1. Nancy D. Vecchioni, RN, MSN, CPHQ Vice President Medicare Operations, MPRO Co-Lead MI STA*AR IHI Improvement Advisor

2. DATA: Medicare readmissions2006–07 Medicare 5% SAF Data; Nursing home admission and readmissions2006 Medicare enrollment records and MEDPAR file; Home health admissions2007 Outcome and Assessment Information Set SOURCE: Commonwealth Fund State Scorecard on Health System Performance, 2009 State Variation: Hospital Admissions Indicators

3. Rehospitalization Rates in Total and by Prior Nursing Home Use among Medicare Beneficiaries, 2000-2006

4. Older patients experience complex care Nursing Home Hospital DiseaseManagement Physicians Family Caregiver Home Care Pharmacy

5. Patient One: He doesnt feel he has any problems getting to his appointments. However, he does have to walk three blocks to the bus stop and then take 3 different buses to reach Dr. X office. He has learned that if he was able to obtain a letter from his physician that the Metro would help him with transportation, but he hasnt gotten around to it and just walks to the bus stop. Patient Two: Both of my legs/feet were swollen-short of breath-I have heart trouble-the Dr. sent into the hospital I dont know why they keep swelling Patient Three: The hospital sent me home with 2 liters of fluid on my lungs so, no sooner than I got home, I got short of breath again. The hospital should have taken the fluid off me before sending me home. Patient Four: I did not do what I was supposed to do. When I got back from the hospital the first time, I wasnt eating properly. I wasnt supposed to drink, but I had a beer or two. When I left [the hospital] they told me I had a bad heart. I came home, I was laying around, I wasnt exercising or anything like that, and it just got worse, and I had to go back. ….Shes ( HIS WIFE) got me eating a lot of cerealcorn flakes and Cheerios and stuff like that. I may have a potato salad, corned beef, some pickles… its a variety of things that I eat. Patient Five: Nothing but the cost of the medication. I have obtained some of the medications but not all of them. I have Medicare Part B. I have an issue with the co- payments. I am enrolled in the spend down program with FIA but I dont know the number. Real Patient Stories

6. Michigan Medicare Patient 30-Day All Cause Readmission Rates (%) by County, 2009 Statewide Medicare Patient Readmission Rate= 18.8% Readmission Rates are Greatest in Southeast Michigan Medicare FFS Inpatient Data, ISAT Database

7. MI STA*AR Overview An Institute for Healthcare Improvement (IHI) initiative to reduce avoidable 30-day rehospitalizations –Commonwealth Fund grant No funding for participating states May 2009 – May 2013 MPRO and MHA co-leading statewide initiative –Improvement Advisors to assist teams Three states selected as partners in this initiative (Massachusetts, Michigan, Washington)

8. Goals Increase patient and family satisfaction with transitions in care and with coordination of care Reduce each states all-cause 30-day rehospitalization rates by 30 percent

9. Steering Committee Members Tina Abbate MarzolfCEO, Area Agency on Aging 1-B Caroline Blaum, MD, MSGerontologist, University of Michigan Amy Boutwell, MD, MPPInstitute for Healthcare Improvement Peggy BreyDeputy Director, Office of Services for the Aging, MDCH Laura ChampagneExecutive Director, Citizens for Better Care Ed GamachePresident, Michigan MICAH David HerbelPresident & CEO, Aging Services of MI Jeanette Klemczak, RN, MSNChief Nurse Executive, MDCH David LaLumiaPresident & CEO, HCAM Cecelia Montoye, RN, MSN, CPHQMichigan Chapter, American College of Cardiology Susan MoranBureau Director, Medicaid Program Operations and QA Richard MurdockExecutive Director, MAHP Julie NovakExecutive Director, MSMS Larry Abramson, DOMichigan Osteopathic Association Jeff TownsMichigan Hospice & Palliative Care Tom Simmer, MDSenior VP & CMO, BCBSM Nancy Vecchioni, RN, MSN, CPHQVP Medicare Operations, MPRO Sam R. Watson, MSA, MT (ASCP)Senior VP Patient Safety and Quality, MHA Pam YagerPolicy Advisor, Office of Governor Jennifer Granholm Robert Yellan, JD, MPHPresident and Chief Executive Officer, MPRO Harvey ZuckerbergExecutive Director, MHHA

10. Cohort 1 - Hospital System Participants Detroit Medical Center Detroit Receiving Hospital & University Health Center Harper/Hutzel Hospital Huron Valley Sinai Sinai-Grace Hospital Mid Michigan Health MidMichigan Medical Center-Midland MidMichigan Medical Center-Gladwin MidMichigan Medical Center-Clare Gratiot Medical Center Spectrum Health System Spectrum Health Blodgett Hospital Spectrum Health Butterworth Hospital Spectrum Health Reed City Hospital Spectrum Health United Hospital St. John Health System St. John Hospital & Medical Center St. John Macomb-Oakland Hospital Providence Hospital Medical Center Providence Park Hospital St. John River District Hospital University of Michigan Hospitals & Health Centers

11. Cohort 1 - Individual Hospital Participants Allegiance Health Battle Creek Health System Botsford Hospital Charlevoix Area Hospital Crittenton Hospital Medical Center Gerber Memorial Health Services Henry Ford Hospital Mecosta County Medical Center Pennock Health Services Portage Health

13. Interventions Acute Care Providing from three to 30-day supply of medications at transition home Health plan uses hospitals first fill program overriding their formulary Switch from brand to generic medications e.g., 8 medications 40 dollars a month Follow-up appointments made prior to the patient transition Nurse calls patients 48 hours post transition Home visits to patient within 1 to 2 days of transition Extended care, home health and health plan case managers make visits to hospitalized patients and discuss case with the hospital team Patients/care givers assist in design of educational materials Standardization of communication handover Eliminating co-pays for high risk patients to see physician post discharge Transitions to nursing homes between 11am and 2pm Non nursing staff conducting Teach Back

14. Interventions Extended Care SBAR communication Consistent assignment/consolidated med pass Standardized process for determining transfers to hospital Nurse to nurse communication prior to transition Work with resident to make follow-up appointment to PCP Call resident 48-72 hours after discharge Shift huddles to discuss high risk residents Home Health Care Front load visits Sliding scale medications SBAR communication Develop personal health plan After hours care-24-7 Telehealth

16. TEAM CO-OPERATIVE to prevent rehospitalization HEALTH CARE/COMMUNITY

17. Nancy Vecchioni, RN, MSN, CPHQ nvecchio@mpro.org 248-465-7454