1. Georgia Medical Care Foundation The Care Transitions Community Initiative Working Together Across Care Settings

2. The Care Transitions Community Initiative A ‘sub national’ QIO project in 14 states August, 2008 – August, 2011

3. The Care Transitions Community Initiative Goals 1.Measurably improve the quality of care for Medicare beneficiaries who transition among care settings through a comprehensive community effort 2.Reduce all cause 30-day readmission rates of Medicare beneficiaries in the community 3.Demonstrate change at a system level resulting from collaborative activity to yield sustainable and replicable strategies

4. The Care Transitions Community Initiative Objectives 1.Define a community/zip code overlap - Metro Atlanta East – Gwinnett, Rockdale, Newton - 18 zip codes 2.Recruit and convene providers - Hospitals, Home Health, Nursing Homes, Hospice, physicians, community services 3. Target chaotic service patterns indentified through: - FFS claims - provider input - root cause analysis 4. Use evidenced-based tools

5. The Care Transitions Community Initiative Evidence based interventions address –Hospital/community wide system level weaknesses Transfer of information across settings –Disease specific conditions that result in rehospitalizations HF, AMI, Pneumonia –Specific reasons for admission Medication adverse events, lack of resources

6. The Care Transitions Community Initiative Evidenced based intervention categories –Medication management Reconciled before discharge and after transfer, management system in place –Plan of care Risk assessment, involve patient and family in POC, POC documented and transferred to next care setting –Post discharge follow-up HH F/u in home, phone calls, PCP visit within 30 days, community services

7. The Care Transitions Community Initiative What will be measured? 1.Patient satisfaction post discharge HCAPS data/medication and discharge questions Discharge Checklist, medication reconciliation, disease-specific education 2.Follow up PCP visits within 30 days post discharge Discharge Checklist, transition coach, discharge advocate, home health referral, NP referral 3.# of Hospital/Community system-wide interventions Discharge Checklist, medication reconciliation, disease specific education, Handover Management tool

8. The Care Transitions Community Initiative 4.Interventions that target rehospitalization for specific diseases or conditions (HF, AMI, Pneumonia) 5.Interventions that target specific reasons for admissions 6.Hospital readmissions within 30 days post discharge.

9. The Care Transitions Community Initiative Working Together Across Care Settings This material was prepared by GMCF, the Medicare Quality Improvement Organization for Georgia, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. 9SOW-GA-TRN-08-15 Helping to make the pieces fit..........