A More Perfect Union: Better Health; Better Care; Lower Costs through Improvement

1. A More Perfect Union: Better Health; Better Care; Lower Costs through Improvement Jean D. Moody-Williams, RN, MPP Director, Quality Improvement Group

3. Collaboration is Hard Work!

4. Characteristics of a Learning Organization • It should review data and respond to it - with tests of new solutions and ideas - every week. • It should bring all participating sites together by phone, in person or webinar frequently • It should set one or two quantifiable, project-level goals, with a deadline, preferably defined in terms of outcomes, related to the project’s area of work. • It should invest more in learning than in teaching.

5. Characteristics of a Learning Organization • It should employ regional “innovator agents” • It should celebrate success • It should use metrics to measure its success such as: • Rate of testing • Rate of spread • Time from idea to full implementation • Commitment rate (rate at which 50% of organizations take action for any specific request) • Number of questions asked per day • Network affinity/reported affection for the network

6. Operating Values for Change • Rapid Cycle Improvement in Quality Improvement Activities and Outputs • Customer Focus and Value of the Quality Improvement Activities • Ability to Prepare the Field to Sustain the Improvements • Valuing Innovation • Commitment to “Boundarilessness” • Unconditional Teamwork • Commitments Secured/Participants Engaged/Results toward Achieving Targets

7. Measuring Progress Towards Goals Track national progress towards the program goals; Support local quality improvement measurement; Obtain feedback on progress, in close to real time, so the project can be effectively managed; and Evaluate the program’s impact on achieving stated goals. J Patient Saf - Volume 8, 2012: Hackbarth etAndrew D. Hackbarth1, MPhil, William B. Munier2, MD, MBA, Noel Eldridge2, MS, Jack Jordan1, MS, Chesley Richards3, MD, MPH, Niall J. Brennan1, PhD , Dennis Wagner1, MPA, Paul McGann1, MD

8. National and CMS Quality Strategy Aims Goals Make care safer Strengthen person and family engagement Promote effective communication and coordination of care • Foundational Principles: • Enable innovation • Foster learning organizations • Eliminate disparities • Strengthen infrastructure and data systems Promote effective prevention and treatment Promote best practices for healthy living Make care affordable

10. Implementation Levers at CMS Fraud & Abuse Enforcement Target surveys Quality Assessment Performance Improvement ACOs Community Based Transitions Care Program Dual Eligible Coverage of services Physician Feedback report Quality Resource Utilization Report Physician Value Modifier Readmissions Demonstration Projects Pilots Partnership for Patients Million Hearts National Quality Strategy Data.gov ESRD QIP Hospital VBP Plans for Skilled Nursing Facility and Home Health Agencies, Ambulatory Surgical Centers HITECH Hospital Inpatient Quality Reporting Programs QIOs QIO Innovation Projects ESRD Networks Learning Communities Hospitals, Home Health Agencies, Hospices, ESRD facilities

11. National Medicare 30 Day Readmissions

12. Innovation Center Initiatives Innovation Center Initiatives Support Care Transformation • ACO Initiatives: Shared Savings Program, Pioneer, Advance Payment, Learning Sessions • Bundled Payments for Care Improvement • Innovation Advisors Program • Multi-Payer Advanced Primary Care Practice Demonstration • Comprehensive Primary Care Initiative • Partnership for Patients • Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration • Medicaid Health Home State Plan Option • State Demonstrations to Integrate Care for Dual Eligible Individuals • Demonstration to Improve Quality of Care for Nursing Facility Residents • Financial Models to Support State Efforts to Coordinate Care for Medicare-Medicaid Enrollees

13. Hospital Readmissions from Post Acute Care (PAC) Settings • CMS work in Progress for PAC settings, over Next Year: • Developing 30-day Readmission Quality Measures for • NHs, LTCHs, IRFs • Key Considerations from Technical Expert Panels: • Risk Adjustment may need to vary by provider setting, population. • Various models to consider. • Planned Readmissions exclusions? Reasons/diagnoses • may vary by provider setting. • 30-day Readmission Measurement Period could cover the 30 days after hospital discharge. Could have separate measure to cover the 30 days after PAC discharge.

14. PAC Readmission: Other CMS Targeting Strategies • CMS is currently updating the surveyor interpretive guidance for transfer and discharge planning regulations • New regulations are being developed to establish Quality Assurance and Performance Improvement (QAPI) programs in all CMS-certified nursing homes.

15. Partnership for Patients:We are still focused on our aim • 40% Reduction in Preventable Hospital Acquired Conditions • 1.8 Million Fewer Injuries • 60,000 Lives Saved • 20% Reduction in Preventable 30-Day Readmissions • 1.6 Million Patients Recover Without Readmission • Potential to save $35 billion in 3 years

17. QIO Content Development • 8th SOW: • Transitions of Care Pilot • VALUE • 9th SOW • Care Transitions Theme • 10thSOW • Integrating Care for Populations & Communities • Community-Based Care Transitions Theme

18. It Worked!! http://jama.jamanetwork.com/article.aspx?articleid=1558278

19. Rehospitalization Trends, Intervention and Comparison Communities -5.7% (p<.001) -2.1% (p=.08) P=.03 (difference)

20. Hospitalization Trends, Intervention and Comparison Communities -5.7% (p<.001) -3.1% (p<.001) P=.01 (difference)

21. Community Results

22. August 1, 2011 Integrating Care for Populations & Communities Aims: • Improve the quality of care for Medicare beneficiaries as they transition between providers • Reduce 30 day hospital re-admissions (nationally) • Reduce hospital admissions (nationally)

23. QIO Accomplishments as of March 31, 2013

24. QIO Recruited Communities

26. National Coalition of QIO-Engaged Communities Early Progress 4.4%

28. National Coalition of QIO-engaged Communities Early Progress 6.0%

29. State by State Admissions/1000

30. State by State Readmissions/1000

31. State by State ED Visits/1000

32. State by State Observation Stays/1000

33. Readmissions - Not Just a Hospital Problem

34. It’s a Community Problem HHA SNF

35. It’s all about the community! Think about different types of coalitions

36. Community Action Teams • Local Leadership (Steering Committee) • Community-wide Meeting • Mastermind Invitation “You were recommended by your peers to participate in a mastermind group . . .” • Call to Action - Personal stories to harness engagement • Established sense of urgency & easy to become involved • Action Teams • Cross-setting; same-setting competitors; “product” oriented

37. Collective Impact • Many organizations with similar work • Aimed to improve the whole continuum • No new funding • Developed a common set of goals and metrics • Structured the process and communication

38. 5 Conditions of Collective Success • Common agenda • Standard measurement system • Mutually reinforcing activities • Continuous communication • Backbone support organizations Collective Impact. Stanford Social Innovation Review, Winter 2011. http://www.ssireview.org/pdf/2011_WI_Feature_Kania.pdf Channeling change: Making collective impact work http://www.fsg.org/Portals/0/Uploads/Documents/PDF/Channeling_Change_SSIR.pdf?cpgn=WP%20DL%20-%20Channeling%20Change

39. So What Does it Take? • Afew champions • Belief in the goal over attribution • Simple measures of progress towards the goal • Relationship building

40. Tools to Help Foster Success:Community Organizing Techniques • Tie participation to values • Include personal narratives • Intentionally develop other leaders • Intentionally develop relationships • Develop flexible tactics

41. On the Right Track!!