1. Option D ADRC Evidence Based Care Transitions Grant Program Evaluator Workgroup Call October 17, 2011 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL aoainfo@aoa.gov | WEB www.aoa.govaoainfo@aoa.gov

2. Agenda Welcome and Introductions Option D Grantee Spotlight: Colorado Resources U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

3. Hawaii * Alaska * MT ID* WA † CO † WY NV CA *† NM AZ MN TX † KS * IA WI IL † KY TN † IN † OH MI ALMS AR LA FL † SC * WV VA NC* PA † VT RI † NH † OR * UT SD ND MO * OK NE NY † CT † MA † DC Care Transitions Activities DE Guam Northern Mariana Islands 34 States with ADRC program sites currently conducting care transitions through formal intervention (Total of 82 active sites with an additional 61 sites within active states currently planning to conduct care transitions) 11 States with ADRC program sites currently planning to conduct care transitions through formal intervention ( Total of 13 sites currently planning care transitions activities within states with no active sites) GA 9 States not reporting current or planned care transition activities Puerto Rico * Indicates state with current CMS Hospital Discharge Planning Model grant † Indicates state with 2010 ADRC care transitions grant MD *† NJ ME †

4. Option D Grantee Spotlight: Colorado Presenters – Peggy Spaulding, Program Specialist, State Unit on Aging – Sarah Johnson, Transition Coach Supervisor Program Model – Care Transitions Intervention (“Coleman Model”)

5. Program Model Overview Quality Improvement Organization (QIO) Grant implemented Eric Coleman Model Training and Care Transition Taskforce in Mesa County Mesa County Dept of Human Services (ADRC) and St Mary’s Hospital Coleman Readiness Assessment Tool Eric Coleman Software U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

6. Partnerships Overview St. Mary’s Hospital Home Care of the Grand Valley Physicians groups Rocky Mountain Health Plan ADRC Hospitalists Discharge Planners Beacon Consortium Money Follows the Person U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

7. Rocky Mountain Health Plan/ Flow Chart Overview

8. Day-to-Day Operations / Flow Chart Overview

9. Case Study One of our first program participants was a 31-year-old father of 3, who was hospitalized for cellulitis that developed from a MRSA infection, and who has a history of incomplete paralysis as a result of a spinal cord injury incurred in a motor vehicle accident two years ago. He is now disabled and struggles with mental health issues, as well. The Transition Coach, along with the home health nurse that was involved, helped the participant and his wife work through the multiple medication discrepancies that were identified. The TC also helped him to identify and work on his personal health goal of improving his mobility, which he accomplished with the assistance of Mesa County ARCH. He was able to obtain new shoes fitted by an orthotist, which immediately improved his personal mobility, and he was connected with transportation options that are paid for by his Medicaid coverage, giving him a greater ability to get to his appointments even when his wife is not available to transport him. The participant was also connected with case management services through Rocky Mountain Health Plans, his Medicaid provider, as a result of the coordination between CTI and RMHP. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

10. Evaluation Activities Rehospitalization Data – St. Mary’s Hospital Agreement – 14, 30, 60, and 90 Days Participant/Caregiver Understanding and Satisfaction Survey – Every Participant/Caregiver – Completed Within 7 Days After Final Phone Call by Supervisor or ADRC Partner U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

11. Lessons Learned Include Physicians Define Transition Coach Duties to Partners Refer Difficult Cases to ADRC Transition Coach Supervisor Had and Continues Positive Relationship with Hospital Be Flexible Take Advantage of Ability to Simplify U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

12. Questions for Colorado team? U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

13. Care Transitions Resources and Upcoming Events Semi-Annual Report Trainings for Fall 2011 – October 18, 2011 from 3:00 – 4:30 pm EST Register for 10/18 SART Training Next Evaluator Work Group Call: – November 14, 2011 at 1:00 p.m. (EST) – Register Register Save the Date: LTQA 2nd Annual Meeting – February 16, 2012 in Washington, D.C.

14. Care Transitions Resources and Upcoming Events Call for participants: – Office of the National Coordinator for Health IT (ONC) and Federal Health Architecture FHA) looking for examples of organizations successfully using nationally recognized standards to securely share patient data – Nominations are due October 26th at 5:00 p.m. ET – Nominations can be submitted here Nominations can be submitted here Grantee-created resource: – New York’s Flow Chart New York’s Flow Chart

15. Questions? Contact Caroline Ryan: caroline.ryan@aoa.hhs.gov caroline.ryan@aoa.hhs.gov U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV