CMS National Conference on Care Transitions

1. CMS National Conference on Care Transitions December 3, 2010

2. There’s No Place Like Home:Home Health Interventions & Strategies To Travel the Yellow Brick Road Sara Butterfield, RN, BSN, CPHQ Senior Director, Health Care Quality Improvement / IPRO

3. NY Home Health Collaboration History

4. Key Drivers Impacting Transitions of Care Cross-setting … • Care Coordination • Communication • Medication Management & Reconciliation • Patient /Caregiver Activation & Self Management Assessment • Assessment of Patient & Care Goals at Transition • Information Transfer

5. Foundation for Success • Cross-setting Partnerships • Patient/Resident Centered Focus • Organizational Self Assessment • Senior Leadership Commitment • Multidisciplinary Involvement • Focus on Process Not the Setting • Shared Learning • Celebration of Improvements

6. Home Health Quality Improvement Campaign www.homehealthquality.org

7. Care Coordination • Acute Care Hospitalization (ACH) Risk-Assessment Tool • Based on individual agency case mix • Cross-walked to OASIS • Used at Start of Care & Resumption of Care • Hard-wired to electronic medical record • High-risk status alert to all shifts / disciplines • Front-Loading Visit Schedule • Telehealth / Telemonitoring • Palliative Care Program

8. Communication • Situation-Background-Assessment-Recommendations (SBAR) Tool • Communication with physician for change in patient status • Interdisciplinary / shift report • Stop & Watch Tool • CNA, Physical & Occupational Therapy • Family and caregiver • Emergency Department Report • Cross-setting Readmission Review Teams

9. Medication Management & Reconciliation • NY Care Transitions Community Best Practice Model • Medication Discrepancy Tool Monitoring • Patient Level • System Level • Tracking and trending with sending providers • Beers Criteria • Potential Interaction Alert System • Medication Simplification Tool • Medication Management Care Planning

10. Medication Management & Reconciliation • Partnering with Colleges of Pharmacy • Medication Review • Home Visits • Education of staff and patients • Follow-up phone monitoring • Community Pharmacy Collaboration • Cross-setting Patient Educational Tools

11. Patient Activation & Self Management Assessment • Care Transitions Intervention Model • Care Transition Measure-3 • Personal Health Record • Red-Yellow-Green Zone Tools • Diagnosis & symptom specific • CNA involvement • Marketing tool • Emergency Care Plan • Teach-Back Model • Beneficiary Outreach • Focus Groups

12. Assessment of Patient & Care Goals at Transition • Cross-setting Teaching Tools • Assessment of learning • Patient centered goals • Hospital Based Case Manager Liaison • Collaborates with ED • Facilitates transfer of critical information • Interviews patient/caregiver regarding ED visit • Coordinates home care referrals • Nurse-To-Nurse Verbal Report • Cross-setting Referral Teams

13. Information Transfer • NY Care Transitions Initiative Universal Transfer Tool • Portal Access to Electronic Health Record • Fax System of Critical Information • Regional Health Information Organization (RHIO) Collaboration

14. Number of Returns To Acute Care Within 30 Days NY Transitions Area Residents Receiving Home Care Between Discharge & ReadmissionSource: CMS Ad Hoc Data

15. Percent Reduction in Number of Returns to Acute Care Within 30 Days NY Transitions Area Residents Receiving Home Care Between Discharge & Readmission2007 – 2009Source: CMS Ad Hoc Data

16. Strategies for Intervention Implementation • HHQI Best Practice Intervention Packages • Leadership Track • Interdisciplinary Tracks • Tools & Resources • Success Stories • Partner with community referral sources • Identify what works well and not so well • Prioritize improvement opportunities • Design & document Implementation Plan

17. Sara Butterfield, RN, BSN, CPHQ Senior Director, Health Care Quality Improvement 518 426-3300 x104 sbutterfield@nyqio.sdps.org http:caretransitions.ipro.org CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY 11042-1002 REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY 12211-2370 www.ipro.org This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 9SOW-NY-THM7.2-10-27

18. For more information, contact: Sara Butterfield, RN, BSN, CPHQ Senior Director, Health Care Quality Improvement IPRO 518 426-3300 x104 sbutterfield@nyqio.sdps.org http:caretransitions.ipro.org This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 9SOW-NY-THM7.2-10-27