1. Intermountain-led CMS Hospital Engagement Network Readmissions November 4, 2014 Affinity Call Andrew Masica, MD, MSCI Baylor Scott & White Health Jennifer Pearce, MPA Lois Cross, RN, BSN, ACM Sutter Health

2. Outline for Discussion Review of the HEN Readmissions work “Just-one-thing” Recommendations High performers NQF Readmission Action Team 2014 plans for improvement: – predictive analytics for readmissions (June) – Continue Webinars for sharing

3. Intermountain HEN 2012-Q2 2014 30-Day All Cause Baseline 8.83 13.1% Decrease

4. Intermountain HEN 2012-Q2 2014 30-Day All Cause Readmissions

5. Intermountain HEN 2012-13 30-Day Medicare Readmissions Baseline 12.3 12.8% Decrease

6. Intermountain HEN 2012-13 30-Day Medicare Readmissions

7. Intermountain HEN 2012-13 submitting 30-Day Heart Failure Readmissions Baseline 15.4 5% Increase

8. Intermountain HEN 2012-13 submitting 30-Day Heart Failure Readmissions

9. Just One Thing Matrix Recommendations Getting StartedWorking HarderAhead of the Curve Transitional care providers capable of performing in- person visits (e.g. home, SNF) to selected patients following hospital discharge. Pharmacist-led medication management (reconciliation, regimen streamlining at discharge; post-discharge follow up regarding medication access and side effects (moderate level of evidence) Robust readmission risk stratification tools.

10. High Performing Hospital Highlight… 30-Day All Cause Readmissions Most Improvement MENLO PARK SURGICAL HOSPITAL SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ OREM COMMUNITY HOSPITAL SOCORRO GENERAL HOSPITAL THE ORTHOPEDIC SPECIALTY HOSPITAL BEAR RIVER VALLEY HOSPITAL PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL AMERICAN FORK HOSPITAL RIVERTON HOSPITAL PARK CITY MEDICAL CENTER Lowest Rates SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ MENLO PARK SURGICAL HOSPITAL OREM COMMUNITY HOSPITAL SOCORRO GENERAL HOSPITAL THE ORTHOPEDIC SPECIALTY HOSPITAL BEAR RIVER VALLEY HOSPITAL PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL AMERICAN FORK HOSPITAL RIVERTON HOSPITAL PARK CITY MEDICAL CENTER

11. High Performing Hospital Highlight… Most Improvement SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ SOCORRO GENERAL HOSPITAL GARFIELD MEMORIAL HOSPITAL MENLO PARK SURGICAL HOSPITAL FILLMORE COMMUNITY MEDICAL CENTER OREM COMMUNITY HOSPITAL THE ORTHOPEDIC SPECIALTY HOSPITAL LINCOLN COUNTY MEDICAL CENTER PARK CITY MEDICAL CENTER PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL 30-Day Medicare Readmissions Lowest Rates OREM COMMUNITY HOSPITAL FILLMORE COMMUNITY MEDICAL CENTER GARFIELD MEMORIAL HOSPITAL SOCORRO GENERAL HOSPITAL MENLO PARK SURGICAL HOSPITAL SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ THE ORTHOPEDIC SPECIALTY HOSPITAL PARK CITY MEDICAL CENTER LINCOLN COUNTY MEDICAL CENTER PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL

12. High Performing Hospital Highlight… Most Improvement OREM COMMUNITY HOSPITAL THE ORTHOPEDIC SPECIALTY HOSPITAL SUTTER DAVIS HOSPITAL SUTTER LAKESIDE HOSPITAL SUTTER MATERNITY & SURGERY CENTER OF SANTA CRUZ PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL SOCORRO GENERAL HOSPITAL ESPANOLA HOSPITAL LDS HOSPITAL AMERICAN FORK HOSPITAL 30-Day Heart Failure Readmissions Lowest Rates LDS HOSPITAL ALTA VIEW HOSPITAL SUTTER LAKESIDE HOSPITAL SUTTER DAVIS HOSPITAL AMERICAN FORK HOSPITAL SEVIER VALLEY MEDICAL CENTER ESPANOLA HOSPITAL PROVIDENCE HOOD RIVER MEMORIAL HOSPITAL PARK CITY MEDICAL CENTER FILLMORE COMMUNITY MEDICAL CENTER

13. SDM as Infrastructure for Enterprise Level Patient Engagement November 2014 Andrew Masica, MD, MSCI

14. What is Shared Decision Making (SDM)? A collaborative process between patient and clinician that engages the patient in decision making by – Helping them understand that a decision needs to be made (decision point), – clarifying all acceptable options and ensure that patients are well- informed regarding the best available medical evidence, and – choosing a course of action consistent with the patients’ needs, preferences, and values. SDM is part of delivering patient centered care. 14

15. Patient Engagement Hibbard et al., Health Affairs 2012

16. Patient Engagement SDM Relationship Between Patient Engagement and SDM

17. Program Implementation Challenges – Workflow in clinics – Survey Administration Tool – Health Coach Turnover – SDM must start very early in the process, not when the patient has already decided to have surgery or once they are in the hospital – Relative perceived value in fee-for service reimbursement Successes – Socialization of SDM as a “best practice” – SDM Training transitioned to on-site program 17

18. CMMI Progress: Ortho September 2013-September 2014 – Enrollment (embedded health coach model) Hip 36 Knee 81 Spinal Stenosis 5 Herniated Disk 2 Referral process, access to single on-site health coach, “pre- determination,” physician acceptance, equivocal patient interest all acted as barriers that impacted accrual 18

19. Revision in Strategy 19 Average annual CMS spend on beneficiaries with DM in BSWH-North Texas PHN (from spring 2014 HVHC report)

20. Leverage Points in Reducing Costs ConditionCase VolumeAverage CMS SpendTotal Orthopedic Surgeries1,500$20-45K$45M CHF5,500$42K$231M Diabetes20,500$20K$400M 20 Orthopedic procedure utilization rate was slightly below the HVHC mean Numerous “touchpoints” for our patients with chronic disease SDM training was rolled out to personnel interfacing with these patient populations (primary care health coaches, hospital- based transitional care staff)

21. Extending SDM’s Reach in the BSWH North Division

22. 22 Improved Accrual in Chronic Disease Patients

23. Is SDM Impacting Outcomes?

24. PCMH as an Ideal Site for SDM 24 Miller, How to Create an Accountable Care Organization, 2009 www.CHQPR.org

25. Redesigning SDM Approach Successfully implementing SDM requires all parts of the healthcare team to play their part with a process fully integrated into the system’s culture and practice SDM is not an intervention that can be conducted at one point in time, it is part of the healthcare delivery and communication process– a whole systems approach 25

26. Transforming Population Health – Achieving accountable, high-quality, cost-effective care for the patients we serve Scalability is the Key Challenge 26 https://fortress.maptive.com/ver3/c9ee95d0ae96b4e648088aeee101e296

27. The Future of SDM Training – PCMH- MA – System Level Care Coordination department Revising & Spreading training, integrating into system quality education program Development of leadership & physician training modules Allocation of operational budget to support this work 27

28. There is always a choice…..

29. © 2014 Sutter Health Jennifer Pearce, MPA Health Literacy Program Manager Sutter Center for Integrated Care Health Literacy & Health Literate Care 29

30. © 2014 Sutter Health How is “health literacy” different from “literacy”? Having the basic skills to read, write and compute without regard to context Literacy Reading, writing, computing, communicating and understanding in the context of health care Health literacy 30 Source: Weiss B. Epidemiology of Low Health Literacy. Understanding Health Literacy: Implications for Medicine and Public Health

31. © 2014 Sutter Health Health literacy includes one’s ability to perform multiple tasks Health literacy Obtain Document literacy ProcessProse literacy Understand Quantitative literacy Communicate: listen and speak Numeric literacy 31 Source: IOM. 2004. Health Literacy: A Prescription to End Confusion Source: Schwartzberg, J. 2005. Understanding Health Literacy: Implications for Medicine and Public Health

32. © 2014 Sutter Health What’s for lunch? Document literacy Prose literacy Quantitative literacy Numeric literacy

33. © 2014 Sutter Health Mismatch leads to harm Source: Parker, R. and Ratzan, S. 2010. “Health Literacy: A Second Decade of Distinction for Americans', Journal of Health Communication” 15: S2, 20 — 33 Health literacy Patient skills/ability Health system demand/complexity

34. © 2014 Sutter Health Patient skills: Prevalence of low health literacy 34 Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy

35. © 2014 Sutter Health Adult health literacy by highest level of education 35 Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy Only 1/3 of those with a graduate degree have the skills to effectively manage a chronic illness NAAL (2003)

36. © 2014 Sutter Health Adult health literacy by age 36 Source: U.S. Department of Education, Institute of Education Sciences, 2003 National Assessment of Adult Literacy Only 3% of those age 65+ have the skills to effectively manage a chronic illness NAAL (2003)

37. © 2014 Sutter Health Best practice Reading abilityEducation level Socio-economic status Universal Precaution Approach 37 Source: Smith, Sandra A. (2001). Patient Education and Literacy in Labus, A. & Lauber, A. (Eds.) Preventive Medicine and Patient Education. Philadelphia: WB Saunders, 266-290.

38. © 2014 Sutter Health Evidence: Easy-to-read is preferred! College educated readers’ response to health information written at 5 th grade level: Recall of key messages Satisfaction Source: Smith SA. Information giving: Effects on birth outcomes and patient satisfaction. Int Electronic J Health Educ 1998:;3:135-145. 38

39. © 2014 Sutter Health System resources 39 One Patient – One Message Disease and condition management (stoplights) Personal health record (electronic & paper) High risk medication tools AcuteAmbulatory Skilled & Rehab Home care, Palliative & Hospice

40. © 2014 Sutter Health Health literate stoplight tool with universal precaution approach applied Center for Plain Language Washington, D.C. 40

41. © 2014 Sutter Health 41 Medication and Route Dose Frequency Reason Instructions Partnered with EMR to develop patient friendly medicine list Font size increased to 14 pt

42. © 2014 Sutter Health Health literacy impacts all six aims

43. © 2014 Sutter Health Health.gov http://www.health.gov/communication/interactiveHLCM/#resources Please feel free to contact me Jennifer Pearce, MPA Health Literacy Program Manager Sutter Center for Integrated Care pearcej1@sutterhealth.org www.suttercenterforintegratedcare.org For questions or additional information: