1. Finger Lakes Health Systems Agency A Three Year Retrospective: Reflecting Back as we Evolve Forward FLHSA 2020 Performance Commission Meeting November 26, 2012

2. 2 2020 Performance Commission 2009 Community Investment Goals: 1.Reduce potentially preventable hospitalizations by 25% by 2014 2. Decrease avoidable ED visits by 15% by 2014 3. Create sustainable plan for Central Finger Lakes region hospitals

3. 3 2020 Performance Commission: Status Preventable Hospitalization and ED Visit Developed targeted work groups Discharge planning Embedded care managers Care Transitions Intervention - Coaching Telemedicine Primary care support Parent education

4. 4 Discharge Planning: Goal Reduce the 30-day Medicare readmission rate through the adoption of four (4) discharge/transition standards Enhance patient safety Ensure the safe transition from hospital to home and the community-based setting

5. 5 Discharge Planning: Status 10 Regional Hospitals committed to standard discharge components: Patient/family participation Medication reconciliation Information transfer Post discharge follow-up Readmissions from nursing homes Sharing hospital experiences Patients and families included in change of shift Hospitals and home-care agencies using improved discharge packets specific to diseases Hospital provider-primary care physician call center Rounds with hospitalists and care managers Sharing opportunities Coaches trained through teach-back training from the Community Health Foundation

6. 6 Embedded Care Managers: Goal Incorporate care managers into primary care practices to reduce hospital readmissions by: Identifying patients at risk of PQI readmissions and ED visits Ensuring patients receive timely follow-up care Medication reconciliation/management Arranging for necessary community services to support the patient and caregivers Coordination with other providers

7. 7 Embedded Care Managers: Status Staffing 9 care managers hired and working in selected primary care practices until March 2013 6 Care Managers will remain in the practice after HEAL 19 Program evaluation Developed tracking tools Care manager encounter log Hospital admissions and ER utilization Risk assessment tool Measuring impact on PQI admissions Insurers’ claims data received Waiting next update Social Work Model URMC/Highland Geriatrics Northridge Medical Group Lifetime Medical Group Jordan Health Center Nursing Model Spencerport Family Medicine Unity Geriatrics Long Pond Medical Group Highland Family Medicine Westside Health Center

8. 8 Care Transition Intervention: Goals Engage patients and their families to be full partners in ensuring improved health and decreasing dependence on hospitals/EDs Based on the nationally recognized Care Transitions Program Shown 20% to 40% lower hospital readmission rates (Medicare beneficiaries receiving coaching) 2011 Goals 18 active patient-care coaches 5 active hospitals accepting coaches 2,500 people will have received coaching Readmission rates and ED rates of coached patients compared with community Physician follow-up visit within 0-7 days of discharge

9. Care Transitions Intervention: Status 21 trained coaches (social workers, nurses, educators) 2 Trainers Over 3300 patients offered CTI from October 2010 – June 2012 5 hospitals actively partnering with home care agencies and accepting coaches on patient floors (Strong, RGH, Unity, Highland, Newark-Wayne with Lifetime Care and VNS) Lifespan awarded $3.2M from the Centers for Medicare and Medicaid Services to expand CTI for Medicare FFS patients Our region is the nation’s first community-based, multi-payer all beneficiary coaching program to demonstrate an impact on reducing hospital readmissions and ED visits 9

10. Emergency Room: Goal Reduce avoidable ER visits through: Telemedicine in pediatric practices Primary care support Parent education 10

11. Emergency Room: Status Telemedicine Expanded use of pediatric telemedicine in the Rochester city schools (189 more telemed visits in Q4 2010 than in Q4 2009) Primary care support Utilizing care managers in PCP offices (providing care management support) Parent education Implemented health-literacy pilot in OB- practice setting to impact ER use in the 0-1 age group Distributed 500 health-care books to expectant parents during 3 rd trimester (English and Spanish) 11

12. 2020 PC / Regional Work Group: Goals Sustain and improve access to care for residents in the Central Finger Lakes region Understand regional hospital challenges Integrate clinical care resources and delivery in the region 12

13. Regional Work Group: Status Work group unanimously voted to move forward with implementation strategies, define next steps Formed Implementation Committee to select, develop and implement strategic options –Composed of hospital CEOs, chairs, and medical professionals Met with CFL hospital boards and the medical communities of each hospital to discuss work group’s findings and opportunities to work together 13

14. 14 Partnership with NYS Strong and historic partnership –HEAL 9 and 19 funding Strengthened by Cuomo Administration –DOH Commissioner Shah visit to Rochester –Fran invited to speak to North Country hospital CEOs in July –Medicaid Redesign Team

15. 15 Partnerships at the Federal Level U.S. Senator Schumer Dr. Jaime Torres, HHS Region II Director Dr. Richard Gilfillan, Acting Director, HHS Center for Medicare and Medicaid Innovation

16. 16 Finger Lakes Health Systems Agency The triangle represents our agency’s role as a fulcrum—the point on which a lever pivots—boosting the community’s health by leveraging the strengths of all stakeholders. The fulcrum is also a point of equilibrium, reflecting our ability to balance the needs of consumers, providers and payers on complex health matters. The inner triangle also evokes the Greek letter delta—used in medical and mathematical contexts to represent change—with a forward lean as we work with our community to achieve positive changes in health care. Give me a lever long enough and a fulcrum on which to place it, and I shall move the world. —Archimedes 1150 University Avenue Rochester, New York 14607-1647 585.461.3520 www.FLHSA.org