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Care Transitions : Are You in the Game?

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Title: Care Transitions : Are You in the Game?


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 well 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. Bs 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, cant 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-timewin-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.homehealthqu
    ality.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 moreCoach/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 appointment
    and 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

39
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40
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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/ .
51
Lessons Learned
Key drivers of 30 day readmission Low patient
activation Lack of standard processes Inadequate
transfer of information across care settings Key
strategies for 30 day readmission reduction
Community organization Patient
activation Multi-provider process improvement
52
End of Life
  • Of discharges of CT residents from the five
    targeted hospitals that result in a 30-day
    readmission to any acute care hospital during the
    last six months of life
  • 35 are discharges to a SNF
  • 33 are discharges to home under the care of a
    HHA
  • 23 are discharges to home or self-care
  • 28 of all readmissions occur during the last six
    months of life

53
Root Cause Analysis
  • Simply stated RCA is a process designed to help
    identify not only
  • What and how BUT
  • Why
  • Leads to interventions selection and ongoing
    identification of gaps in care delivery across
    settings.

54
Intervention Selection
  • Derived from root cause findings
  • Monitor Measure
  • Process Measures
  • System Components
  • Outcome Measures
  • Effect of change on patient

55
Intervention Selection by Driver
  • Patient Activation
  • Standard/Known Process
  • Transfer of Information

56
PROJECT RED(ReEngineered Discharge)
  • Evidenced based toolkit.
  • Developed by Boston University Medical Center
  • Addresses key factors identified in RCA
  • Delayed Transfer of Discharge Summary
  • Unknown Test Results
  • Patients Failure to Follow-up
  • Medication Interactions and Adverse Events

57
Transfer of Information
  • Communication Re-design
  • HIT
  • SBAR
  • Beneficiary and community outreach

58
Patient Activation
  • INTERACT
  • RED (Re-engineered Discharge)
  • Medication Reconciliation
  • Coaching
  • Teach-Back

59
Coming together is a
beginning.Keeping together is progress.Working
together is success. Henry Ford
60
Community Care Transitions Program

61
The Communitybased Care Transitions Program
(CCTP)
  • The CCTP, mandated by section 3026 of the
    Affordable Care Act, provides funding to test
    models for improving care transitions for high
    risk Medicare beneficiaries.
  • Increasing rates of avoidable hospital
    readmissions will result in negative health
    outcomes for Medicare beneficiaries impacting
    their levels of safety and quality of care.
  • The CCTP seeks to correct these deficiencies by
    encouraging communities to come together and work
    together to improve quality, reduce cost, and
    improve patient experience.

62
CCTP Program Goals
  • Improve transitions of beneficiaries from the
    inpatient hospital setting to other care settings
  • Improve quality of care
  • Reduce readmissions for high risk beneficiaries
  • Document measureable savings to the Medicare
    program

63
Eligible Applicants
  • Are statutorily defined as Acute Care Hospitals
    with high readmission rates in partnership with a
    community based organization
  • Community-based organizations (CBOs) that provide
    care transition services
  • There must be a partnership between the acute
    care hospitals and the CBO

64
CCTP Definition of CBO
  • Community-based organizations that provide care
    transition services across the continuum of care
    through arrangements with subsection (d)
    hospitals-Whose governing bodies include
    sufficient representation of multiple health care
    stakeholders, including consumers

65
CCTP Key Points
  • CBOs will use care transition services to
    effectively manage transitions and report process
    and outcome measures on their results.
  • Applicants will not be compensated for services
    already required through the discharge planning
    process under the Social Security Act and
    stipulated in the CMS Conditions of
    Participation.
  • Applicants will be required to participate in
    ongoing learning collaboratives

66
CCTP Application Guidance
  • Applicants are required to complete a root cause
    analysis
  • The proposals must specify how the root causes
    will be addressed
  • The proposal will describe how they will work
    with accountable care organizations and medical
    homes if applicable
  • The proposal will describe how they will align
    their care transition programs

67
CCTP Conclusion
  • The program solicitation was announced in the
    Federal Register and is now available at
  • http//www.cms.gov/DemoProjectsEvalRpts/M
    D/itemdetail.asp?itemIDCMS1239313
  • The program will run for 5 years with the
    possibility of expansion beyond 2015
  • If community progress is not occurring within 2
    years of receiving funding, funding will be
    stopped
  • Please direct CCTP questions to
  • http//www.cms.gov/DemoProjectsEvalRpts/MD/itemdet
    ail.asp?itemIDCMS1239313

68
CCTP Website
  • Visit the program website for daily updates on
    program status at http//www.cms.gov/DemoProjectsE
    valRpts/MD/itemdetail.asp?itemIDCMS1239313
  • Do not forget to note Frequently-Asked Questions
  • On the Site

69
What Actions Can You Take?
  • Look at your process
  • What do you already have in place?
  • What strength do you bring to the community?
  • Be a good team player
  • How can you collaborate to
  • Improve care delivery across the continuum
  • Reduce errors and avoidable re-admissions
  • Share resources and reduce cost
  • Improve communication and information transfer
  • Improve Care Transitions

70
10th Scope of Work The Opportunity for You.
  • Communities are developing
  • Position yourselves
  • Promote cross setting best practices you have
    implemented
  • Integrate with upstream and downstream providers
  • Be part of the discussion and strategic planning
  • Let everyone know the role of home care and the
    services are critical to decreasing the rate of
    30-day readmissions
  • Be part of the solution!

71
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72
QIO Technical Assistance
  • Learning and Action Networks (LAN) on a
    state-wide level
  • Webinars provided and recorded
  • Connect to downstream providers
  • Provide current Medicare data to providers

73
Resource Sharing
  • Upcoming conferences or meetings
  • E-newsletters
  • Share with us/success stories
  • Or how can we share an article with you?
  • Contact Krista Davis at kdavis_at_wvmi.org or
  • nhauser_at_wvmi.org
  • www.qipa.org

74
You must be the change you wish to see in the
world
MahatmasGandhi
75
This material was prepared by Quality Insights of
Delaware, the Medicare Quality Improvement
Organization for Delaware, 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. Publication
number 10SOW-DE-ICP-KD-010612A. App. 1/12.
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