning payment to support high leverage interventions, developing state rehospitalization data reports

12. Evidence-Based Interventions • Boutwell, A. Griffin, F. Hwu, S. Shannon, D. Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions. Cambridge, MA: Institute for Healthcare Improvement; 2009 • Kanaan SB. Homeward Bound: Nine Patient-Centered Programs Cut Readmissions. CHCF, Sept 2009. • Osei-Anto A, Joshi M, Audet AM, Berman A, Jencks S, Health Care Leader Action Guide to Reduce Avoidable Readmissions. Health Research & Educational Trust, Chicago, IL. January 2010

13. IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations Improved Transitions and Coordination of Care Reduction in Avoidable Rehospitalizations or * Additional Costs for these Services Patient and Family Engagement Cross-Continuum Team Collaboration Evidence-based Care in All Clinical Settings Health Information Exchange and Shared Care Plans

14. IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations Improved Transitions and Coordination of Care Reduction in Avoidable Rehospitalizations or * Additional Costs for these Services Patient and Family Engagement Cross-Continuum Team Collaboration Evidence-based Care in All Clinical Settings Health Information Exchange and Shared Care Plans

15. Co-designing Processes to Improve Transitions

16. 4 Key Changes to Improve the Transition from Hospital to Home • Perform an Enhanced Assessment of Post-Hospital Needs • Provide Effective Teaching and Facilitate Enhanced Learning • Ensure Post-Hospital Care Follow-Up • ProvideReal-Time Handover Communications

17. 1. Enhanced Assessment

18. 2. Effective Teaching and Facilitate Learning

19. 3. Follow-up Care

20. 4. Handover Communications

21. IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations Improved Transitions and Coordination of Care Reduction in Avoidable Rehospitalizations or * Additional Costs for these Services Patient and Family Engagement Cross-Continuum Team Collaboration Evidence-based Care in All Clinical Settings Health Information Exchange and Shared Care Plans

22. New Frontiers in the STAAR Initiative Engaging Payers: • Payers are motivated to reduce avoidable rehospitalizations • Individual payer efforts • Mostly focus on pre-discharge preparation • CMS 3026 to pay for additional community-based care • Discrepancies between what providers get paid for and what is needed for care • Supplemental services for high-risk patients are of paramount importance • What is the comparative effectiveness for various interventions for high-risk patients? • Myriad payer-based discharge planning and care coordination services create chaos at provider level. How can interests be aligned and coordinated?

23. Execution Improving Transitions and Reducing Avoidable Rehospitalizations Will RESULTS Build confidence New possibilities Ideas Sequencing and tempo

24. What Changes Are You Working On?

25. What Changes Are You Working On?

26. Cohort 1

27. Cohort 2

28. Analysis of Results-to-Date • Reducing readmissions is dependent on highly functional cross continuum teams and a focus on the patient’s journey over time • Improving transitions in care requires co-design of transitional care processes among “senders and receivers” • Providing intensive care management services for targeted high risk patients is critical • Reliable implementation of changes in pilot units or pilot populations require 18 to 24 months

29. The Next Year in the MA STAAR Initiative • Two 1.5-day state-wide Learning Sessions plus monthly content coaching calls • State Leaders and IAs facilitate monthly networking/peer coaching calls • Improvement Science in Action Workshop (for day-to-day leaders in hospitals, SNFs, HC agencies and OPs) plus monthly coaching calls • IHI and expert faculty will facilitate Learning Networks for clinicians and staff in OP, SNFs and HC Agencies • MA STAAR State Leaders and State-wide Steering Committee Meetings align initiatives and address systemic barriers