1. Finger Lakes Health Systems Agency May 12, 20151 CMS Community-Wide Care Transitions Intervention

2. Overview 1. How we got here 2. What we are doing 3. What is important to support success May 12, 20152

3. FLHSA: Vision, Mission & Strategy Vision: A local health-care system that makes people healthier and saves money, by delivering the right care, in the right place, and at the right time for everyone in the community. Mission: We are an independent organization working to improve health care in Rochester and the Finger Lakes region, by analyzing the needs of the community, bringing together stakeholders and organizations to solve health problems, and measuring results. May 12, 20153

4. FLHSA Community Health 2020 Commission May 12, 20154 Shifted focus from individual CON applications to a determination of the aggregate community need Recognized the unsustainable trend in growth driven by failure of optimal care in the community Bed approvals scaled back and a commitment to “community investment” to alter the trend by improving care in the community

5. FLHSA 2020 Commission May 12, 20155 The 2020 Commission recommended FLHSA convene the 2020 Performance Commission “to engage all stakeholders in a process that will result in community initiatives and requisite investments to improve access to care, avoid unnecessary hospital use, and eliminate disparities in health status across the region.”

6. Interactive Components HS/Plan Organization of Health Care Self- management support Delivery system design Decision support Clinical information systems Provider’s Job Prepared, proactive practice team Productive Interactions Quality and value outcomes; ROI; engaged, satisfied participants HS/Plan’s Job Informed, activated patient HS = health system; ROI = return on investment. Wagner EH. Effective Clinical Practice. 1998;1(1):2-4. Community Resources and policies

7. Community Investment Goals The 2020 Commission created specific goals for the community –A decrease of 15% in the number of low acuity (non- urgent) visits to emergency rooms –A decrease of 25% in the number of admissions for Ambulatory Sensitive Conditions that are manageable in outpatient settings – 2350 admits in 2011 –A decrease of 20% in the number of low acuity admissions to Monroe County hospitals of residents from outlying communities Recommended creation of the 2020 Performance Commission to guide community activities to reach the established goals May 12, 20157

8. Three Dimensions of Value Population Health Experience of Care Per Capita Cost Readmissions ED use PQI admissions Admissions from outlying communities Access CAHPS surveys 8May 12, 2015 8

9. Measures Defined by 2020 Performance Commission Agreed Upon Measures for 2014: –PQI admissions: goal to decrease by 25% –Low acuity ED visits: goal to decrease by 15% –Low acuity admissions to Monroe County hospitals: goal to decrease by 20% Implied goal: have the right bed available 99% of the time (this was the measure used to calculate the beds needed to determine bed need) May 12, 20159

10. Reducing Avoidable Admissions: Disease Condition as a Variable Hospitalizations per 100,000 population, Percent of age adjusted All PQI Admissions Respiratory Condition 657.7 (<US) 43% Heart Conditions 439.3 (<US) 29% Diabetes 153.7 (<US)10% Other 278.0 18% All Adult PQIs 1,528.7 (<US) 100% May 12, 201510

11. Reducing Avoidable Admissions: Insurance Status as a Variable May 12, 201511

12. Reducing Avoidable Admissions: Geography as a Variable May 12, 201512

13. Reducing Avoidable Admissions: Ethnicity as a Variable May 12, 201513

14. Reducing Avoidable Admissions: SES as a Variable May 12, 201514

15. PQI – Finger Lakes Region Adult Respiratory and Circulatory conditions account for over 70% of all PQI Admissions in the six county Finger Lakes Region. Between 2004-2006, 13% of all hospital discharges were PQI discharges. Each day 295 hospital beds in the region were filled by patients who potentially could have avoided hospitalization. This equates to 10% of Hospital charges for these admissions (charges not costs). May 12, 201515

16. Conclusions from FLHSA Data Patients with PQI admits are generally older and insured Rochester’s inner city has significantly higher rates of PQI admits African-Americans and to a lesser degree Latinos experience increased PQI admits Lower socioeconomic status is an important contributor to PQI admits Reaching the target reduction in PQI admits requires decreasing PQI admits in the white population as well as in underserved minority populations May 12, 201516

17. Conclusions from National Data Rehospitalization is the low hanging fruit of PQI hospitalization reduction Most admissions are related to cardiovascular and respiratory diseases Major factors in reducing Medicare re- hospitalizations are: –Having a primary care practitioner –Seeing that practitioner often post discharge –Having a team to coordinate care May 12, 201517

18. CMS Community-Wide Care Transitions Program 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 May 12, 201518

19. The Care Transition Intervention Coaching models, when applied to transitions in care, have been shown to reduce readmissions by 20-40%. Patient/family coaching actively engages patients and their families to be full partners in insuring improved health and decreasing unnecessary dependence on hospitals and emergency departments. Community organizations and home care agencies will lead the effort, fulfilling Wagner’s model of optimally treating chronic conditions. May 12, 201519

20. Our Phased Approach to a Community-wide Care Transition Intervention Insurers pilot Commercial and Medicare Advantage Monroe Plan for Medicaid Services pilot for Medicaid HMO HEAL 19 funds the uninsured and Medicaid FFS patients CMS CTTP grant for Medicare FFS patients target launch June 2012 May 12, 201520

21. Self – Reported Aggregate Coaching Data MeasureOct – Dec 2010Jan – March 2011 Totals through March 2011 Patients agreeing to coaching in hospital 219351670 Patients who Accepted Coaching - (Defined as patient seen at home) 130230360 Acceptance rate59%65% 62% # completing program104195299 % completing80%84% 82% # readmitted to hospital with in 30 days 15Incomplete % readmitted in 30 d 14.4Incomplete #/% T&R from ED in 30 d* 6/6Incomplete May 12, 201521 * Based on coaching organizations data tracking, not health plan data

22. Initiatives at Hospitals 1.Identify and Track Reasons for Readmissions 2.Risk Assessment Stratification 3.Medication Reconciliation 4.Provider Checklist for High Risk Patients 5.Teach backs 6.Community Standards for Discharge Planning 7.Timely PCP Follow up Appointments 8.Hospitalist to SNF Communication May 12, 201522

23. FLHSA CMS Community-wide Process Coordinated community meeting: 60 regional representatives Agreed to scope of work: Build upon previous experience; expand & spread Defined work Determined patient eligibility criteria based on data review Designed and Clarified hospital integration with CTI Integrated Community based services Calculated costs of intervention and ROI Designed tracking and reporting processes Talked, talked, talked, and…… talked more! May 12, 201523

24. Our CMS Community - Wide Care Transitions Intervention Lifespan ; an AOA –funded non-profit organization Five hospitals: –Rochester General, Unity, Strong Memorial, Highland and Newark-Wayne Target Population: Medicare FFS beneficiaries with an active PQI diagnosis having 2 or more characteristics at risk of re-hospitalization: –3 co-morbid chronic illnesses –5 prescription medications –2 hospital admissions within the last 12 months –Failure to teach back –Special Circumstances subject to interdisciplinary judgment May 12, 201524

25. Putting your plan into Action Secure and maintain leadership commitment Form multi-disciplinary workgroups Analyze root cause analysis Understand processes Anticipate and confront resistance / barriers Identify improvement opportunities Develop a measurement plan Estimate ROI Employ and Commit to Continuous Quality Improvement Establish Trust Go for it!!! May 12, 201525

26. May 12, 201526 Establish and Maintain Trust Clearly define and agree to your goals Explicitly define guiding principles and adhere to core values Use data to guide and inform your work Anticipate concerns, encourage and solicit input, and provide a feedback loop

27. Finger Lakes Health Systems Agency Thank You!!! Melissa Wendland Associate Director, Planning and Research Finger Lakes Health Systems Agency 1150 University Avenue Rochester, New York 14607-1647 melissawendland@flhsa.org May 12, 201527

28. May 12, 201528 Finger Lakes Health Systems Agency The triangle represents our agency’s role as a fulcrum—the point on which a lever pivots—boosting the community’s health by leveraging the strengths of all stakeholders. The fulcrum is also a point of equilibrium, reflecting our ability to balance the needs of consumers, providers and payers on complex health matters. The inner triangle also evokes the Greek letter delta—used in medical and mathematical contexts to represent change—with a forward lean as we work with our community to achieve positive changes in health care. Give me a lever long enough and a fulcrum on which to place it, and I shall move the world. —Archimedes 1150 University Avenue Rochester, New York 14607-1647 585.461.3520 www.FLHSA.org