1. Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012

2. Welcome • What we’ll cover today: • Introduction of Care Transitions Program • The Role of HCA in the Community • Discuss Evidence Based Interventions to reduced avoidable readmissions • Share Lessons Learned form 3 Year Pilot • Open Discussion

3. Why Are We Here? • To learn about and promote safe/effective transitions of care as patients navigate from one provider setting to another – or one caregiver to another • Develop partnerships

4. Integrated Care For Populations and Communities GOAL To promote safe/effective transitions of care as patients navigate from one provider setting to another – or one caregiver to another

5. 30 Day Readmissions: The Problem • Nationally – 17.6% of Medicare beneficiaries discharged from the hospital are readmitted within 30 days. • More than 85% of these re-hospitalizations are unplanned. • 20-40% of re-hospitalizations are possibly preventable. • 64% of Medicare beneficiaries who are readmitted within 30 days do not receive any post-discharge care before readmission.

6. Mrs. B’s Story

7. 339 Days in the Life of Mrs. B • Day 1 – New internal medicine physician, poorly controlled diabetes with neuropathy, HTN, osteoporosis. To see physician q. 2 wks • Day 15 – Sees physician, fully functional, assists with care of grandchild and husband • Day 60 – Mrs. B falls on the ice, to ER, no fractures but abrasions. Referred to home health • Day 68 – Not feeling well • Day 69 – Hospitalized with Staph Septicemia, dehydration, ARF, CHF, A-Fib, PN and uncontrolled diabetes • Day 82 – Transferred to SNF for short-term rehab and wound care • Day 182 – Discharged to home, depressed, abrasions healed, diabetes under good control • Day 183 – Nauseated, can’t find her teeth, dgt intends to call home health • Day 184 – Readmitted to the hospital for dehydration, CHF, A-Fib and diabetes • Day 191-337 – Admitted to in-pt rehab then to nursing home • Day 338 – Readmitted to hospital w/ ARF, CHF, ARF • Day 339 – Mrs. B dies

8. Timeline for payment penalty for hospitals • Beginning October 2012 Medicare will apply penalties and will withhold payment for avoidable 30 day acute care readmissions with a progressively increasing scale for certain DRGs.

9. July2008-August 2011 Pilot Project

10. 14 QIOs with 14 Target Communities • AL: Tuscaloosa • CO: Northwest Denver • FL: Miami • GA: Metro Atlanta East • IN: Evansville • LA: Baton Rouge • MI: Greater Lansing area • NE: Omaha • NJ: Southwestern NJ • NY: Upper capital • PA: Western PA • RI: Providence • TX: Harlingen HRR • WA: Whatcom county

11. Targeted Community • Higher than state average re-admission rate • Located in southwestern PA, in a community surrounding the southern Pittsburgh metropolitan area • Community spans most of Westmoreland County and small portions of Allegheny, Washington, and Fayette counties

12. 9th SOW Overview • CMS • 14 states • Community cross-setting • Transparent • Remove silos • SWPA • 5 hospitals • 8 home health agencies • 15 nursing homes • 2 AAAs • 32 interventions • 14% relative improvement

13. Structure of the Project • Cross-setting • Community-based • Collaborative

14. The Shift to… • Chronic illness management • Self-care management • Empowerment • Responsibility • Accountability • Patient activation

15. Cross-Setting Goal • Develop a practical, cross-setting approach • Unite providers from all settings • Share vision of improved health care quality • Equal voices • Identify provider strength

16. The Role of Agencies • Home Health • Hosicpe

17. Hospital Elements • Leadership buy-in • Operational level leadership • Education • Silos • Bureaucracy/slow to change • Competitive • Non-transparent

18. Hospital Interventions • Self reported readmission rate • Discharge process • Discharge instructions • End of life options • 48-hour follow-up call • Schedule follow-up PCP visit • CTI-AAA

19. SNF Elements • Education • Eager to learn • Eager to share • Share competence levels • Family • Physicians • Turnover

20. SNF Interventions • SBAR • Communication transfer form • Chart reviews • End of life options/education • POLST/AD • Coach CTI

21. Home Health Elements • Focus on ACH vs. readmissions • Medication management • Low referral rates • Educate on referral criteria • Coaching • Hands on in home care

22. Drivers of Hospital Readmission • Same for home care as other health care providers: • Patient activation • Standard, known processes • Transfer of information

23. Home Health Compare • Top 20% for this measure has maintained an unplanned hospitalization rate of 21% since last quarter • While stakeholders are focusing on reducing unnecessary hospitalizations, the data tells us that we still have work to do and… • What about those 30-day readmissions? • Low-hanging fruit for home care to determine root cause and intervene in real-time—win-win for everyone

24. Home Health Compare • The latest Home Health Compare (HHC) scores were published on October 13th and reflect a data collection period of July 2010 - June 2011. Overall, the results have improved. • Hospitalization result has had a setback • Hospitalization worsened from 26% last quarter to 27% www.Fazzi.com

25. Intervention HHA • Communication transfer sheet • Front load visits • Telehealth • Phone monitoring • Life line • Chronic care education • Coaching/partnering • Depression screening • Chart reviews

26. Best Practices • Home Health Quality Improvement National Campaign Best Practice Intervention Packages (BPIPs) • Focus on reducing ACH, improving management of oral medications and cross-setting collaboration • Simplified approach to use packages • Standardized steps to follow for each publication • Flexible for HHA implementation • BPIPs free to download at: http://www.homehealthquality.org/hh/default.aspx

27. BPIPs Include • Hospitalization Risk Assessment • Emergency Care Planning • Medication Management • Fall Prevention • Care Transitions • Coaching • Patient Self-Management • Disease Management • Telehealth • Introduction to new ideas/topics: Patient Centered Medical Home; Accountable Care Organizations and others

28. Learn more…Coach/HH nurse • Coaching and home health service • Increase Medicare HH referrals • Oasis takes time • Coach non-clinical • Different role • Medication review… patient driven • Complementary/respectful

29. Lessons Learned • Community focus • Root cause analysis • Communication • Transparency • Leadership buy-in • Collaboration • Patient-centered • Ongoing monitoring • Community outreach • Sustainability

30. Lessons Learned • Re-Engineers the discharge process (Project Red, Project Boost, Medication reconciliation) • Change the paradigm of patient education (Teach Back) • Improve information transfer (Cross setting transfer form) • Increase community outreach (Collaboration with community resources, Handover) • Increase post discharge process and support (PHR, Medication management,PCP f/u appointmentand coaching)

31. August 2011-July 2014 10th SOW

32. AIMS and Goals Strategic Aims “What will be done” • Integrate Care for Populations • Care Transitions that reduce re-admissions by 20% within 3 years.

33. CMS 10th SOW for QIOs • Form a community coalition to ensure community-wide adoption of improved practices in care transitions • Assist communities in applying for the CMS 3026 CCTP funding opportunity • Form a Learning and Action Network (LAN) and provide evidence-based interventions associated with known drivers of hospital readmissions (Jan. 26, 2012) • Host quarterly LAN sessions; one in-person each year

34. CMS 10th SOW for QIOs • Provide the community with a template for coalition charters to help the partners formalize structure and procedures • Assist the community with root cause analysis to identify community-specific causes for poor transitions and develop data reports to monitor progress • Assist in the selection of the most appropriate evidence-based interventions

35. The Importance of Communities to Improve Health Care Integrating Care for Populations and Communities

36. CMS Defines a Community • Defined by contiguous zip codes • Medicare beneficiaries that live in those zip codes • Committed providers and stakeholders

37. Community Essentials • Developed around collaborative care delivery • Shared vision • Shared mission • Shared resources • Shared decision making • Environment of trust

38. A Community • Social network analysis for Medicare beneficiaries in 2009 • Allows visualization of relationships between providers through network diagrams • Shows flow of transitions among providers • Senders, receivers, provider type and strength of relationship

42. 4 Recruited Communities • Western Pennsylvania • Lehigh Valley • York • Chester County

43. Building Community • Leaders reach to other leaders • Expand the circle of support • Grow more resources • Develop/sustain commitment • Recruit people The more volunteers or members who find purpose in the community -the more they will commit resources that you may never have known existed.

44. Community Development • CMS suggested communities • Hospitals in contiguous Zip Codes • Overlap of beneficiaries/penetration • Desire to reduce re-admission rates • Agree to collaboration/relationship • Transparency • Downstream Providers

45. Provider Responsibilities • Leadership commitment • Active involvement of provider teams including leadership in meetings, conference calls, webinars and coalition activities • Implement improvement strategies using rapid cycle testing • Create new strategies that maximize improvement for all participants • Track, monitor and share real time data

46. Stakeholder Support • Are the cornerstone for the community • Learn from the community • Inform members of CT strategies • Support/provide community education sessions • Participate in quarterly calls • Provide publications via newsletter • Post information/links of CT on Web sites

47. Expand the Circle of Support… Motivating Call to Action

48. Community Intervention Selection

49. Standard/Known Process • BOOST (Better Outcomes for Older adults through Safe Transitions) • TCM (Transitional Care Model) • F/U appointment made at discharge • Pharmacy • Telephone F/U • Document standardization

50. Drivers of Readmissions Based on discharges from 2007. Clinical Classification Software (CCS) 2008 downloadable from http://www.ahrq.gov/data/hcup/ .