It Takes a Village Community-Based Care Transitions Improvement Marian Boxer, RN Colorado Foundation for Medical Care February 22, 2012 This material was prepared by CFMC (PM CO 2011), the Medicare Quality Improvement Organization for Colorado, 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.

Objectives Reducing Readmissions 4 Important things we learned from the Care Transitions Theme Where to start – Drivers and Settings New /Current opportunities

Walkers: just starting to think about care transitions & reducing readmissions Joggers: currently involved in efforts to improve care transitions & reduce readmissions Marathoners: have a permanent structure in place to improve care transitions & reduce readmissions (Accountable Care Organizations) A Variety of Opportunities QIO Support Community-Based Care Transitions Program (CCTP)

14 QIOs with 14 Target Communities  AL: Tuscaloosa  CO: Northwest Denver  FL: Miami  GA: Metro Atlanta East  IN: Evansville  LA: Baton Rouge  MI: Greater Lansing area  NE: Omaha  NJ: Southwestern NJ  NY: Upper capital  PA: Western PA  RI: Providence  TX: Harlingen HRR  WA: Whatcom county

Results

1. It’s not a hospital project

HHA SNF It’s a Community Problem

Why are people readmitted? No Community infrastructure for achieving common goals Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers Provider-Patient interface U nmanaged condition worsening Use of suboptimal medication regimens Return to an emergency department

CMS’ Table of Interventions Available at:

Blah blah blah, blah blah. Any questions? No I’m good to go. Whatever you say is what we’ll do Doctor What’s he saying? I sure hope my wife is getting this.. 2. Patient activation trumps all

PATIENT ACTIVATION

The CMS Discharge Planning Checklist

Knowledge, skills and confidence 15 Sample Questions: #1: “When all is said and done, I am the person who is responsible for taking care of my health.” #12: “I am confident I can figure out solutions when new problems arise with my health” The PAM is scored on a 100 point continuum. Most patients score between 35 and 80 The Patient Activation Measure PATIENT ACTIVATION

The PAM is very helpful to guide interventions

3. Local adaptation is inevitable Adapt gold standard models Do not adapt others’ adaptations

4. Ask the community to help “Brought to you by your Community Partners”

To Organize a Community.. Tie participation to values Include personal narratives Develop flexible tactics

DEVELOPING A COMMUNITY PROJECT TO REDUCE HOSPITAL READMISSIONS Identify the community Determine drivers of readmission Select intervention strategies Develop a ‘backbone’ agency

I think it’s an elephant!

The ‘Zip Code Overlap’ Community Definition FFS Medicare beneficiaries living in zip codes of interest Target Population Community identity supports both social and economic sustainability FFS beneficiaries discharged from hospitals of interest

Social Network Analytic techniques for displaying the provider network 23

Building Community Infrastructure

1.RCA Drivers 1.Data 2.Medical record review 3.Process assessment 2.Drivers + Settings = Interventions

Intervention Packages InterventionReferenceMain toolsDriver addressed# SKPPActInf Care Transitions Intervention personal health record, medication discrepancy tool ?XXXX13 Transitional Care Nursingwww.transitionalcare.info/index.htmlRisk assessment, nursing training materials XXX 2 CMS Discharge Checklistwww.medicare.govPatient and family checklist of important items to address before discharge ?XXXX 9 BOOSTwww.hospitalmedicine.org/ResourecRoom Redesign Screening/assessment, provider discharge checklist, transition record, teach-back instructions, data collection and tracking XXXXX2 Best Practices Intervention Package (BPIP) ces/interventionpackages/default.aspx Comprehensive manual for HHA process improvement includes CTI teaching XX 11 InterActInteract.geriu.orgCommunication tools, clinical care paths, advanced care planning XX 10 Transforming Care at the Bedside (TCAB) s/TransformingCareAt TheBedside.htm (Re)Admission assessment, teach-back, pt and family communication, scheduled f/u XXXXXX4 Re-Engineered Discharge (RED) discharge advocate, pharmacy f/u medication teaching, PCP f/u booklet XXXXX4

1.RCA Drivers 1.Data 2.Medical record review 3.Process assessment 2.Drivers + Settings = Interventions 3.Backbone ‘agency’

EXAMPLES

Provider Pair: HHAs and hospital pharmacy (NY) Butterfield, Stegel, Tartaglia. Improving outcomes through re-engineering care transitions: The New York Experience. Remington Report May/June MULTI-PROVIDER INTERVENTIONS

Lateral Cluster: 30day hospital readmission rate from SNFs in Harlingen

Partnering for coached discharges: Improved activation (Co) PATIENT ACTIVATION

The HHS National Quality Strategy ( Three-Part Aim o Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe. o Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care. o Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

o Goals: o Improve quality of care for Medicare beneficiaries as they transition between healthcare settings o Reduce 30-day hospital readmission rates by 20% over 3 years for the nation QIO technical assistance for all communities:

Shared savings ? Other TA Zip Code Overlap Social Network Display Community coalition formation Root cause analysis Intervention selection Statewide Learning Networks Assistance with CCTP applications Quarterly data feedback if not in CCTP CCTP payment ( mdetail.asp?itemID=CMS ) PAM, CTM, HCAHPS support Collaborative Learning Connection with best practices Quarterly monitoring data Technical Assistance

The Care Transitions Toolkit: 1.Getting Started 2.Participants 3.Community Engagement 4.Root Cause Analysis 5.Interventions 6.Measurement m

Care Transitions Statewide Learning in Action Network Care Transitions Learning in Action Network  Quarterly Statewide sessions (3 calls & 1 in-person meeting) Mechanism by which large scale improvement is fostered, studied, adapted and rapidly spread regardless of the change methodology, tools, or time-bounded initiative used to achieve the aim Action oriented Real time learning/problem solving (Community Development) Transparent, flexible, interchangeable, purposeful

To pay for improved transitions of care for Mcare beneficiaries from the inpatient hospital setting to home or other care settings Improve quality of care Reduce readmissions for high risk beneficiaries Document measureable savings to the Medicare program 38 Community-Based Care Transitions Program: ACA Section 3026 $500 Million

“IT’S CLEAR THAT SOMEBODY HAS TO DO SOMETHING AND IT’S INCREDIBLY PATHETIC THAT IT HAS TO BE US” Jerry Garcia