1. Care Transitions: Improving Care and Quality of Life Qsource 11/21/2013

2. Readmissions Project Overview Qsource undertook a project to describe geographic patterns of healthcare utilization focusing on readmissions within 6 Metropolitan Health Referral Areas across Tennessee. The overall purpose has been to engage community stakeholders in discussions around shared accountability for population health outcomes and healthcare expenditures. Qsource has also supported communities interested in federal and state funding by providing assistance in root cause analyses and interventional approaches. Those communities that are not funded but want to engage in continued work to improve transitions will have continued support with the statewide Learning and Action Network.

3. The Path to Improved Care Transitions

4. Each readmission represents a breakdown in care, a patient safety concern, and an opportunity to eliminate wasteful spending. Measures designed for hospital reporting do not easily translate to a community level. Community rate of readmissions is a better indicator of healthcare delivery system functioning. Our goal is to help set a priority for the community to focus energy as a unit and break down silos. Opportunity to focus on system-level changes while targeting scarce resources toward patients for whom the current delivery system works least well. Why Community?

5. Community Approach Six communities statewide was original goal As of August 2013, nine communities organized Two communities have received formal funding Qsource continues to work with all interested communities on developing projects/plans to improve health of our residents and reduce hospital readmissions through August 2014-end of the 10 SoW

6. Community Organizing Model

7. What is Community Building? A practice and a framework for building capacity to make change. Organizing enables a community to be transformed into a constituency that is mobilized towards a common goal.

8. Interests and Resources Community Members Interests/Resources Commitment Leadership Constituency Support Competition Opposition Community Development and Groth Community Campaign What change do we want? (What is our interest?) Who has the resources to create that change? What do they want? (What is their interest?) What resources do we have that they want?

9. 30-Day Medicare Re-hospitalization Measure Report to all TN hospitals. 30-day readmissions for Medicare patients discharged from your hospital over time. These rates are not risk-adjusted, thus may be different from rates used for Hospital Compare and the Readmissions Reduction program. Used for tracking purposes and early identification of trends. Example on next slide. Hospital-Specific Reports

10. Table 1. Hospital-Specific 30-Day Readmission Rates for All Medicare Patients Discharged from Hospital Three-Month Period by Date of Discharge Jan11- Mar11 Apr11- Jun11 Jul11- Sep11 Oct11- Dec11 Jan12- Mar12 Apr12- Jun12 Jul12- Sep12 All-Cause Re-hospitalization Facility # of live discharges1141106210071061122610491115 Facility # of readmission to same hospital176167156171181172152 Facility # of readmission to other hospitals26212629221523 Facility # of total readmission202188182200203187175 Facility readmission rate to same hospital15.4315.7315.4916.1214.7616.4013.63 Facility readmission rate to other hospitals2.281.982.582.731.791.432.06 Facility Total Readm Rate17.70 18.0718.8516.5617.8315.70 Facility Readmission Rate Rank out of 106 TN hosp46495363335836 TN Statewide Total Readmission Rate18.4518.4318.2618.4318.0317.6717.34 Example Report

11. Quarterly Diagnosis-Specific Admissions

12. Quarterly Diagnosis-Specific Readmissions

13. Tennessee Post-Acute Care Setting Readmissions January 1, 2011-December 31, 2011

14. Rates of Readmission per 1,000 MCARE Across Tennessee Health Referral Regions

15. Change in Rates of Readmission per 1,000 MCARE Across Tennessee HHRs

16. Reduction in Readmission Costs from 2010 to 2012 by County

18. West Tennessee Two communities currently involved in project Multiple hospitals, SNFs, home health providers, and other community providers collaborating on ongoing projects ESRD network working diligently with this group Very engaged group willing to remove silos and work across all disciplines to improve outcomes Continuing to develop projects to improve transitions and healthcare quality in this region A Regional View

19. Middle Tennessee Four communities currently involved in project Vanderbilt community awarded Innovations Challenge Grant Multiple hospital systems and providers involved Strong partnerships formed with home health providers in this region Communities working across rural and urban settings to improve care in this region

20. A Regional View East Tennessee Three communities currently involved in project Chattanooga awarded 3026 funding Diverse communities across region with strong AAA leadership for all communities Multiple hospital systems collaborating to improve care All communities involved in multiple projects and forming committees to carry out plans developed for this region

21. Models for Action Models for Intervention in place statewide Care Transitions Intervention Project RED Project BOOST Bridge Model STAAR Transitional Care Model INTERACT

22. Community-Based Summary Points Removing silos, breakdown of barriers between hospital systems and all providers of care vital to project Community rate of readmission is a better indicator of healthcare delivery system functioning-community involvement is key Our goal is to help set a priority for the community to focus energy as a unit and break down silos Opportunity to focus on system-level changes while targeting scarce resources toward patients for whom the current delivery system works least well

23. Safe Transitions Across Tennessee

24. Questions? Missy Weeks QI Specialist 865-771-1772 mweeks@qsource.org This presentation was prepared by Qsource, the Medicare Quality Improvement Organization (QIO) for Tennessee, under a contract with the Centers for Medicare & Medicaid Services (CMS), a federal agency of the U.S. Department of Health and Human Services (DHS). Contents do not necessarily reflect CMS policy. 13.PREV.08.033