NoCVA North Carolina Preventing Avoidable Readmissions Collaborative

1. NoCVA North CarolinaPreventing Avoidable Readmissions Collaborative Community Engagement and CMS Reports Preview November 8, 2012 NoCVA Hospital Engagement Network

2. How to Participate Today • Use the Hand Icon to raise your hand, your line will then be unmuted • Submit text questions through the Questions box NoCVA Hospital Engagement Network

3. Collaborative Action PeriodTimeline NoCVA Hospital Engagement Network

4. Agenda NoCVA Hospital Engagement Network • Hospital sharing of improvement strategy: Katherine Barmer, Carteret General Hospital • CMS “Dry Run” Readmissions Report: Erica Preston-Roedder, Director of Quality Measurement • Preview of Community Engagement: Linda McNeil, CCME

5. Carteret General HospitalOutreach Services Reducing unnecessary ED visits and preventable readmissions at Carteret General Hospital by improving transitions of care and building and strengthening community partnerships

6. Carteret General HospitalOutreach Services • Readmission Collaborative • Community Care Plan • The Learning Center • Stroke Transitional Care • Community Transitions Project • Telehealth

7. Community Care Plan • Public/private partnership • Carolina Access Medicaid • Drive down cost and utilization while increasing quality of care • Physician-drive, patient-centered care

8. Carteret General Hospital Learning Center • DSME-ADA Recognized • Educating/empowering patients in managing their diabetes at home • MNT patients • Group and individual therapy

9. Carteret General HospitalStroke Transitional Care Program • In Hospital Visit Program introduction/stroke education • Home Visit 48-72 hours post discharge • Call Back Program At 1 week, 1 month, 2 months, and 3 months post discharge

10. Carteret General HospitalStroke Transitional Care Program Program Successes *Provider follow up within 7 days of discharge *Post discharge monitoring *Referrals for diabetes education, MNT, smoking cessation *Enhanced post acute assessment of outpatient needs

11. Carteret General HospitalStroke Transitional Care Program Program Successes *Patient specific medication education *Reinforcement of stroke education utilizing teach back method *Early recognition of signs and symptoms of stroke and initiation of action plan

12. Community Transitions Project • Partnership with CCME-QIO and other community health care providers and stakeholders • Work collaboratively in a comprehensive, community-wide effort to measurably improve the quality of care provided to Medicare beneficiaries who transition between care settings. The goal of this project is to reduce 30-day readmission rates. • Test and measure practice innovations, share experiences, and communicate openly with CCME and other providers in the CT Program on quality improvement activities.

13. Carteret General Hospital Telehealth Program • Patients with CHF or related diagnosis • Follow patients 60 days post discharge • Work with patient to monitor early signs and symptoms of their heart failure and develop action plan • Case management in the outpatient setting • Follow up within 7 days of discharge • Collaboration with Cardiologist/PCP

14. Carteret General Hospital Telehealth Program • Exception monitoring • Empower patient to be an advocate for their own health • Expansion

15. Questions?

16. NoCVA Hospital Engagement Network Question Has your team identified an improvement in each of the four key areas? Yes No Yes for the first two areas only

17. NoCVA Hospital Engagement Network Question Has your team conducted a Plan-Do-Study-Act cycle? Yes No

18. Readmissions: Understanding CMS Hospital-wide readmission reports NoCVA Hospital Engagement Network

19. So many sources for info… NoCVA Hospital Engagement Network • CCNC Medicaid PPR readmissions reports, sent to your CCNC representative twice per year & to your Quality Director (or equivalent) • Extensive info on your Medicaid population • CMS ‘dry-run’ reports • Excess readmissions ratio • Hospital-wide readmissions measure

20. CMS Hospital Readmissions Reduction Program NoCVA Hospital Engagement Network • Hospital readmission reductions program • Tied to payment; ‘excess readmissions ratio’ • Publicly reported: Was reported initially in FY 2013 IPPS Final Rule, and results will be posted on HospitalCompare • CMS had a data error and has had to re-calculate HRR for all hospitals. Corrected results have been sent. • Measure uses AMI, HF, PN patients • CMS has circulated hospital-specific reports on QualityNet. Also, NCHA has circulated hospital-specific reports to the CFOs. Both contain similar info.

21. NoCVA Hospital Engagement Network

22. Hospital-Wide Readmission Measure NoCVA Hospital Engagement Network • New measure • Added to Inpatient Quality Reporting (IQR) program in IPPS final rule for FY 2013… • …so hospitals have just started reporting it to CMS • Will be publicly reported on HospitalCompare as of 2013 • I haven’t heard anything about this being tied to payment • You received your dry run report in Sept, had opportunity to ask questions up until Oct 5. Dry run report covered 2010 discharges. • Source for more info is QualityNet. • Navigation: claims-based measures/hospital-wide readmission & hip/knee measures

23. Basics of the Methodology NoCVA Hospital Engagement Network • First, various exclusions are made • Each patient is assigned one of 5 ‘specialty cohorts’ • Surgery/gynecology, cardiorespiratory, cardiovascular, neurology, general medicine • Any readmission to any hospital for any reason within 30 days is counted—unless the readmission is planned.

24. NoCVA Hospital Engagement Network

25. NoCVA Hospital Engagement Network

27. Admissions to other hospitals? NoCVA Hospital Engagement Network

28. To find another hospital’s Medicare ID NoCVA Hospital Engagement Network

29. Questions? NoCVA Hospital Engagement Network

30. Community Engagement NoCVA Hospital Engagement Network Community Self Assessment Expectations for Action Period 2 of Collaborative Expectations for Learning Session 2 on Jan. 10

31. Community Engagement with CCME

32. Second Action Period-Community Engagement Three tracks will run concurrently • Track 1: Not yet engaged in community building but beginning to implement changes within the hospital. • Track 2: Strong engagement in improving hospital processes but haven’t started with community building • Track 3: High level of engagement and success in hospital changes and community building

33. January meeting-community segment • Overview of community engagement • Breakout sessions for each track • Panel discussion • Toolkit with resources to complete the work

34. Before January 10th Prework checklist Submit zip codes to define community area Data use agreement Complete a community self-assessment and return it to CCME by November 20th Identify a community lead/partner to attend January meeting with you

35. Readiness Assessment Snapshot of the first items on the assessment.

36. Questions? This material was prepared by The Carolinas Center for Medical Excellence (CCME), the Medicare Quality Improvement Organization for North and South Carolina, 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. Product Number Needed

37. Contacts NoCVA Hospital Engagement Network • For more information, contact Laura Maynard, Director of Collaborative Learning at: lmaynard@ncha.org or 919-677-4121 or • Dean Higgins, Project Manager at dhiggins@ncha.org or 919-677-4212 • Erica Preston-Roedder, Director of Quality Measurement, at eroedder@ncha.org or 919-677-4125 • Linda Touvell McNeill, Care Improvement Specialist, CCME at: 919-356-3548 or LMcNeill@thecarolinascenter.org