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Improving Care Transitions in Northwest Denver

Risa Hayes, CPC Program Manager, CFMC Integrating Care for Populations and Communities AHRQ Annual Conference September 21, 2011. Improving Care Transitions in Northwest Denver. Our Equation. Readmissions and Admissions. ( ). ( ). Who is the Community?. Acute Care Hospitals

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Improving Care Transitions in Northwest Denver

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  1. Risa Hayes, CPC Program Manager, CFMC Integrating Care for Populations and Communities AHRQ Annual Conference September 21, 2011 Improving Care Transitionsin Northwest Denver

  2. Our Equation Readmissions and Admissions ( ) ( )

  3. Who is the Community? Acute Care Hospitals LTACs SNFs Home Health Agencies Non-medical Home Care companies Senior Resource Centers Physician Offices Patient Advocates Hospice providers Palliative Care providers Medical Society Mental Health AAA QIO Hospitalists Physician management group

  4. Why are people readmitted? Provider-Patient interface Unmanaged condition worsening Use of suboptimal medication regimens Return to an emergency department Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers No community infrastructure for achieving common goals

  5. The Project Goal: • Improve care transitions for Medicare beneficiaries in 44 zip codes in NW Denver • As evidenced by: • 2% reduction in 30 day all-cause readmission rate What we did: Community Action Teams Standardized Community PHR Post-acute Care Options Tool Coaching PAM®-tailored CTISM Volunteer Advocates

  6. Community Unity • A true NW Denver Partnership • Involved a large group of community providers • 21,000 printed copies • Available online for future use

  7. Community Developed Tools Post Acute Care Decision Support Tool

  8. Timeline: Care Transitions in NW Denver

  9. Outcomes: Care Transitions Intervention℠ & Patient Activation Measure® NW Denver longitudinal data (sample size: 49) http://www.insigniahealth.com/solutions/patient-activation-measure • Coleman CTI℠ model1 • >300 patients coached • Measurement • Patient Activation Measure® (PAM®; Insignia Health)2

  10. Mr. H: A patient story “I feel that I must tell someone about how greatly I benefited from and appreciate the services of the nurse who follows up on patients discharged from your hospital. She comforted me and helped make several forceful phone calls, and soon all was well. What a great help! What a relief! Thanks.”

  11. Results

  12. Outcome: Reduce hospital readmissions and improve patient activation Evaluation & Next Steps: Apply for CCTP funding AND… Peak: Create PHR, PAC tool, Palliative/Hospice curriculum and community talks Peak: Form Action teams Kick off: Community meeting Northwest Denver: Campaign Peak: Celebration meeting – June 21st Foundation: Determine community

  13. Inspiration Northwest Denver Connected for Health: Story of Now

  14. Questions? • Risa Hayes, CPCProgram Manager, Integrating Care for Populations and CommunitiesCFMCrisah@cfmc.org • Find your QIO and Access the Toolkit: http://www.cfmc.org/caretransitions/

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