Title: Care Transitions : Are You in the Game?
1Care Transitions Are You in the Game?
- Naomi Hauser RN, MPA
- Director Care Transitions
- Quality Insights of Pennsylvania
- May 16, 2012
2Welcome
- 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
3Why 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
4Integrated 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 -
530 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.
6Mrs. Bs Story
7339 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
8Timeline 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.
9July2008-August 2011
1014 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
11Targeted 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
129th 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
13Structure of the Project
- Cross-setting
- Community-based
- Collaborative
14The Shift to
- Chronic illness management
- Self-care management
- Empowerment
- Responsibility
- Accountability
- Patient activation
15Cross-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
-
-
16The Role of Agencies
17Hospital Elements
- Leadership buy-in
- Operational level leadership
- Education
- Silos
- Bureaucracy/slow to change
- Competitive
- Non-transparent
18Hospital 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
-
19SNF Elements
- Education
- Eager to learn
- Eager to share
- Share competence levels
- Family
- Physicians
- Turnover
20SNF Interventions
- SBAR
- Communication transfer form
- Chart reviews
- End of life options/education
- POLST/AD
- Coach CTI
-
21Home Health Elements
- Focus on ACH vs. readmissions
- Medication management
- Low referral rates
- Educate on referral criteria
- Coaching
- Hands on in home care
-
22Drivers of Hospital Readmission
- Same for home care as other health care
providers - Patient activation
- Standard, known processes
- Transfer of information
23Home 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
24Home 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
25Intervention HHA
- Communication transfer sheet
- Front load visits
- Telehealth
- Phone monitoring
- Life line
- Chronic care education
- Coaching/partnering
- Depression screening
- Chart reviews
-
26Best 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
27BPIPs 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
28Learn 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
29Lessons Learned
- Community focus
- Root cause analysis
- Communication
- Transparency
- Leadership buy-in
- Collaboration
- Patient-centered
- Ongoing monitoring
- Community outreach
- Sustainability
30Lessons 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)
31August 2011-July 2014
32AIMS and Goals
- Strategic Aims
- What will be done
- Integrate Care for Populations
- Care Transitions that reduce re-admissions by 20
within 3 years.
33CMS 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
34CMS 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
35The Importance of Communities to Improve Health
Care
- Integrating Care for Populations and Communities
36CMS 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
38A 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
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424 Recruited Communities
- Western Pennsylvania
- Lehigh Valley
- York
- Chester County
43Building 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.
44Community 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
45Provider 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
46Stakeholder 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
47Expand the Circle of Support Motivating Call to
Action
48 - Community
- Intervention Selection
49Standard/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
50Drivers of Readmissions
Based on discharges from 2007. Clinical
Classification Software (CCS) 2008 downloadable
from http//www.ahrq.gov/data/hcup/ .
51Lessons 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
52End 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
53Root 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.
54Intervention Selection
- Derived from root cause findings
- Monitor Measure
- Process Measures
- System Components
- Outcome Measures
- Effect of change on patient
55Intervention Selection by Driver
- Patient Activation
- Standard/Known Process
- Transfer of Information
56PROJECT 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
57Transfer of Information
- Communication Re-design
- HIT
- SBAR
- Beneficiary and community outreach
58Patient 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
60Community Care Transitions Program
61The 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.
62CCTP 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
63Eligible 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
64CCTP 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
65CCTP 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
66CCTP 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
67CCTP 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
68CCTP 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
69What 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
7010th 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!
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72QIO 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
73Resource 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
74You must be the change you wish to see in the
world
MahatmasGandhi
75This 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.