Working Together to Improve Care Transitions in Oklahoma

1. Working Together to Improve Care Transitions in Oklahoma Elanor Wallis Care Transitions Manager

2. Today’s Objectives Following the presentation, participants will be able to: • Summarize alignment of this project with the National Priorities and Partnership for Patients • List three potential approaches to accomplish the work in Oklahoma • Name one way you might participate to improving care in Oklahoma

3. Oklahoma Foundation for Medical Quality • Private non-profit organization. The Quality Improvement Organization (QIO) for the state of Oklahoma for 40 years • Provides quality improvement training and technical assistance in diverse healthcare settings (hospitals, nursing homes, physician practices) • Works in partnership with providers and organizations to develop and communicate high quality processes and methods for improvement in both individual and population health (www.ofmq.com)

4. Quality Improvement Organization • Recruit and convene providers, practitioners and patients to identify knowledge gaps, build and share best practices • Work toward rapid, wide-scale improvements in patient care, improvements in population health and decreases in health care cost • Match organizations that have questions with those that have answers

5. Aligned with National Priorities QIO initiatives support • National Quality Strategy • Six priorities: safer care, coordinated care, person- and family-centered care, preventive care, community health, making care more affordable • Partnership for Patients • Including work with Hospital Engagement Contractors

6. QIOs Seek Improvement Synergies

7. “None of us is as smart as all of us” Ken Blanchard

8. Care Transitions The movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

9. Care Transition and the Patient • Empower beneficiaries to participate in health care decision making and take an active role in managing their own health • Care Transitions improvement removes the socioeconomic, educational and cultural barriers that can prevent beneficiaries from obtaining appropriate health care

10. Feedback • Do you know of an effort in your community to improve transitions of care? • Yes • No

11. Feedback • Are you interested in a follow up Web Conference to learn about convening a community group and aligning goals toward improving care transitions? • Yes • No

12. Why Improve Care Transitions? • Patient care is fragmented • Patients are unhappy1 • Providers are dissatisfied • Within 30 days of discharge 19.6% of Medicare patients are rehospitalized2 • Up to 76% of these readmissions may be preventable3 1 Care Quality Information from the Consumer Perspective Hospital Survey (HCAHPS) Pilot 2 Jencks SF, Williams MV, Coleman EA: Rehospitalizations among patients in the Medicare Fee-for-service Program. NEJM 2009 Apr 2; 360(14):1418-28. 3 MedPAC: June 2007 Report to the Congress: Promoting Greater Efficiency in Medicare

13. Who is at Risk for Readmission? • Patients with fragile social support systems • Certain health behaviors and disease states • Patients with multiple chronic diseases • Terminal patients • Patients unable to attend to basic daily needs http://www.healthcare.gov/compare/partnership-for-patients/safety/transitions.html

14. Feedback • Which of these causes do you think is most evident in your own community? a. Patients with fragile social support systems b. Certain health behaviors and disease states c. Patients with multiple chronic diseases d. Terminal patients e. Patients unable to attend to basic daily needs

15. Elements of a safe, effective Care Transition • Patient (or caregiver) training to increase activation and self-care skills. For example, the Care Transitions InterventionSM, developed by Eric A. Coleman, MD, MPH • Patient-centered care plans--negotiated with patient and family and responsive to the medical and social situation and the availability of services--that are shared across settings of care

16. Elements of a safe, effective Care Transition • Standardized and accurate communication and information exchange between the transferring and receiving provider in time to allow the receiving provider to effectively care for the patient. • Medication reconciliation and safe medication practices • Ensured transportation for health care-related travel • Procurement and timely delivery of durable medical equipment • Ensuring the sending provider maintains responsibility for care of the patient until the receiving clinician/location confirms the transfer and assumes responsibility

17. Evidence based Interventions • Project RED (Reengineering Discharge) • BOOST (Better Care for Older Adults through Safe Transitions) • The Care Transitions Model (CTM) • Interact II (Nursing Home Model to reduce readmissions) • Guided Care

18. Hospital Readmissions Reduction Program • Section 3025 of the Affordable Care Act established the “Hospital Readmissions Reduction Program” effective for discharges from an “applicable hospital” beginning on or after October 1, 2012.

19. Hospital Readmissions Reduction Program • What is a readmission? • Any hospital admission that occurs within 30 days of discharge, except for readmissions that are unrelated to the prior discharge (such as planned readmissions or transfers to another hospital). • The AMI readmission measure does not count as a readmission within 30 days if it includes PTCA or CABG unless the readmission principal diagnosis is heart failure, AMI, unstable angina, arrhythmia, or cardiac arrest

20. Section 3026 • The Community Based Care Transitions Program (CCTP) goals are; • to reduce hospital readmissions, • test sustainable funding streams for care • transition services, • maintain or improve quality of care, and • document measureable savings to the • Medicare program.

21. 3026 Funding CMS invites Community Based Organizations (CBOs) to submit an application for funding which describes the proposed care transition intervention(s) and the community or communities in which they will be applied.

22. Community Based Organizations (CBO) • Must partner with at least one hospital; preference given to CBOs working with multiple hospitals and to CBOs working with hospitals with high readmission rates • Must be physically located in the communities where they practice • Must be a legal entity able to bill and accept money

23. Role of the CBO • Payment is based on a blended rate proposed in the response to the solicitation. • The blended rate can reflect different costs for different categories of patients • Does not include initial training. Sites must have some previous experience with care transitions, so they must have paid for initial training. • CMS payment also cannot directly support travel expenses for attending the required meetings in Baltimore (this funding must come from some other source).

24. Role of the CBO • Bills and receives payment on a per eligible discharge basis for Medicare beneficiaries at high risk for readmission, including those with multiple chronic conditions, depression, and cognitive impairments • Use care transition services to effectively manage transitions in the community • Report process and outcome measures on their results

25. Where to Begin The application should include a community root cause analysis and a description of the targeted Medicare population who are at high risk for avoidable readmission.

26. Start now. Work within communities. • Have conversations about Care Transitions • Form effective care transitions coalitions • Reduce avoidable hospital readmissions • Build capacity to qualify for funding through Section 3026 of the Affordable Care Act

27. Feedback Can you think of someone in your community who may be appropriate as a CBO? • Yes • No • I would participate in a follow up Web Conference regarding Community Based Organizations and the 3026 funding opportunities

28. OFMQ Analytic Assistance

29. OFMQ Analytic Assistance • Analysis and feedback reports for self-collected • intervention data • Patient/Provider satisfaction data • Patient activation surveys • Improvement process measures • Analysis of readmission outcomes

30. OCTLAN • Oklahoma Care Transitions Learning and Action Network (OCTLAN) • Community Engagement • Online interaction, tools, resources • Interactive List Serve • Educational opportunities

31. To Join the CT-List Serve • Open a new email message from the inbox you wish to receive Care Transitions postings. • Enter ct-subscribe@list.ofmq.comin the To: field. • Enter ‘subscribe’ in the subject field. • Click Send.

32. How Does This Impact You? • How do national programs and services align with your health quality priorities? • What can we offer to strengthen or extend your improvement initiatives? • How can we make an impact on health and health care for our communities, together?

33. Thank you for your time. • Please begin answering evaluation questions • There are 10 questions, so please scroll to the end of the questions before you “submit”. • Slides will be posted to www.ofmq.com/octlan by end of business Thursday January 26, 2012

34. Web Resources • www.ofmq.com/octlan • www.cfmc.org/integratingcare/toolkit.htm • www.healthcare.gov/compare/partnership-for-patients/safety/transitions.html • www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313

35. Questions? This material was prepared by Oklahoma Foundation for Medical Quality, the Medicare Quality Improvement Organization for Oklahoma, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10C8ICPC-1387-OK-0112 Elanor Wallis Care Transitions Project Manager ewallis@ofmq.com