Transcript Slide 1

It Takes A Village:
Community Engagement across the Health
Care Continuum to Improve Care Transitions
& Reduce Readmissions
Alicia Goroski, MPH
Colorado Foundation for Medical Care
Integrating Care for Populations and Communities
National Coordinating Center
www.cfmc.org/integratingcare
This material was prepared by CFMC, the Medicare Quality Improvement Organization for Colorado, 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. PM-4010-035 2013
Objectives for Today’s Session
Participants will:
• Hear how a community-based approach to reducing
readmissions is effective
– Engage, motivate and sustain the work
– National strategies and best practices
• Determine how to incorporate community organizing
strategies into readmissions reduction work
– Why the solution to readmissions is community
collective action and organizing
– Why the solution to community action is you
2
Content Development
• 8th SOW:
– Transitions of Care Pilot
– VALUE
• 9th SOW
– Care Transitions Theme
• 10th SOW
– Integrating Care for Populations & Communities
– Community-Based Care Transitions Program
It Worked!!
http://jama.jamanetw
ork.com/article.aspx?
articleid=1558278
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
Interim Quarterly Results
Baseline Quarter Readmissions = 12,926
First quarter after intervention readmissions = 12,151
20.00%
19.80%
19.68%
19.60%
19.48%
19.40%
19.20%
p=0.0024
19.00%
18.80%
Jan07Apr07- Jul07-Sep07 Oct07Jan08Apr08- Jul08-Sep08 Oct08Jan09Apr09- Jul09-Sep09 Oct09Jan10Apr10- Jul10-Sep10 Oct10Mar07
Jun07
N = 62060
Dec07
Mar08
Jun08
N = 59098
Dec08
Mar09
Jun09
N = 56395
Dec09
Mar10
Jun10
N = 57984
Dec10
N = 66590 N = 64621
N = 62822 N = 65689 N = 61781
B
N = 59962 N = 61517 N = 58825
N = 57766 N = 60616 N = 59422
N = 59630
A
C
D
Numerator and Denominator Quarterly
48, 000
10, 000
53, 000
15, 000
58, 000
20, 000
Denominator (admissions)
63, 000
25, 000
30, 000
68, 000
Numerator (readmissions)
5,0 00
43, 000
Jan07-Mar07 Apr07-Jun07 Jul07-Sep07 Oct07-Dec07 Jan08-Mar08 Apr08-Jun08 Jul08-Sep08 Oct08-Dec08 Jan09-Mar09 Apr09-Jun09 Jul09-Sep09 Oct09-Dec09 Jan10-Mar10 Apr10-Jun10 Jul10-Sep10 Oct10-Dec10
N = 66590
N = 64621
N = 62060
N = 62822
N = 65689
N = 61781
N = 59098
N = 59962
N = 61517
N = 58825
N = 56395
N = 57766
N = 60616
N = 59422
N = 57984
N = 59630
A
B
C
D
Quarter
The unit N represents target community eligible beneficiaries.
MIlestones: A) baseline quarter; B) Care Transitions theme initiation (Aug 2008);
C) intervention implementation (Jan 2009); and D) 28-month follow up quarter.
Rehospitalization Trends, Intervention and Comparison Communities
-5.7% (p<.001)
-2.1% (p=.08)
P=.03 (difference)
Hospitalization Trends, Intervention and Comparison Communities
-5.7% (p<.001)
-3.1% (p<.001)
P=.01 (difference)
Statistical process control
• Assesses variation in an outcome presumed to be
related to system functioning
• A change worth investigating:
– Reduced variation (increased control)
– Significant change in the value of the outcome
Process control limits = 3sd from the mean variation during ‘baseline’
‘Significant’: 8 points in a row above/below the mean with at least one
point in the ‘during intervention’ time period
OR
A single point above/below the process control limit in the ‘during
intervention’ time period
Community Results
Rehospitalizations
Intervention
Comparison
Special cause decrease
10/14 (71%)
22/50 (44%)
Special cause increase
2/14 (14%)
13/50 (26%)
Hospitalizations
Intervention
Comparison
Special cause decrease
13/14 (93%)
31/50 (63%)
Special cause increase
0/14 (0%)
8/50 (16%)
Control Charts – an innovative way to
measure progress in healthcare
Target Community - AL_0
3s Limits
For n=2:
22
UCL=22.01
20
X=20.08
The
Improvement
continues….
LCL=18.14
18
Test1
Test1
Test1
Test1
16
Test1
Test1
Test1Test1
14
0
2
4
6
8
10
12
14
16
18
20
22
24
Target Community - TX_0
3s Limits
For n=2:
22
Readmissions per 1000 Benes
Readmissions per 1000 Benes
24
UCL=20.66
20
X=18.54
18
16
Test1
LCL=16.42
Test2
Test2 Test1
Test1 Test1
Test1
Test1
Test1
Test1
14
0
2
4
6
8
10
12
14
16
18
20
22
24
What’s important about this
publication?
• Intervention communities avoided twice as many
rehospitalizations (1 hospitalization for every 1000
Medicare beneficiaries) and hospitalizations (5 for every
1000 beneficiaries) as comparison communities
• Improvement for whole communities is a promising
strategy
– Providers engaged based on relevance
– QIOs in the role of convener/supporter
– Included community and social services
• Unadjusted geographic population data allows easy data
display/sharing
What Else was Important?
• Allowing flexibility leverages local
resources/context
• Shewhart control charts published in a major
peer-reviewed journal
• Rehospitalizations/1000 and
hospitalizations/1000 metrics proved useful for
improvement work
Collective Impact as a framework
• Why the solution to readmissions (care
transitions quality improvement) is
community collective action
• Why the solution to community collective
action is you
– Within your ‘industry’
– Within a greater community
Collective Impact. Stanford Social Innovation Review, Winter 2011.
http://www.ssireview.org/pdf/2011_WI_Feature_Kania.pdf
The Tragedy of the Commons
“The… problem has no technical solution; it requires a fundamental
extension of morality.”
Garret Hardin
Science, New Series, Vol. 162 (3859): 1243-8, 1968.
Principles of Enduring CPR Arrangements
1. Clearly defined boundaries
2. Congruence between rules governing the
taking (appropriation) and providing of
resources and local conditions
3. Collective-choice arrangements allowing for
the participation of most of the appropriators in
the decision making process
4. Effective monitoring by monitors who are
part of or accountable to the appropriators
5. Graduated sanctions for appropriators who
do not respect community rules
6. Conflict-resolution mechanisms which are
cheap and easily available
“Polycentric Local Management”
What does this have to do with
healthcare?
http://content.healthaffairs.org/content/29/9/1678.full.html
Common-Pool Resource Management
CPR Management
Clearly defined borders
Geographic isolation
Local adaptation of access ‘rules’
Local payer serving community needs
Participation of ‘appropriators’ in
decision-making process
Longstanding culture of collective action
Effective monitoring by appropriators
Physician utilization comparison ranking
Graduated sanctions for those not
respecting community rules
Payment incentives, pride in ranking
Conflict resolution mechanisms that are
cheap and accessible
IPA culture, payment incentives, social
networks – ‘the grocery store factor’
http://en.wikipedia.org/wiki/Common-pool_resource
Readmissions - not just a
hospital problem
It’s a Community Problem
HHA
SNF
5 conditions of collective success
•
•
•
•
•
Common agenda
Standard measurement system
Mutually reinforcing activities
Continuous communication
Backbone support organizations
Collective Impact. Stanford Social Innovation Review, Winter 2011.
http://www.ssireview.org/pdf/2011_WI_Feature_Kania.pdf
Channeling change: Making collective impact work
http://www.fsg.org/Portals/0/Uploads/Documents/PDF/Channeling_Change
_SSIR.pdf?cpgn=WP%20DL%20-%20Channeling%20Change
So what does it take?
•
•
•
•
A few champions
Belief in the goal over attribution
Simple measures of progress towards the goal
Relationship building
Tools to help foster success:
Community Organizing Techniques
• Tie participation to
values
• Include public
narratives
• Intentionally develop
other leaders
• Intentionally develop
relationships
• Develop flexible tactics
Public Narrative
Strong
commitment to
the
relationships
Thanks to Marshall Ganz, NOI, OfH and others
En
Creating shared relational commitment
Relationship as Interest
Common Interests
New Interests
Interests
Interests
Resources
Resources
New Resources
Common Resources
Relationship as Resource
Creating shared structure
31
Organizing in Healthcare
• NW Denver Sustainability Campaign
• National Health Service in GB
• Organizing for Health
– Operation Safe Surgery, SC
– Healthy South Carolina
– QIO 10th SOW
– CCTP Partners
Public Narrative - example
33
QIO Accomplishments as of January 31, 2013
# of Engaged Communities
# of Beneficiaries Living there
359
12,455,368
# Formally Recruited Communities
222
# Communities with Signed Coalition Charter
219
# Applications Submitted
126
# Communities Receiving Formal Funding
66
# Recruited Hospitals
850
# Recruited Nursing Homes
1,482
# Recruited Home Health Agencies
880
# Recruited Hospice Facilities
333
# Recruited Dialysis Facilities
96
# Recruited Outpatient Physicians
> 1,914
QIO
th
10
SOW
• National Map with 400+ QIO Communities
National Coalition of QIO-recruited Communities Early Progress
6.8%
National Coalition of QIO-recruited Communities Early Progress
9.1%
Texas Data
•
•
•
•
•
•
Highest number of recruited communities
Highest number of community coalition charters
3rd highest number of engaged communities
3rd highest number of accepted CCTP applications
16th in admissions reduction
27th in readmissions reduction
Select Interim Improvement!!!
10/1/10-3/31/11 compared to 10/1/11-3/31/12
41
Community
Admissions
Readmissions
Statewide
5.07%
5.75%
Katy
6.16%
1.22%
Lubbock
5.01%
12.00%
Laredo
6.08%
11.19%
Nacogdoches
8.10%
2.46%
Brownsville
3.55%
2.61%
Harlingen
6.68%
19.56%
San Antonio
4.56%
5.53%
Waco
4.07%
4.89%
Lufkin, Texas
42
Lufkin, Texas
Intervention
# Beneficiaries
Touched
Follow Up Appointment Scheduled for CHF Patients
151
Follow Up Appointments Scheduled for CHF, AMI, and PNE patients
190
Patient Education: Use of CHF Zone tool for CHF patients
50
Follow-up Appointments Scheduled for
CHF Patients
80.0%
75.0%
70.0%
63.6%
60.0%
54.5%
(7)
(6)
50.0%
43.8%
40.0%
30.0%
(12)
33.3%
27.2%
(3)
27.8%
(4)
(5)
(3)
20.0%
40.0%
(7)
30.8%
20.0%
(2)
(2)
12.5%
(4)
20.0%
(2)
10.0%
n=11
n=9
n=13
n=16
n=18
n=10
n=16
n=10
n=11
n=11
n=10
n=16
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Follow-up Appointments for CHF, AMI, PNE
Patients
70.0%
60.0%
57.7%
52.6% (10)
52.4%
(15)
(11)
50.0%
50.0%
(5)
43.5%
40.0%
40.0%
40.0%
(6)
(6)
(4)
30.0%
40.0%
(10)
33.3%
27.3%
(7)
26.3%
(3)
(5)
20.0%
n=19
n=10
n=21
n=15
n=21
n=26
n=11
n=19
n=15
n=10
n=23
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
30-day Readmission for HF Patients
50.0%
44.4%
40.0%
30.0%
20.0%
16.7%
13.6%
10.0%
7.7%
0.0%
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
8.9%*
5.3%*
*10.1.10-3.31.11
compared to
10.1.11-3.31.12
Acknowledgements
We welcome your suggestions for improving this guide further for future training sessions. We also
welcome you to use it and adapt it for your own training needs, subject to the restrictions below.
Many of these materials have been developed by Kate Hilton, Janet Groat, Erin McFee, Sarah KopseSchulberg, Chris Lawrence-Pietroni, Liz Pallatto, Joy Cushman, Devon Anderson, Jake Waxman, Hope
Wood, Ella Auchincloss, New Organizing Institute staff, and many others.
Restrictions of Use
This information is provided to you pursuant to the following terms and conditions of use. Your
acceptance of the work constitutes your acceptance of these terms:
You may reproduce and distribute the work to others for free, but you may not sell the work to others.
You may not remove the legends from the work that provide attribution as to source (i.e., “originally
adapted from the works of Marshall Ganz of Harvard University”).
You may modify the work, provided that the attribution legends remain on the guide, and provided
further that you send any significant modifications or updates to [email protected] or
Marshall Ganz, Hauser Center, Harvard Kennedy School, 79 JFK Street, Cambridge, MA 02138
You hereby grant an irrevocable, royalty-free license to Marshall Ganz and his successors, heirs, licensees
and assigns, to reproduce, distribute and modify the work as modified by you.
You shall include a copy of these restrictions with all copies of the guide that you distribute and you shall
inform everyone to whom you distribute the guide that they are subject to the restrictions and
obligations set forth herein.
Questions
[email protected]
www.cfmc.org/integratingcare