1. Jane Brock, MD, MSPH Colorado Foundation for Medical Care www.cfmc.org/caretransitions This material was prepared by CFMC, 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. 1

2. A ‘subnational’ QIO Theme Started August 1, 2008 Competitively awarded 2

3. Tuscaloosa HRR Metro Atlanta East Harlingen HRR NW Denver Whatcom County Evansville Omaha Greater Lansing Area Western PA SW NJ Upper Capital Region Providence RI Baton Rouge Miami 14 QIOs with 14 Target Communities 3

4. The Care Transitions Theme: Define a community Zip code overlap Recruit and convene providers Target chaotic service patterns FFS claimsmetrics/patterns Provider input RCA specific situations To reduce unplanned 30d hospital readmissions for the community Using evidence based tools 4

5. Why Engage a Community? Every readmission begins with hospital discharge Every transition has 2 sides The problem of home Patients are people too Isolated medical information is not safe medical management Inevitably need to share Visibility to drive improvement and mission Providers are people too 5

6. Visibility to Drive Improvement 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 6

7. Building Community-ness 1. Multi-representative steering committee 2. Aggregate providers vertically in clusters, then merge 3. Aggregate providers by setting then vertically integrate 4. Individual improvement projects, with information and data-broker Make it visibly a community effort 7

8. CMS’ Table of Interventions Available at: www.cfmc.org/caretransitions 8

9. Care Transitions Intervention SM (CTI) Implemented by 13 QIO Communities* Description: Care transitions coaches support patients by providing specific tools and teaching self-management skills to ensure their needs are met during the transition from the acute care setting to home. Resource: http://www.caretransitions.org Evidence: Coleman et al. (2006): Lower 30-day readmission; lower readmission at 90 days and 180 days. Coleman et al. (2004): Lower readmission for same diagnosis at 90 days and 180 days. * Some communities are implementing a modified coaching model, rather than full CTI model 9

10. Attributing Change to Interventions 3 levels of measurement: 1. Degree of dissemination 2. Effect of disseminated intervention on targeted driver 3. Effect of intervention on utilization (readmission/ED use) 10

11. 6 Interim Measures I-1 Definition: The percent of patient care transitions (FFS Medicare) in the specified geographic area that are attributable to providers who agree to participate. I-2 Definition: The percent of patient care transitions (FFS Medicare) in the specified geographic area that are the potential subject of an implemented intervention that addresses hospital / community systemwide processes. I-3 Definition: The percent of patient care transitions (FFS Medicare) in the specified geographic area that are the potential subject of an implemented intervention that addresses AMI, CHF, or PNE. I-4 Definition: The percent of patient care transitions (FFS Medicare) in the specified geographic area that are the potential subject of an implemented intervention that addresses specific reasons for readmission. I-5 Definition: Percentage of implemented interventions in the specific geographic area that are measured. I-6 Definition: The percentage of patient care transitions (FFS Medicare) in the specified geographic area to which implemented and measured interventions apply. 11

12. 18-Month Results QIOs targeted: 14 communities 66 hospitals 277 SNFs 316 HHAs 89 Other Provider Types ~ 1.1 million Medicare Beneficiaries 12

13. 18-Month Results QIOs achieved: Recruitment and full engagement of providers accounting for 70% of transitions Implementation of 946 interventions Interventions implemented which affect nearly 60% of transitions Measurement of interventions which affect nearly 50% of transitions 268,221 transitions 219,994 transitions 184,407 transitions 13

14. 6 Outcome Measures O-1a Definition: Percentage of patients aged 65 years or older who rate hospital performance as meeting HCAHPS Survey performance standard for information about medicines O-1b Definition: Percentage of patients aged 65 years or older who rate hospital performance as meeting HCAHPS Survey performance standard for information about discharge information O-2 Definition: Percentage of patients discharged to community and readmitted within 30 days who are seen by a physician between discharge and readmission 14

15. 6 Outcome Measures (cont.) O-3 Definition: Percentage of patient care Transitions (FFS Medicare) in the Target Region for which implemented and measured interventions show improvement O-4 Definition: Percentage of patients discharged to community and readmitted within 30 days who are seen by a physician between discharge and readmission O-5 Definition: Adjusted percentage of patients from target hospital(s) rehospitalized within 30 days of discharge following an index hospitalization with a principal discharge diagnosis of: Acute Myocardial Infarction - AMI (O-5a) Heart Failure - HF (O-5b) Pneumonia - PN (O-5c) 15