Hosted by the RARE Operating Partners:

1. Health Plans and Hospitals: Working Together to Prevent Readmissions - A Collaborative Approach to Transition ManagementJuly 30, 2013 Hosted by the RARE Operating Partners: Institute for Clinical Systems Improvement, Minnesota Hospital Association, Stratis Health

2. Our host today will be… Kim McCoy, Project Manager – Stratis Health Ms. McCoy provides leadership on health care quality initiatives throughout Minnesota. She supports development and implementation of Minnesota’s participation in the Patient Safety and Clinical Pharmacy Services Collaborative, a national initiative to reduce adverse drug events. Kim provides technical assistance to participating pharmacists and health care teams to successfully integrate medication therapy management and clinical pharmacy services into their organizations. She also provides leadership for the RARE Campaign to reduce hospital readmissions and community-based efforts to improve care transitions as part of the Centers for Medicare & Medicaid Services (CMS) Quality Improvement Organization contract.

3. Why RARE Conversations? Share Networking opportunities Learn Engage Conversation

4. July’s Conversation… A Collaborative Approach to Transition Management Sharing their work: Ucare

5. More about the presenters… Caroline Dietz-Carlson, RN  Caroline Dietz-Carlson is a Quality Improvement Specialist at UCare. Caroline is a Registered Nurse (RN) with extensive clinical, program development, project management, and performance improvement background. She is a team member with the 2012 Collaborative Performance Improvement Project (PIP) for the Readmission topic: “Improving Transitions Post-hospitalization”, a partnership among four Minnesota health plans – Blue Plus, Medica, Metropolitan Health Plan, and UCare.

6. More about the presenters… Lorraine Cummings, LPN • Lorraine Cummings is a Quality Improvement Specialist at UCare. Lorraine is a Licensed Practical Nurse (LPN) with a background in health plan, managed care, clinic, and hospital settings and has project management experience in quality improvement, disease management, and health education. • She is the project lead with the 2012 Collaborative Performance Improvement Project (PIP) for the Readmission topic: “Improving Transitions Post-hospitalization”, a partnership among four Minnesota health plans - Blue Plus, Medica, Metropolitan Health Plan, and UCare.

7. A Collaborative Approach to Transition Management

8. Care Transition Management Session Objectives: • Understand the health plan care coordinator’s role and responsibility with transition support. • Explore improved communication and collaboration between hospitals and health plans to provide effective transitions and reduce avoidable readmissions.

9. 2012 CMS QIP / 2013 DHS PIP: Improving Transitions Post-hospitalization Goal: • To reduce hospital readmissions by improving member support for the transition from hospital to home or a care setting for: • Minnesota Senior Health Options (MSHO) • Minnesota Senior Care Plus (MSC+) • Special Needs BasicCare (SNBC) members

10. Care Coordinators Who are they? • Registered Nurse or Licensed Social Worker • Health plans have “delegate” care coordinators (contracts with care systems, counties, agencies) What do they do? • Communicate, support, educate, arrange services • Communicate with members and their health care providers

11. Care Coordinator’s Role • Coordinate services • Provide effective transition support • Communicate with individuals involved in the discharge process • Assess issues known to impact readmissions • Identify and note current services and needed changes • Update care plan

12. Communication and Efficiencies • On admission, ask member if they have a care coordinator and connect with care coordinator • They want to help you with your job • Good resource - they can assist and provide info • They can help get services / authorize services • They know benefit sets

13. Key Interventions: • Improve Transition of Care (TOC) Log • Train care coordinators in use of TOC Log • Annual audits of TOC Logs

14. Additions to TOC Log Four Pillars for Optimal Transition: • Timely follow-up visit • Medication self-management • Knowledge of red flags • Use of personal health record As a result of this transition discussion: • Have you updated the member’s care plan? • Services Started, Stopped, Changed and/or Refused?

15. Reality: • Hospital: 24/7 • Health Plan: M-F (9-5) • Weekend coverage and processes • RN / SW discharge planners, health coaches and health plan RN / SW care coordinators

16. Care Coordinator Challenges: • Care coordinator often does not know when a member is admitted or discharged • Difficult to connect with hospital discharge planners • They call hospital and can’t obtain info - HIPAA • Member may not know reason for admission (e.g. Non-English speaking)

17. What Health Plans Hope to Achieve: • Timely notification of admission and discharge info • Reduce duplication • Decrease confusion • Optimize coordination of care and communication • Reduce readmissions • Request that hospital discharge planner give patient the health plan care coordinator’s contact info and let them know they will connect with them post-discharge

18. Questions & Answers Discussion

19. Questions or Feedback Kim McCoy, MPH, MS Program Manager, Stratis Health KMCCOY@stratishealth.org 952-853-8563 Caroline Dietz-Carlson, RN, BS Quality Improvement Specialist, UCare cdietz-carlson@ucare.org 612-676-3341 Lorraine Cummings Quality Improvement Specialist, UCare  lcummings@ucare.org 612-676-3246

21. Upcoming RARE Events…. • RARE Action Learning Day, • November 11, 2013, (8:30 a.m. – 3:30 p.m.) • Next RARE Webinar, August 23, 2013 at noon. Stay tuned for more details.

22. Future webinars… • To suggest future webinar topics, contact Kathy Cummings at kcummings@icsi.org.