Ordinary to Extraordinary Improving Healthcare in Florida

1. Ordinary to ExtraordinaryImproving Healthcare in Florida Ferdinand Richards III, MD Chief Medical Director Peggy Loesch, BSN, MBA, RN Care Transitions Quality Specialist

2. Overview • FMQAI – Information for Healthcare Improvement • Quality Improvement Organization (QIO) Program • End Stage Renal Disease (ESRD) Network Program • Key activities and opportunities to participate • Improving Care Transitions through Collaboration, Commitment, and Action • Care transitions and the reduction of avoidable readmissions • Root causes of readmissions in Florida • Coalition building across care settings to improve patient-centered care

3. FMQAIInformation for Healthcare Improvement

4. Who is FMQAI? • Established in 1992 as Florida Medical Quality Assurance, Inc. • Improve quality care and outcomes through data, education, and technical assistance • Collaborate with physicians, health plans, home health agencies, nursing homes, dialysis facilities, rehabilitation facilities, and hospitals • Nationally recognized healthcare contractor • Florida Quality Improvement Organization (QIO) • End Stage Renal Disease (ESRD) Networks – Arkansas, Florida, Louisiana, Oklahoma, and Southern California • Department of Health • Private medical record review and chart abstraction

5. The QIO Program • Legislated under sections 1152-1154 of the Social Security Act • 53 QIOs tasked with review of medical care, investigation of beneficiary complaints, and implementation of quality improvement activities for Medicare • Evolution of the QIO program • 1970s – Professional Standards Review Organization (PSRO) – performed utilization reviews and special studies to improve quality of care • 1982 – Utilization and Quality Control Peer Review Organization (PRO) – data analysis to determine unnecessary, inappropriate, or poor quality • 1992 – Health Care Quality Improvement Initiative (HCQII) – focus shifted from case review to reporting patterns of care • 2001 – QIO Program – renamed to be consistent with collaboration

6. QIO 10th Statement of Work • Bold goals – supports the aims of the DHHS National Quality Strategy • Patient-centered care – includes the voice of the beneficiary in all their activities • Boundarilessness– breaks down organizational, cultural, and geographic barriers • Learning and Action Network (LAN) – accelerates change and spread of best practices where everyone teaches and learns • Value-based purchasing – provides technical assistance, including sharing best practices and QI activities

7. Medical Case Review • Beneficiary complaints • Immediate advocacy • Appeals • Higher Weighted Diagnosis-Related Groups (HWDRGs) • Emergency Medical Treatment and Active Labor Act (EMTALA)

8. Patient Safety • Hospitals • Central line-associated bloodstream infections (CLABSI) • Catheter-associated urinary tract infections (CAUTI) • Clostridium difficile (C. diff) • Surgical site infections (SSI) • Nursing homes • Pressure ulcers • Physical restraints • Use of antipsychotic medications • Clinical pharmacists, physicians, and facilities • Adverse drug events (ADE) • Potential ADEs

9. Prevention • Assist physician practices with use of electronic health record (EHR) system • Coordinate prevention services • Report quality measures • Reduce patient risk factors for cardiac disease • Partner with local Health Information Technology Regional Extension Centers (REC)

10. Additional QIO Efforts • Maintenance & Development of Medication Measures • Hospital Outpatient / Ambulatory Surgical Center Quality Reporting Program Support Contractor • Beneficiary-centered Model for Weight Loss in African American Communities – Senior Lifestyle Improvement Movement (SLIM) • Patient and Family Engagement Campaign – Promoting e-Health Technology, Awareness & Knowledge (PEAK) Heart Health • Beneficiary and Family-centered Care National Coordinating Center

11. The ESRD Network Program • The Social Security Amendments of 1972 created the national ESRD Program, which extended Medicare coverage to individuals with ESRD • The Social Security Act was again amended in 1978 to create the ESRD Network Program • Originally 32 regional ESRD Networks, now only 18 Networks • Responsible for effective and efficient administration of ESRD benefits • Improve quality of care, collect data, provide technical assistance, and review patient grievances

12. Strategic Aims Drivers of Change Current ESRD Statement of Work • Patient experience of care • Access to dialysis • Vascular access management • Patient safety – healthcare acquired infections (HAIs) • Immunization rates • ESRD quality incentive program • Facility data submission Breakthrough collaboratives Patient engagement Campaigns Technical assistance On-site visits Learning and Action Networks (LANs)

13. Key Activities & Opportunities • HealthHub – community portal to promote sharing and collaboration of information resources, tools, and knowledge • Learning and Action Networks – initiative that brings together healthcare professionals, patients, and other stakeholders • No Place Like Home – stakeholders across care continuum to improve transitions of care and prevent hospital readmissions • QIO Strategic Council (QSC) – leadership group to assist with coordinating efforts, minimizing duplication, maintaining momentum, enhancing commitment, and spreading the best practices

14. www.healthhubfl.com • Password protected • Secure repository for documents, tools, and resources • Forums • Polls • Calendar of events

15. Learning and Action Network April 11, 2014 Tampa, Florida • Connect with organizations and individuals from across all provider types that have similar QI goals and challenges • Learn from others in an "all teach, all learn" environment • Benefit from others' best practices • Receive and share free information and tools • Be recognized for meeting or exceeding improvement targets

16. Improving Care Transitions through Collaboration, Commitment, and Action

17. Objectives • Know the significance of improving the quality of care transitions to reduce avoidable readmissions • Understand the root causes of readmissions in Florida • Recognize the importance of coalition building across care settings to improve patient-centered care

18. National Strategy for Quality Improvement in Healthcare • Established by the Affordable Care Act • Develops an infrastructure at the community level that assumes responsibility for improvement efforts • Promotes patient-centered outcomes, efficiency, and appropriate care while reducing or eliminating waste from the healthcare system Source: http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm#fig3

19. “Three-Part Aim”

20. National Strategy for Quality Improvement in Healthcare Source: www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm#fig3

21. Timeline for National Quality Initiatives Hospital value-based purchasing program penalties Hospital Medicare readmission penalties NH Value-based purchasing demo (ended June 2012) 2010 2011 2012 2013 2014 2015/2016 Reduce avoidable hospitalizations among nursing facility residents (ends August 2016) Community-based care transitions program Expansion of pilot programs to evaluate bundling payment for an episode of care QAPI demonstration project (ended August 2013) • Source: The Henry J. Kaiser Foundation. Health Reform Implementation Timeline : www.kff.org/healthreform/8060.cfm.

22. Definition of Readmissions “… in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital with in 30 days from the date of discharge.” Source: http://www.cms.gov/Medicare/Medicare-fee-for-ServicePayment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

23. Readmissions Impact Multiple Areas

24. Magnitude of the Problem • Analysis of 2007 Medicare data finds: • 20% of beneficiaries are re-hospitalized within 30 days • 35% are re-hospitalized within 90 days • Among those re-hospitalized within 30 days: • 50% had no claim for physician services between discharge and re-hospitalization Source: Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. The New England Journal of Medicine. 2009;360:1418-1428.

25. Magnitude of the Problem (continued) Beneficiaries with 10 or more chronic conditions are 6 times more likely to be readmitted to the hospital. Source: Berkowitz SA, Anderson GF. Medicare beneficiaries most likely to be readmitted. J. Hosp. Med. Nov 2013;8(11):639-641.

26. Magnitude of the Problem (continued) A managed care organization with 18 hospitals: 250 out of 537(or 47%) readmissions were considered potentially avoidable. Factors contributing to avoidable readmissions: • Index stay • Suboptimal management of the condition present • The discharge process, care transitions, and care coordination • Unaddressed psychological and social needs • Follow-up care • Failure to adjust the plan of care to better meet patient needs Source: Feigenbaum P, Neuwirth E, Trowbridge L, et al. Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals. Med. Care. Jul 2012;50(7):599-605

27. 30-Day Readmission Rates Nation 18.60% Florida 19.36% Source: ICPC Quarterly Scorecard for Florida, 1/1/2009-12/31/2012 issued 6/1/2013 from Colorado Foundation for Medical Care

28. Risk of Readmissions

29. Issues Related to Care Transitions: Findings From Florida Communities

30. Examples of Causes of Readmissions in Florida

31. Industry Impact $ $ $ $ At $9,600 per readmission in 2011 readmission cost Nation: $18,931,200,000 Florida: $47,833,440 $ $ Source: Medicare FFS Inpatient Claims, 2011.

32. Patient Impact • Re-hospitalization places patient and family under significant physical and emotional distress. • The patient is at risk for potential medical errors, falls, and infections. • Exposed to Post-Hospital Syndrome: • “During hospitalization, patients are commonly deprived of sleep, experience disruption of normal circadian rhythms, are nourished poorly, have pain and discomfort, confront a baffling array of mentally challenging situations, receive medications that can alter cognition and physical function, and become deconditioned by bed rest or inactivity…” Source: Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N. Engl. J. Med. Jan 10 2013;368(2):100-102.

33. State and National Quality Initiatives

34. FMQAI – The Florida QIO Collaboration Commitment

35. Role of FMQAI in Care Transitions • Facilitate in coalition building • Assist with conducting root cause analyses • Provide education and support for the selection of evidence-based interventions, implementation, and measurement • Partner with local, regional, & statewide groups • Provide technical assistance including readmission data for the coalitions

36. The Role of the Community Organization • Spearheads coalition building among providers, stakeholders, and service organizations • Seen as trusted community presence • Understands and transcends the politics of the community • Motivates and engages in ongoing communications among community stakeholders • Promotes a shared vision for patient-centered change

37. The Role of the Community Organization (continued) • Provides expertise in the local community regarding needs and resources to maintain the health, independence, and choice of older adults and individuals with disabilities • Represents the voice of the patient • Identifies the self-management support needed to enhance patient and family engagement in their care

38. The Care Transitions Solution Partnering with Beneficiary Advocacy Groups Partnering with Beneficiary Service Organizations

39. CMS Partnership for Patients • Hospital Engagement Networks (HENs) • Community-based Care Transitions Program (CCTP) • Patient and family engagement (through HEN, CCTP, and QIO) Source: http://partnershipforpatients.cms.gov/about-the-partnership/aboutthepartnershipforpatients.html

40. 26 Hospital Engagement Networks 8 of the 26 HENs are working with Florida Hospitals • The Health Research & Educational Trust, an affiliate of the American Hospital Association (AHA) • Ascension Health • Intermountain Healthcare • Joint Commission Resources, Inc. • LifepointHospitals, Inc. • Premier • UHC (formerly University Health System Consortium) • VHA Source :http://partnershipforpatients.cms.gov/about-the-partnership/hospital-engagement-networks/thehospitalengagementnetworks.html

41. The Goals of the Hospital Engagement Networks (HENs) Source: http://partnershipforpatients.cms.gov/about-the-partnership/hospital-engagement-networks/thehospitalengagementnetworks.html

42. Community-based Care Transitions Program (CCTP) The CCTP Partners – 5 in Florida • Elder Options FL – Gainesville • Catholic Health Care Transitions Services, Inc. − Lauderdale Lakes • Osceola-St. Cloud Community-based Care Transitions Coalition • The Greater Miami Coalition to Prevent Unnecessary Rehospitalizations FL • West Central Florida Area Agency on Aging − Tampa

43. The Goals of the Community-Based Care Transitions Program Source: http://innovation.cms.gov/initiatives/CCTP

44. No Place Like Home Campaign • A campaign supported by a broad and growing base of stakeholders in the Florida healthcare community • Focused on: • Addressing the drivers of through the implementation of evidenced-based practices READMISSIONS

45. No Place Like Home Campaign (continued) • Shared Vision: • A healthcare system where discharged patients: • UNDERSTANDtheir conditions • KNOWwho to contact with questions (and when) • ARE SUPPORTED by healthcare professionals who have access to the right information, at the right time

46. No Place Like Home Campaign (continued)

47. No Place Like Home Campaign Basics • Hospitals assign a multidisciplinary team • Team lead, physician champion, and other team players • Collect and analyze data • Invite post-discharge providers to participate • Skilled nursing facilities, home health, managed care organizations • Develop and evaluate corrective actions using Plan, Do, Study, Act (PDSA) • Implement successful corrective actions • Share lessons learned throughout the organization and community

48. 30-day All-Cause Readmissions by Regions Source: Medicare fee-for-service claims for Florida inpatient discharges January 1, 2013 – June 30, 2013.

49. www.noplacelikehomefl.com (continued)

50. www.noplacelikehomefl.com (continued)