1. Progress in the MA STAAR Collaborative and Working Across the Continuum
Pat Rutherford
Rebecca Steinfield
(The presenters have nothing to disclose)
MA STAAR Collaborative Learning Session
October 11, 2011

2. Session Objectives Participants will be able to:
Describe the case for creating a more patient-centered transition from the hospital to post-acute care
Describe IHI/CMWF strategies and identify key interventions promoted in the MA STAAR Collaborative to reduce avoidable rehospitalizations
Share an overview of the MA STAAR Collaborative progress to-date

5. Systems of Care
“The quality of patients’ experience is the “north star” for systems of care.” –Don Berwick

6. Rebecca’s Story
Rebecca Bryson lives in Whatcom County, WA and she suffers
from diabetes, cardiomyopathy, congestive heart failure, and a
number of other significant complications; during the worst of her
health crises, she saw 14 doctors and took 42 medications. In
addition to the challenges of understanding her conditions and the
treatments they required, she was burdened by the job of
coordinating communication among all her providers, passing
information to each one after every admission, appointment, and
medication change.

7. Rebecca’s Story
Rebecca said if she were to dream up a tool that would be
truly helpful, it would be something that would help her
keep her care team all on the same page. Bryson described
typical medical records as being “location or process
centered, not patient-centered.” She also describes how
difficult it can be for patients to navigate a large health care
system. Rebecca summarizes her experience in this way –
“Patients are in the worst kind of maze, one filled with
hazards, barriers, and burdens.”

8. “North Star” in STAAR?
Whose experience of care is the “north star” for your system of care?

9. Strategic Questions for Executive Leaders
Is reducing the hospital’s readmission rate a strategic priority for the executive leaders at your hospital? Why?
Do you know your hospital’s 30-day readmission rate?
What is your understanding of the problem?
Have you assessed the financial implications of reducing readmissions? Of potential decreases in reimbursement?
Have you declared your improvement goals?
Do you have the capability to make improvements?
How will you provide oversight for the collaborative, learn from the work and spread successes?

10. What can be done, and how?
There exist a growing number of approaches to reduce
30-day readmissions that have been successful locally
Which are high leverage?
Which are scalable?
Success requires engaging clinicians, providers across organizational and service delivery types, patients, payers, and policy makers
How to align incentives?
How to catalyze coordinated effort?

11. STAAR Initiative: Two Concurrent Strategies
Provide technical assistance to front-line teams of providers working to improve the transition out of the hospital and into the next care setting
Actively engage hospitals and their community partners in co-designing processes to improve transitions
Provide coaching by content experts and facilitate collaborative learning with the goals of creating exemplary cross continuum models in each state and identifying high-leverage changes in each care setting
Develop quality improvement expertise and content experts to mentor others
Create and support state-based, multi-stakeholder initiatives to concurrently examine and address the systemic barriers to improving care transitions, care coordination over time.
State leadership, steering committees, key allies, aligning initiatives
Technical assistance to “staff” challenges in framing the issue, designing strategy, scanning for developments in best practice/policy
Specific focus areas: understanding the financial impact of success, aligning payment to support high leverage interventions, developing state rehospitalization data reports

12. Evidence-Based Interventions
Boutwell, A. Griffin, F. Hwu, S. Shannon, D. Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions. Cambridge, MA: Institute for Healthcare Improvement; 2009
Kanaan SB. Homeward Bound: Nine Patient-Centered Programs Cut Readmissions. CHCF, Sept 2009.
Osei-Anto A, Joshi M, Audet AM, Berman A, Jencks S, Health Care Leader Action Guide to Reduce Avoidable Readmissions. Health Research & Educational Trust, Chicago, IL. January 2010

13. Transition from Hospital to Home
Enhanced Assessment
Teaching and Learning
Real-time Handover Communications
Follow-up Care Arranged
Post-Acute Care Activated
MD Follow-up Visit
Home Health Care (as needed)
Social Services (as needed)
Skilled Nursing Facility Services
Alternative or Supplemental Care for High-Risk Patients *
Hospice/Palliative Care
Transitional Care Models
Intensive Care Management (e.g. Patient-Centered Medical Homes, HF Clinics, Evercare)
IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations
Improved Transitions
and Coordination
of Care
Reduction in
Avoidable
Rehospitalizations or
Myriad payer-based discharge planning and care coordination services create chaos at provider level. How can interests be aligned and coordinated?
* Additional Costs for these Services
Patient and Family Engagement
Cross-Continuum Team Collaboration
Evidence-based Care in All Clinical Settings
Health Information Exchange and Shared Care Plans

14. Transition from Hospital to Home
Enhanced Assessment
Teaching and Learning
Real-time Handover Communications
Follow-up Care Arranged
Post-Acute Care Activated
MD Follow-up Visit
Home Health Care (as needed)
Social Services (as needed)
Skilled Nursing Facility Services
Alternative or Supplemental Care for High-Risk Patients *
Hospice/Palliative Care
Transitional Care Models
Intensive Care Management (e.g. Patient-Centered Medical Homes, HF Clinics, Evercare)
IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations
Improved Transitions
and Coordination
of Care
Reduction in
Avoidable
Rehospitalizations or
Myriad payer-based discharge planning and care coordination services create chaos at provider level. How can interests be aligned and coordinated?
* Additional Costs for these Services
Patient and Family Engagement
Cross-Continuum Team Collaboration
Evidence-based Care in All Clinical Settings
Health Information Exchange and Shared Care Plans

15. Co-designing Processes to Improve Transitions
Hospitals
Perform an enhanced assessment  of post-hospital needs
Provide effective teaching and facilitate enhanced learning
Ensure post-hospital care follow-up
Provide real-time handover communications
Office Practices
Provide timely access to care following a hospitalization
Prior to the visit: prepare patient and clinical team
During the visit: assess patient and initiate new care plan or revise existing plan
At the conclusion of the visit: communicate and coordinate ongoing care plan
Home Care
Meet the patient, family caregiver(s), and inpatient caregiver(s) in the hospital and review transition home plan
Assess the patient, initiate plan of care, and reinforce patient self-management at first post-discharge home care visit
Engage, coordinate, and communicate with the entire clinical team
Skilled Nursing Facilities
Ensure that SNF staff are ready and capable to care for the resident patient’s needs
Reconcile the Treatment Plan and Medication List
Engage the resident and their family or caregiver in a partnership to create an overall place of care
Obtain a timely consultation when the resident’s condition changes

16. 4 Key Changes to Improve the Transition from Hospital to Home
Perform an Enhanced Assessment of Post-Hospital Needs
Provide Effective Teaching and Facilitate Enhanced Learning
Ensure Post-Hospital Care Follow-Up
Provide Real-Time Handover Communications

17. 1. Enhanced Assessment
1. Perform an Enhanced Assessment of Post-Hospital Needs
Involve the patient, family caregiver(s) and community provider(s) as full partners in completing a needs assessment of the patient’s home-going needs.
B. Reconcile medications upon admission.
C. Create a customized discharge plan based on the assessment

18. 2. Effective Teaching and Facilitate Learning
2. Provide Effective Teaching and Facilitate Enhanced Learning
Involve all learners in patient education.
B. Redesign the patient education process.
C. Redesign patient teaching print materials.
D. Use Teach Back regularly throughout the hospital stay to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care.

19. 3. Follow-up Care 3. Ensure Post-Hospital Care Follow-up
3. Ensure Post-Hospital Care Follow-up
Reassess the patient’s medical and social risk for readmission.
B. Prior to discharge, schedule timely follow-up care and initiate clinical and social services based upon the risk assessment.

20. 4. Handover Communications
4. Provide Real-Time Handover Communications
A. Give patient and family members a patient-friendly post-hospital care plan which includes a clear medication list.
B. Provide customized, real-time critical information to next clinical care provider(s).
C. For high-risk patients, a clinician calls the individual(s) listed as the patient’s next clinical care providers(s) to discuss the patient’s status and plan of care.

21. Transition from Hospital to Home
Enhanced Assessment
Teaching and Learning
Real-time Handover Communications
Follow-up Care Arranged
Post-Acute Care Activated
MD Follow-up Visit
Home Health Care (as needed)
Social Services (as needed)
Skilled Nursing Facility Services
Alternative or Supplemental Care for High-Risk Patients *
Hospice/Palliative Care
Transitional Care Models
Intensive Care Management (e.g. Patient-Centered Medical Homes, HF Clinics, Evercare)
IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations
Improved Transitions
and Coordination
of Care
Reduction in
Avoidable
Rehospitalizations or
Myriad payer-based discharge planning and care coordination services create chaos at provider level. How can interests be aligned and coordinated?
* Additional Costs for these Services
Patient and Family Engagement
Cross-Continuum Team Collaboration
Evidence-based Care in All Clinical Settings
Health Information Exchange and Shared Care Plans

22. New Frontiers in the STAAR Initiative
Engaging Payers:
Payers are motivated to reduce avoidable rehospitalizations
Individual payer efforts
Mostly focus on pre-discharge preparation
CMS 3026 to pay for additional community-based care
Discrepancies between what providers get paid for and what is needed for care
Supplemental services for high-risk patients are of paramount importance
What is the comparative effectiveness for various interventions for
high-risk patients?
Myriad payer-based discharge planning and care coordination services create chaos at provider level. How can interests be aligned and coordinated?

23. Improving Transitions and Reducing Avoidable Rehospitalizations
Will
RESULTS
New
possibilities
Build
confidence
Hospitals are increasingly launching into new improvement projects with goals to improve outcomes, efficiency, quality, costs, and safety. Organizations devote time, resources, and human capital to increase the safety and efficiency of patient care. However, according to a recent study by Aiken and colleagues, up to 70 percent of all change fails. [Aiken C, Keller S, Rennie M. The Performance Culture Imperative. McKinsey & Co.] Why does this happen when well-intentioned people set out to improve what they do? It is largely because many institutions have expertise in the important clinical elements that need improving, but lack skills in the operational processes that act as the engine needed to drive improvement. For a portfolio of improvement projects to truly achieve success at the system level, a proficient operational skill set is required.
The Goal
To help organizations operationalize improvement across their systems, the Institute for Healthcare Improvement (IHI) is offering its latest Expedition titled, Successful Execution: Securing the Link from Aims to Results. This five-part, web-based program will help you to achieve breakthrough levels of performance by demonstrating how to implement a framework of execution rooted in the elements of Will, Ideas, and Execution, an IHI model for improvement.
This framework involves:
Setting appropriate goals
Developing a portfolio of projects
Deploying resources appropriately
Establishing an oversight and learning system to increase the likelihood of producing intended results from improvement initiatives  
Expert faculty will explain all the components of the framework using real-world examples. They will then work with participants on how to apply the framework to take their organization’s improvement efforts to the next level — a level where change is identified, and spread and sustainability are designed into the system to create a cycle of continuous learning.
Objectives
At the conclusion of this Expedition, participants will be able to:
Set a breakthrough aim for their organization
Design a portfolio of projects with appropriate staffing and resources
Formulate a plan to build or ensure improvement capability
Convene a cross-functional team for an oversight meeting
Execute a plan that can be applied over time, in other years, with other departments or programs in the organization
Ideas
Execution
Sequencing and tempo

24. What Changes Are You Working On?

25. What Changes Are You Working On?

26. Cohort 1

27. Cohort 2

28. Analysis of Results-to-Date
Reducing readmissions is dependent on highly functional cross continuum teams and a focus on the patient’s journey over time
Improving transitions in care requires co-design of transitional care processes among “senders and receivers”
Providing intensive care management services for targeted high risk patients is critical
Reliable implementation of changes in pilot units or pilot populations require 18 to 24 months

29. The Next Year in the MA STAAR Initiative
Two 1.5-day state-wide Learning Sessions plus monthly content coaching calls
State Leaders and IAs facilitate monthly networking/peer coaching calls
Improvement Science in Action Workshop (for day-to-day leaders in hospitals, SNFs, HC agencies and OPs) plus monthly coaching calls
IHI and expert faculty will facilitate Learning Networks for clinicians and staff in OP, SNFs and HC Agencies
MA STAAR State Leaders and State-wide Steering Committee Meetings align initiatives and address systemic barriers