Transcript It Takes a Village: Community
It Takes a Village
Community-Based Care Transitions Improvement Jane Brock, MD, MSPH Colorado Foundation for Medical Care December 8, 2011 This material was prepared by CFMC (PM-4010-031 CO 2011), 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.
Objectives
Introduction: Common Pool Resource Management Lessons from the Care Transitions Theme Drivers of Readmission, or why reducing hospital readmissions is a community engagement project Developing a community project in care transitions ‘Collective Impact’ as a framework for managing the project A collection of insights
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 “Polycentric Local Management” 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
What does this have to do with healthcare?
Year
1992 2006
What does this have to do with healthcare?
Spending ($)
3209 5873
Rank
304 301
Year
1992 2006
What does this have to do with healthcare?
Spending ($)
3209 5873
Rank
304 301 A history of collective action to serve a visible group of people… Common mission/vision Local control Place Identity
http://content.healthaffairs.org/content/29/9/1678.full.html
Common-Pool Resource Management
CPR Management
Clearly defined borders Local adaptation of access ‘rules’ Participation of ‘appropriators’ in decision making process Effective monitoring by appropriators Graduated sanctions for those not respecting community rules Conflict resolution mechanisms that are cheap and accessible Geographic isolation Local payer serving community needs Longstanding culture of collective action Physician utilization comparison ranking Payment incentives, pride in ranking IPA culture, payment incentives, social networks – ‘the grocery store factor’ http://en.wikipedia.org/wiki/Common-pool_resource
CAN IT BE REPLICATED?
LESSONS FROM THE CARE TRANSITIONS THEME
The real world as opposed to ‘clearly defined borders’
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
Results
50,00 45,00
11 1
40,00 3
13
35,00 30,00
12 7 8
9
6 10 5
25,00 20,00 15,00 4
2
14
30-day hospital readmissions per 1,000 eligible beneficiaries, semi-annual (O-4) Best-fit lines for observed rates
Lower is better. Statistically significant trends, per Cochrane-Armitage test, are indicated by bolded p-values.
11 (p<0.0001)
3 (p=0.8862)
1 (p<0.0001) 13 (p<0.0001)
9 (p=0.6007)
12 (p=0.0010)
4 (p=0.0526)
2 (p<0.0001)
14 (p=0.1434) 10,00 Oct07-Mar08* Jan08-Jun08 Apr08-Sep08 Jul08-Dec08 Oct08-Mar09 Jan09-Jun09 Apr09-Sep09 Jul09-Dec09 Oct09-Mar10† Jan10-Jun10
Evaluation Period
Baseline measurement is indicated by an asterisk (*).
Follow-up evaluation is indicated by a dagger ( † ).
Apr10-Sep10 Jul10-Dec10
It’s not a hospital project
It’s a Community Problem
HHA SNF
HHA SNF
The ‘Zip Code Overlap’ Community Definition
FFS Medicare beneficiaries living in zip codes of interest Target Population FFS beneficiaries discharged from hospitals of interest Community identity supports both social and economic sustainability
Social Network Analytic techniques for displaying the provider network
19
DEVELOPING A COMMUNITY PROJECT TO REDUCE HOSPITAL READMISSIONS
1. RCA Drivers Data Medical record review Process assessment
Why are people readmitted?
Provider-Patient interface
U nmanaged 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
1. RCA Drivers 1. Data 2. Medical record review 3. Process assessment 2. Drivers + Settings = Interventions
Why are people readmitted?
Provider-Patient interface
U nmanaged 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
CMS’ Table of Interventions
Available at: www.cfmc.org/caretransitions
Intervention Packages
Intervention Reference
Care Transitions Intervention www.caretransitions.org
Transitional Care Nursing www.transitionalcare.info/index.html
Main tools Driver addressed
SKP Coaches, personal health record, medication discrepancy tool
?
Risk assessment , nursing training materials
XX
PAct
XXX X
Inf
X XX
CMS Discharge Checklist BOOST www.medicare.gov
www.hospitalmedicine.org/ResourecRoom Redesign Patient and family checklist of important items to address before discharge Screening/assessment , provider discharge checklist, transition record, teach-back instructions, data collection and tracking
?
XXX XXX X XX #
13 2 2 9 Best Practices Intervention Package (BPIP) www.homehealthquaqlity.org/hh/ed_resour ces/interventionpackages/default.aspx
Comprehensive manual for HHA process improvement includes CTI teaching InterAct Interact.geriu.org
Communication tools, clinical care paths, advanced care planning Transforming Care at the Bedside (TCAB) www.ihi.org/IHI/Programs/StrategicInitiative s/TransformingCareAt TheBedside.htm
(Re)Admission assessment, teach-back, pt and family communication, scheduled f/u Re-Engineered Discharge (RED) www.bu.edu/fammed/projectred/index.gtml
Nurse discharge advocate, pharmacy f/u medication teaching, PCP f/u booklet
XX XX XX XXX XX XXX XX
11
XX X XX
10 4 4
Building Community Infrastructure
1. RCA Drivers 1. Data 2. Medical record review 3. Process assessment 2. Drivers + Settings = Interventions 3. Backbone ‘agency’
Why are people readmitted?
Provider-Patient interface
U nmanaged 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
I think it’s an elephant!
• • • • Backbone ‘agency’ Common agenda Common measures Structured collaboration
3 IMPORTANT THINGS WE LEARNED:
What’s he saying? I sure hope my wife is getting this..
No I’m good to go. Whatever you say is what we’ll do Doctor Blah blah blah, blah blah. Any questions?
1. Patient activation trumps all
PATIENT ACTIVATION
The CMS Discharge Planning Checklist
http://www.medicare.gov/Publications/Pubs/pdf/11376.pdf
The Patient Activation Measure
www.insigniahealth.com
Sample Questions:
#1: “When all is said and done, I am the person who is responsible for taking care of my health.” The PAM is scored on a 100 point continuum. Most patients score between 35 and 80 #12: “I am confident I can figure out solutions when new problems arise with my health” Knowledge, skills and confidence
PATIENT ACTIVATION
37
The PAM is very helpful to guide interventions
2. Local adaptation is inevitable
Adapt gold standard models Do not adapt others’ adaptations
3. Ask the community to help
• “Brought to you by your Community Partners”
Community Organizing Techniques
Tie participation to values Include personal narratives Intentionally develop other leaders Intentionally develop relationships Develop flexible tactics
EXAMPLES
Provider Pair:
25
HHAs and hospital pharmacy (NY)
20 15 10 5 HHA 1 HHA 2 0 Q 1 (2009) Q 2 Q 3 Q 4 Q 1 (2010) Q 2 Butterfield, Stegel, Tartaglia. Improving outcomes through re-engineering care transitions: The New York Experience. Remington Report May/June 2010.
MULTI-PROVIDER INTERVENTIONS
Lateral Cluster: 30day hospital readmission rate from SNFs in Harlingen
http://www.cfmc.org/caretransitions/files/Feb24_2011%20Learning%20Session_FINAL.pdf
0,4 0,2 1,2 1 0,8 0,6 1,8 1,6 1,4 2
Partnering for coached discharges: Improved activation (Co)
30-day hospital readmissions per 1,000 eligible beneficiaries Hospital A, monthly
Median: 1.16
Monthly readmissions per 1,000 eligible Medicare FFS beneficiaries in the target community depict a reduction in readmissions, first observed in July 2009, due to special cause.
Readmission rate Median
PATIENT ACTIVATION
“IT’S CLEAR THAT SOMEBODY HAS TO DO SOMETHING AND IT’S INCREDIBLY PATHETIC THAT IT HAS TO BE US”
Jerry Garcia