1. IMPACT: Improving Care Transitions Risk Stratification Tool Elya Moore, PhD Deputy Director Whatcom Alliance for Health Advancement Presented at Washington State Hospital Association Safe Table, 7/10/13

2. IMPACT IMProved Care Transitions Contract with Centers for Medicare and Medicaid Services (CMS) Part Community-Based Care Transition Program (CCTP) Transition services for Medicare fee-for-service beneficiaries IMPACT Aims 1.empower patients and their family members to understand their health so they can actively maintain and manage it 2.to reduce preventable hospital readmissions An initiative of the Partnership for Patients, a nationwide public-private partnership launched in April 2011 that aims to cut preventable errors in hospitals by 40 percent and reduce preventable hospital re-admissions by 20 percent over a three-year period. Goals are to reduce hospital re-admissions, test sustainable funding streams for care transition services, maintain or improve quality of care, and document measurable savings to the Medicare program. Presented at Washington State Hospital Association Safe Table, 7/10/13

3. Risk Stratification Tool Goal: To quickly and accurately identify Medicare fee-for-service beneficiaries –eligible for IMPACT –at high risk of readmission Presented at Washington State Hospital Association Safe Table, 7/10/13

4. Timeline May 2012 CMS application approved.June 2012 Request data from hospitalOctober 2012 Receive analytic data set from hospitalFebruary 2013 Analyze data and agree on recommendations based on analysesMarch 2013 Begin implementation work with PeaceHealth analystMay 2013 Generate first risk stratification report. Begin monitoring processJuly 2013 Preliminary evaluation Presented at Washington State Hospital Association Safe Table, 7/10/13

5. Tools and process  Red (100-67)= STOP!!!  Green (0-33)= PASS… Presented at Washington State Hospital Association Safe Table, 7/10/13

6. How is it used? A 3-Step Process –Use a subset of predictors to rank patients upon admission according to risk of readmission and sort each daily admission census according to this rank. –Display the most predictive risk factors for readmission on the census to provide further guidance to hospital personnel for triaging. –Draw from clinical experience, intuition and common sense. Monitor, evaluate and adjust as needed Presented at Washington State Hospital Association Safe Table, 7/10/13

7. Lessons learned Health information exchange is tantamount –Fair-weather Whatcom residents Listen to your staff –Include social support! Importance of inter-organizational collaboration –PeaceHealth, Northwest Regional Council, WAHA Find your champions –Care transitions oversight group –Qualis Health –Medical and content experts Presented at Washington State Hospital Association Safe Table, 7/10/13

8. Validation Population - level 12 readmits since started using tool Mean score for readmitters: 35.8 Mean score for non-readmitters: 15.1 P value <0.001 Individual –level 7 out of 12 readmits were in the “green” category Lower the thresholds (>6 ED visits prev. 6 months; >3 Inpatient admissions prev. 6 months) Presented at Washington State Hospital Association Safe Table, 7/10/13

9. Next steps Modify thresholds Continue monitoring Test in other populations Make tool available to the community Presented at Washington State Hospital Association Safe Table, 7/10/13

10. Acknowledgements Dr. Serge Lindner, MD, Center for Senior Health, PeaceHealth Medical Group Ian Hogan, Analytic Services, PeaceHealth Larry Thompson, Executive Director, Whatcom Alliance for Health Advancement Discharge Referral Coordinators: Sheila Rhodes, Becky Sandall and Lynnette Treen Northwest Regional Council: Julie Johnson, Silva Sarafian, Rosann Pauley and Victoria Doerper Care Transitions Oversight Group, Whatcom County Presented at Washington State Hospital Association Safe Table, 7/10/13

11. Contact Elya Moore Deputy Director Whatcom Alliance for Health Advancement eemoore@hinet.org (360) 788-6560 Presented at Washington State Hospital Association Safe Table, 7/10/13

12. Questions

13. Variables in the model Previous ED visits Previous inpatient visits Length of stay at previous visit High risk diagnosis (heart failure, diabetes, cancer, stroke or COPD) Poor social support Palliative care Depression, bipolar, schizophrenia or dementia Poly pharmacy Recent surgery (stent, hip, knee, vascular or bowel) Presented at Washington State Hospital Association Safe Table, 7/10/13