ReACH National Demonstration Collaborative Reducing Acute Care Hospitalization

1. ReACH NationalDemonstration CollaborativeReducing Acute Care Hospitalization Overview Penny H. Feldman, PhD ReACH Principal Investigator Visiting Nurse Service of New York Center for Home Care Policy and Research The project team gratefully acknowledges the support from AHRQ (1 U18 HS 13694) and the Robert Wood Johnson Foundation (042588)

2. ReACH Structure and Objectives • Partnership to advance home health care quality • VNSNY Center for Home Care Policy and Research (CHCPR) • Home care QIOSC – Quality Insights of PA • 16 QIOs • 169 home health agencies (HHAs) from 20 states • Objectives • Test a collaborative model for HHA practice improvement • Reduce acute care hospitalization rates

3. HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA QIO QIO QIO QIO QIO QIO QIO QIO QIO HHA HHA HHA HHA HHA HHA HHA HHA HHA ReACH Project Staff HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA HHA QIOSC CHCPR ReACH Partnership Model

4. Background 2002: Partnership for Achieving Quality Homecare (PAQH) - Funded by AHRQ and RWJ 2004: PAQH Diabetes Learning Collaborative: - 8 HHAs - Significant improvement in 8 of 9 measures -- 30 percentage point increase in rate of patients with glucose in target range 2005: Acute Care Hospitalization (ACH) Pilot Project - QIOSC and CHCPR – evidence review and best practices 2005-2007: ReACH – 2 seven-month waves

5. Context • ~8100 Medicare-certified HHAs; ~3.4m discharges • Mandated “OASIS” assessments & publicly reported outcomes • Impending pay for performance • <20% agencies accredited • Variable quality/weak quality infrastructure • Dispersed work force/poor support for frontline managers • No history of voluntary industry partnerships • CMS-funded Home Health Quality Improvement Campaign (HHQI) 2007-2008

6. ReACH Project Goal Reduce acute care hospitalizations of home health patients and make substantial progress toward CMS target of 23% risk-adjusted rate (already achieved by 25% of all HHAs nationwide) For those agencies with rates at 23% or lower: sustain the rate, and identify ways to reduce it further

7. ReACH Best Practices • “Target” group selection (e.g.,region, office, dx) • Risk Assessment • Emergency Plans and Risk-Appropriate Care Plans • Front load visits and increase contacts (phone calls; telemedicine) for high risk patients • Medication reconciliation • Improved MD communication (Situation-Background-Assessment-Recommendation (SBAR))

8. ReACH Evaluation Level 1 – Perceptions • Participant satisfaction, challenges, lessons learned Level 2 – Care processes • Core measures, strategies and actions Level 3 – Results • Percentage of episodes ending with hospitalization Data sources • On-line surveys; phone interviews • Monthly record reviews – data entered on line • OASIS reports (Home Healthcare Compare)

9. ReACH Process Results Target patients with completed risk assessments: Total patients in target group identified at risk: +46.0 +40.6 +17.0 -8.3

10. ReACH Process Results Target patients with risk-specific care plans: +50.0 +44.4

11. +1.5 +1.9 ReACH Process Results Average home care visits in first two weeks for patients at-risk of hospitalization in target group:

12. -4.0 -7.4 ReACH Hospitalization Results Home care episodes resulting in acute care hospitalization for target group:

13. HHQI – National ACH Campaign Results • Comparison of 7,452 Medicare-certified HHAs • 4,352 Early Participating (EP) Agencies • 972 Later Participating (LP) Agencies • 2,128 Non Participating (NP) Agencies • ACH rate over a 12-month period: March 2007 February 2008 EP 30.73% 30.48% LP 32.06% 32.33% NP 34.61% 35.39% • HHAs achieving at least 5% improvement: EP (38.4%) LP (37.9%) NP (34.6%)

14. Challenges to ReACH Implementation • QIOs • Varied expertise and skills • Varied agency selection processes • HHAs • Varied QI experiences and skills • Competing priorities • Staff changes • ReACH mechanism • Long-distance faculty • Reliance on QIOs to transmit skills/knowledge • Technical issues related to virtual communication • Evaluation • Varied target groups • Varied implementation of varied strategies and tools

15. Lessons Learned • QIOs’ need/demand for TA, tools, support • HHAs’ positive response to Collaborative Learning model • Importance of face-to-face information transfer (local learning sessions) and TA • Efficiencies from leveraging QIO resources • Recruitment, TA, Data • Value of • Peer to peer reinforcement, shared experiences • Web-based data collection • Central resources • Leadership involvement key

16. Collaboration – Next Steps • Geriatric CHAMP Program • Promote National Framework to Advance Geriatric Home Care Excellence • Build geriatric capacity in significant number of HHAs • Achieve significant, measurable improvement in home care for older persons through • E-learning programs • A National Community of Practice to support quality improvement and share the Framework findings • Corollary activities and products • Collaborations (e.g., NAHC, VNAA, state associations; QIOSCs; accrediting bodies; consumer groups) • Funding – Atlantic Philanthropies, John A. Hartford Foundation, California Health Care Foundation, New York State Health Foundation, others