1. Voice of CMS: Our National Campaign For National Breakthrough in Health System Performance: Partnership for Patients and CCTP Dennis Wagner, Paul McGann Ashley Ridlon & Traci Archibald Partnership for Patients U.S. Department of Health & Human Services CMS Center for Medicare & Medicaid Innovation CCTP Learning Collaborative, March 20-21, 2012

2. Purposes of Presentation Show How CCTP fits into the Partnership for Patients (Ashley, Traci, & CCTP Team) Outline Key Requests for Rapid Action and Results Over the Near Term (Dennis & Paul) Engage and Interact on this Work and the Requests (All)

3. Better Health for the Population Better Care for Individuals Lower Cost Through Improvement We Are Accountable for Results on 3 Major Fronts 3

4. Partnership for Patients Begins with the Aims 40% Reduction in Preventable Hospital Acquired Conditions –1.8 Million Fewer Injuries –60,000 Lives Saved 20% Reduction in 30-Day Readmissions –1.6 Million Patients Recover Without Readmission Up to $35 Billion Dollars Saved

5. CCTP Goals Improve transitions of Medicare FFS beneficiaries from the inpatient hospital setting to home or other care settings Improve quality of care Reduce readmissions for high risk beneficiaries Document measurable savings to the Medicare program and expand program beyond the initial 5 years

6. We Know Major Improvement Is Possible Look at the People Sitting in this Room! 1.Significant Reduction in Readmissions from 14 QIO Communities, impacting a population of more than 1 million Medicare beneficiaries. The top 5 performers are your Faculty today.  Although we attempted only to impact 30-day readmissions, we also impacted overall hospital admission rates (a huge cost- driver).  Standard “trial methodology” is too slow for this work to be successful. We need to study, and perfect, “rapid-cycle techniques”. 2.The previous experience and successes of the first selected CCTP sites – YOU – and your peers! 6

7. Learn from the QIO 9 th SOW: 14 Communities Improving Care Transitions

8. Preliminary Results*: Relative Improvement July 2007-June 2008 compared to July 2009-June 2010 14 Care Transitions Communities vs. 52 Peer Communities *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.

10. Hospital Engagement Networks American Hospital Association (1528) Premier Healthcare Alliance (438) VHA (148) NC Hospital Assoc (110) Intermountain HealthCare (69) GA Hospital Assoc (115) TX Hospital Assoc (198) MN Hospital Assoc (116) Healthcare Assoc of NY State (160) IA Healthcare Collaborative (120) PA Hospital Assoc (94) WA Hospital Assoc (97) DFWHC Foundation (37) OH Hospital Assoc (60) NJ Hospital Assoc (66) Ascension Health (67) TN Hospital Assoc (50) MI Health&Hospital Assoc (66) National Public Hospital & Health Institute (23) LifePoint Hospitals, Inc (49) Joint Commission Resources (24) OCHSPS National Children’s Network (28) Dignity Healthcare (34) NV Hospital Assoc (23) Carolinas Health Care (26) UHC (56)

11. CCTP Hospitals in HENs (30 sites)

12. What the Care Transitions Team Saw in Your Proposals That Excited Us Most…

13. Call On Us. We Commit to Partnering With You in A Certain Way: As Servant Leaders As Relentless Advocates for Action, Testing, Change and Results As Brokers & Connectors with others Who Can Contribute to and Benefit From What You Do 13

14. Our Operating Values How shall we work together and with others? Boundarilessness Speed and Agility Unconditional Teamwork Valuing Innovation Customer Focus Servant Leadership Constant Testing and Iteration, with Transparency Bias for Action Celebrating and Focusing on Success

15. Start Now. Don’t Wait. Take Initiative. Team. Work Together. Cut Deals. Spread Success Throughout All Possible Networks. Collaborate with Other Payers and Partners. Engage Patients in Their Care & Our Work. Look for and Fill in Gaps. Join Us in Iteration and Evolving in Real Time. Generate and Spread Net Forward Energy. Requests for Action, Teamwork & Learning

16. Sense-Making Aims, Baselines & Targets -- National Measurement Strategy -- AimBaselineTarget 40% Reduction in 137/1000111/1000 Preventable HACs 20% Reduction in Readmissions 14.4%11.5% Initial Data Becomes Available for Prior Year in October with Final Validation in May. PfP will get 2011 data in October, 2012. 16

17. 2009 Readmission Rates by Payer

18. Pathway to 20% Reduction by 2013 Partnership Aim: Prevent 841,068 Readmissions Annually Program # Readmissions Prevented Annually Best Current Estimate of “Footprint”, in Place Now (March 2012) CCTP11,294 30 Communities, 126+ Hospitals, 20 States 223,000 high-risk beneficiaries QIO ICPC Aim23,609129 Communities, 50 states+3 territories HENTBD26 HENs, 3,800+ hospitals AoA ADRC GranteesTBD 100 current sites, 169 Active Hospitals, 3,708 individuals served CMMI/MMCO Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents TBDTBD – announced on 3/15/2012

19. How many of the 841,068 annual readmissions will your community prevent in 2012? In 2013? How can we “learn our way” to doing more?

20. Let’s hear from two CCTP Communities Tim Landrin, Southwestern PA Area Agency on Aging Charleroi, PA Janice Sparks, Care Connection Aging and Disability Resource Center, Houston, TX –What are your plans? –What are some of the numbers that undergird your plans and targets? –What ideas and opportunities do you see for learning as you go?

21. Evolution & Development of Our Learning Collaborative Network

22. Real Time Tracking, Reporting, Improvement & Results Share with us and each other, monthly: # of high-risk patients discharged from hospital # initiated intervention # completed intervention # completed who were readmitted within 30 days # readmissions among high-risk patients (regardless of intervention) Use the data to get better results than initially estimated and projected *We will discuss these more thoroughly in the measurement session.

23. Request for CCTP Communities to Show Extraordinary National Leadership on Results Reach even more beneficiaries than you proposed. Get More Effective: Constantly refine your targeting to ensure you achieve results with the highest risk, highest cost patients. Reduce Your Program Costs: Provide even more value than you initially proposed. Put your implementation plan into action even faster than you initially proposed. Avert even more readmissions than you initially projected, especially in the first two years.

24. Bias for Action Here Is How Our Work Can Show Up…Fast 1.We Will Share Your Data and Results with the Administrator & the Secretary – the 1 st Tuesday of each Month 2.Call or Email Your HEN Today and Offer to Help With Their Next Event 3.Meet with Your HEN…Next Week 4.A CCTP Community will join HHS at the National Priorities Partnership Meeting on April 30 to Share A Powerful Local Example of Action & Commitment 5.As a Community of Practice, You Present the CCTP Overarching Aims and Action Agenda(s) to HEN National Event on May 22 & 23 –Make Offers to the HENs –Show How CCTP is Already in Action Locally with HENs –Model Action, Teamwork, Commitment to Learning & Results

25. Purposes of Presentation Show How CCTP fits into the Partnership for Patients (Ashley, Traci, and CCTP Team) Outline Key Requests for Rapid Action and Results Over the Near Term (Dennis & Paul) Engage and Interact on this Work and the Requests (All)

26. Group Discussion & Action What requests am I hearing? What excites me about these requests? What offers am I making in response?