It Takes a Village

Community-Based Care Transitions Improvement Marian Boxer, RN Colorado Foundation for Medical Care February 22, 2012 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

Reducing Readmissions 4 Important things we learned from the Care Transitions Theme Where to start – Drivers and Settings New /Current opportunities

A Variety of Opportunities

Walkers: just starting to think about care transitions & reducing readmissions QIO Support Community-Based Care Transitions Program (CCTP) Joggers: currently involved in efforts to improve care transitions & reduce readmissions Marathoners: have a permanent structure in place to improve care transitions & reduce readmissions (Accountable Care Organizations)

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

1. It’s not a hospital project

It’s a Community Problem

HHA SNF

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

CMS’ Table of Interventions

Available at: www.cfmc.org/caretransitions

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?

2. 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

15

The PAM is very helpful to guide interventions

3. Local adaptation is inevitable

Adapt gold standard models Do not adapt others’ adaptations

4. Ask the community to help

• “Brought to you by your Community Partners”

To Organize a Community..

Tie participation to values Include personal narratives Develop flexible tactics

DEVELOPING A COMMUNITY PROJECT TO REDUCE HOSPITAL READMISSIONS

Identify the community Determine drivers of readmission Select intervention strategies Develop a ‘backbone’ agency

I think it’s an elephant!

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

23

Building Community Infrastructure

1. RCA Drivers 1. Data 2. Medical record review 3. Process assessment 2. Drivers + Settings = Interventions

Intervention Packages

Intervention Reference

Care Transitions Intervention www.caretransitions.org

Transitional Care Nursing www.transitionalcare.info/index.html

CMS Discharge Checklist www.medicare.gov

BOOST www.hospitalmedicine.org/ResourecRoom Redesign

Main tools Driver addressed

SKP Coaches, personal health record, medication discrepancy tool

?

Risk assessment , nursing training materials

XX

PAct

XXX X

Inf

X XX

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

1. RCA Drivers 1. Data 2. Medical record review 3. Process assessment 2. Drivers + Settings = Interventions 3. Backbone ‘agency’

EXAMPLES

Provider Pair: HHAs and hospital pharmacy (NY)

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

Partnering for coached discharges: Improved activation (Co)

PATIENT ACTIVATION

The HHS National Quality Strategy

(http://www.healthcare.gov/center/reports/quality03212011a.html) Three-Part Aim o Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe. o Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care. o Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

o Goals: o Improve quality of care for Medicare beneficiaries as they transition between healthcare settings o Reduce 30-day hospital readmission rates by 20% over 3 years for the nation QIO technical assistance for all communities:

• • • • • • • • Zip Code Overlap

Technical Assistance

Social Network Display Community coalition formation Root cause analysis Intervention selection Statewide Learning Networks Assistance with CCTP applications Quarterly data feedback if not in CCTP • CCTP payment (http://www.cms.gov/DemoProjectsEvalRpts/MD/ite mdetail.asp?itemID=CMS1239313) • PAM, CTM, HCAHPS support • Collaborative Learning • • Connection with best practices Quarterly monitoring data • • Shared savings ? Other TA

The Care Transitions Toolkit:

1. Getting Started 2. Participants 3. Community Engagement 4. Root Cause Analysis 5. Interventions 6. Measurement http://www.cfmc.org/caretransitions/toolkit.ht

m

Care Transitions Statewide Learning in Action Network Care Transitions Learning in Action Network meeting)  Quarterly Statewide sessions (3 calls & 1 in-person Mechanism by which large scale improvement is fostered, studied, adapted and rapidly spread regardless of the change methodology, tools, or time-bounded initiative used to achieve the aim Action oriented Real time learning/problem solving (Community Development) Transparent, flexible, interchangeable, purposeful

Community-Based Care Transitions Program: ACA Section 3026 To pay for improved transitions of care for Mcare beneficiaries from the inpatient hospital setting to home or other care settings Improve quality of care Reduce readmissions for high risk beneficiaries Document measureable savings to the Medicare program

$500 Million

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“IT’S CLEAR THAT SOMEBODY HAS TO DO SOMETHING AND IT’S INCREDIBLY PATHETIC THAT IT HAS TO BE US”

Jerry Garcia