Care Transitions : Are You in the Game?

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Care Transitions Are You in the Game?

• Naomi Hauser RN, MPA
• Director Care Transitions
• Quality Insights of Pennsylvania
• May 16, 2012

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Welcome

• What well cover today
• Introduction of Care Transitions Program
• The Role of HCA in the Community
• Discuss Evidence Based Interventions to reduced
  avoidable readmissions
• Share Lessons Learned form 3 Year Pilot
• Open Discussion

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Why Are We Here?

• To learn about and promote safe/effective
  transitions of care as patients navigate from one
  provider setting to another or one caregiver to
  another
• Develop partnerships

4
Integrated Care For Populations and
Communities

• GOAL
• To promote safe/effective transitions of care as
  patients navigate from one provider setting to
  another or one caregiver to another

5
30 Day Readmissions The Problem

• Nationally 17.6 of Medicare beneficiaries
  discharged from the hospital are readmitted
  within 30 days.
• More than 85 of these re-hospitalizations are
  unplanned.
• 20-40 of re-hospitalizations are possibly
  preventable.
• 64 of Medicare beneficiaries who are readmitted
  within 30 days do not receive any post-discharge
  care before readmission.

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Mrs. Bs Story
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339 Days in the Life of Mrs. B

• Day 1 New internal medicine physician, poorly
  controlled diabetes with neuropathy, HTN,
  osteoporosis. To see physician q. 2 wks
• Day 15 Sees physician, fully functional,
  assists with care of grandchild and husband
• Day 60 Mrs. B falls on the ice, to ER, no
  fractures but abrasions. Referred to home health
• Day 68 Not feeling well
• Day 69 Hospitalized with Staph Septicemia,
  dehydration, ARF, CHF, A-Fib, PN and uncontrolled
  diabetes
• Day 82 Transferred to SNF for short-term rehab
  and wound care
• Day 182 Discharged to home, depressed,
  abrasions healed, diabetes under good control
• Day 183 Nauseated, cant find her teeth, dgt
  intends to call home health
• Day 184 Readmitted to the hospital for
  dehydration, CHF, A-Fib and diabetes
• Day 191-337 Admitted to in-pt rehab then to
  nursing home
• Day 338 Readmitted to hospital w/ ARF, CHF, ARF
• Day 339 Mrs. B dies

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Timeline for payment penalty for hospitals

• Beginning October 2012 Medicare will apply
  penalties and will withhold payment for avoidable
  30 day acute care readmissions with a
  progressively increasing scale for certain DRGs.

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July2008-August 2011

• Pilot Project

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14 QIOs with 14 Target Communities

• AL Tuscaloosa
• CO Northwest Denver
• FL Miami
• GA Metro Atlanta East
• IN Evansville
• LA Baton Rouge
• MI Greater Lansing area
• NE Omaha
• NJ Southwestern NJ
• NY Upper capital
• PA Western PA
• RI Providence
• TX Harlingen HRR
• WA Whatcom county

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Targeted Community

• Higher than state average re-admission rate
• Located in southwestern PA, in a community
  surrounding the southern Pittsburgh metropolitan
  area
• Community spans most of Westmoreland County and
  small portions of Allegheny, Washington, and
  Fayette counties

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9th SOW Overview

• CMS
• 14 states
• Community cross-setting
• Transparent
• Remove silos

• SWPA
• 5 hospitals
• 8 home health agencies
• 15 nursing homes
• 2 AAAs
• 32 interventions
• 14 relative improvement

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Structure of the Project

• Cross-setting
• Community-based
• Collaborative

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The Shift to

• Chronic illness management
• Self-care management
• Empowerment
• Responsibility
• Accountability
• Patient activation

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Cross-Setting Goal

• Develop a practical, cross-setting approach
• Unite providers from all settings
• Share vision of improved health care quality
• Equal voices
• Identify provider strength
• 
  
• 
  

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The Role of Agencies

• Home Health
• Hosicpe

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Hospital Elements

• Leadership buy-in
• Operational level leadership
• Education
• Silos
• Bureaucracy/slow to change
• Competitive
• Non-transparent

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Hospital Interventions

• Self reported readmission rate
• Discharge process
• Discharge instructions
• End of life options
• 48-hour follow-up call
• Schedule follow-up PCP visit
• CTI-AAA
• 
  

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SNF Elements

• Education
• Eager to learn
• Eager to share
• Share competence levels
• Family
• Physicians
• Turnover
  
  

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SNF Interventions

• SBAR
• Communication transfer form
• Chart reviews
• End of life options/education
• POLST/AD
• Coach CTI
• 
  

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Home Health Elements

• Focus on ACH vs. readmissions
• Medication management
• Low referral rates
• Educate on referral criteria
• Coaching
• Hands on in home care
• 
  

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Drivers of Hospital Readmission

• Same for home care as other health care
  providers
• Patient activation
• Standard, known processes
• Transfer of information

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Home Health Compare

• Top 20 for this measure has maintained an
  unplanned hospitalization rate of 21 since last
  quarter
• While stakeholders are focusing on reducing
  unnecessary hospitalizations, the data tells us
  that we still have work to do and
• What about those 30-day readmissions?
• Low-hanging fruit for home care to determine root
  cause and intervene in real-timewin-win for
  everyone

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Home Health Compare

• The latest Home Health Compare (HHC) scores were
  published on October 13th and reflect a data
  collection period of July 2010 - June 2011.
  Overall, the results have improved.
• Hospitalization result has had a setback
• Hospitalization worsened from 26 last quarter to
  27

www.Fazzi.com
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Intervention HHA

• Communication transfer sheet
• Front load visits
• Telehealth
• Phone monitoring
• Life line
• Chronic care education
• Coaching/partnering
• Depression screening
• Chart reviews
• 
  

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Best Practices

• Home Health Quality Improvement National Campaign
  Best Practice Intervention Packages (BPIPs)
• Focus on reducing ACH, improving management of
  oral medications and cross-setting collaboration
• Simplified approach to use packages
• Standardized steps to follow for each publication
• Flexible for HHA implementation
• BPIPs free to download at http//www.homehealthqu
  ality.org/hh/default.aspx

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BPIPs Include

• Hospitalization Risk Assessment
• Emergency Care Planning
• Medication Management
• Fall Prevention
• Care Transitions
• Coaching
• Patient Self-Management
• Disease Management
• Telehealth
• Introduction to new ideas/topics Patient
  Centered Medical Home Accountable Care
  Organizations and others

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Learn moreCoach/HH nurse

• Coaching and home health service
• Increase Medicare HH referrals
• Oasis takes time
• Coach non-clinical
• Different role
• Medication review patient driven
• Complementary/respectful

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Lessons Learned

• Community focus
• Root cause analysis
• Communication
• Transparency
• Leadership buy-in

• Collaboration
• Patient-centered
• Ongoing monitoring
• Community outreach
• Sustainability

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Lessons Learned

• Re-Engineers the discharge process (Project Red,
  Project Boost, Medication reconciliation)
• Change the paradigm of patient education (Teach
  Back)
• Improve information transfer (Cross setting
  transfer form)

• Increase community outreach (Collaboration with
  community resources, Handover)
• Increase post discharge process and support
  (PHR, Medication management, PCP f/u appointment
  and coaching)

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August 2011-July 2014

• 10th SOW

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AIMS and Goals

• Strategic Aims
• What will be done
• Integrate Care for Populations
• Care Transitions that reduce re-admissions by 20
  within 3 years.

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CMS 10th SOW for QIOs

• Form a community coalition to ensure
  community-wide adoption of improved practices in
  care transitions
• Assist communities in applying for the CMS 3026
  CCTP funding opportunity
• Form a Learning and Action Network (LAN) and
  provide evidence-based interventions associated
  with known drivers of hospital readmissions (Jan.
  26, 2012)
• Host quarterly LAN sessions one in-person each
  year

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CMS 10th SOW for QIOs

• Provide the community with a template for
  coalition charters to help the partners formalize
  structure and procedures
• Assist the community with root cause analysis to
  identify community-specific causes for poor
  transitions and develop data reports to monitor
  progress
• Assist in the selection of the most appropriate
  evidence-based interventions

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The Importance of Communities to Improve Health
Care

• Integrating Care for Populations and Communities

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CMS Defines a Community

• Defined by contiguous zip codes
• Medicare beneficiaries that live in those zip
  codes
• Committed providers and stakeholders

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Community Essentials

• Developed around collaborative care delivery
• Shared vision
• Shared mission
• Shared resources
• Shared decision making
• Environment of trust

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A Community

• Social network analysis for Medicare
  beneficiaries in 2009
• Allows visualization of relationships between
  providers through network diagrams
• Shows flow of transitions among providers
• Senders, receivers, provider type and strength of
  relationship

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4 Recruited Communities

• Western Pennsylvania
• Lehigh Valley
• York
• Chester County

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Building Community

• Leaders reach to other leaders
• Expand the circle of support
• Grow more resources
• Develop/sustain commitment
• Recruit people
• The more volunteers or members who find purpose
  in the community -the more they will commit
  resources that you may never have known existed.

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Community Development

• CMS suggested communities
• Hospitals in contiguous Zip Codes
• Overlap of beneficiaries/penetration
• Desire to reduce re-admission rates
• Agree to collaboration/relationship
• Transparency
• Downstream Providers

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Provider Responsibilities

• Leadership commitment
• Active involvement of provider teams including
  leadership in meetings, conference calls,
  webinars and coalition activities
• Implement improvement strategies using rapid
  cycle testing
• Create new strategies that maximize improvement
  for all participants
• Track, monitor and share real time data

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Stakeholder Support

• Are the cornerstone for the community
• Learn from the community
• Inform members of CT strategies
• Support/provide community education sessions
• Participate in quarterly calls
• Provide publications via newsletter
• Post information/links of CT on Web sites

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Expand the Circle of Support Motivating Call to
Action
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• Community
• Intervention Selection

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Standard/Known Process

• BOOST (Better Outcomes for Older adults through
  Safe Transitions)
• TCM (Transitional Care Model)
• F/U appointment made at discharge
• Pharmacy
• Telephone F/U
• Document standardization

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Drivers of Readmissions
Based on discharges from 2007. Clinical
Classification Software (CCS) 2008 downloadable
from http//www.ahrq.gov/data/hcup/ .
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Lessons Learned
Key drivers of 30 day readmission Low patient
activation Lack of standard processes Inadequate
transfer of information across care settings Key
strategies for 30 day readmission reduction
Community organization Patient
activation Multi-provider process improvement
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End of Life

• Of discharges of CT residents from the five
  targeted hospitals that result in a 30-day
  readmission to any acute care hospital during the
  last six months of life
• 35 are discharges to a SNF
• 33 are discharges to home under the care of a
  HHA
• 23 are discharges to home or self-care
• 28 of all readmissions occur during the last six
  months of life

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Root Cause Analysis

• Simply stated RCA is a process designed to help
  identify not only
• What and how BUT
• Why
• Leads to interventions selection and ongoing
  identification of gaps in care delivery across
  settings.

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Intervention Selection

• Derived from root cause findings
• Monitor Measure
• Process Measures
• System Components
• Outcome Measures
• Effect of change on patient

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Intervention Selection by Driver

• Patient Activation
• Standard/Known Process
• Transfer of Information

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PROJECT RED(ReEngineered Discharge)

• Evidenced based toolkit.
• Developed by Boston University Medical Center
• Addresses key factors identified in RCA
• Delayed Transfer of Discharge Summary
• Unknown Test Results
• Patients Failure to Follow-up
• Medication Interactions and Adverse Events

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Transfer of Information

• Communication Re-design
• HIT
• SBAR
• Beneficiary and community outreach

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Patient Activation

• INTERACT
• RED (Re-engineered Discharge)
• Medication Reconciliation
• Coaching
• Teach-Back

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Coming together is a
beginning.Keeping together is progress.Working
together is success. Henry Ford
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Community Care Transitions Program

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The Communitybased Care Transitions Program
(CCTP)

• The CCTP, mandated by section 3026 of the
  Affordable Care Act, provides funding to test
  models for improving care transitions for high
  risk Medicare beneficiaries.
• Increasing rates of avoidable hospital
  readmissions will result in negative health
  outcomes for Medicare beneficiaries impacting
  their levels of safety and quality of care.
• The CCTP seeks to correct these deficiencies by
  encouraging communities to come together and work
  together to improve quality, reduce cost, and
  improve patient experience.

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CCTP Program Goals

• Improve transitions of beneficiaries from the
  inpatient hospital setting to other care settings
  
• Improve quality of care
• Reduce readmissions for high risk beneficiaries
• Document measureable savings to the Medicare
  program

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Eligible Applicants

• Are statutorily defined as Acute Care Hospitals
  with high readmission rates in partnership with a
  community based organization
• Community-based organizations (CBOs) that provide
  care transition services
• There must be a partnership between the acute
  care hospitals and the CBO

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CCTP Definition of CBO

• Community-based organizations that provide care
  transition services across the continuum of care
  through arrangements with subsection (d)
  hospitals-Whose governing bodies include
  sufficient representation of multiple health care
  stakeholders, including consumers

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CCTP Key Points

• CBOs will use care transition services to
  effectively manage transitions and report process
  and outcome measures on their results.
• Applicants will not be compensated for services
  already required through the discharge planning
  process under the Social Security Act and
  stipulated in the CMS Conditions of
  Participation.
• Applicants will be required to participate in
  ongoing learning collaboratives

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CCTP Application Guidance

• Applicants are required to complete a root cause
  analysis
• The proposals must specify how the root causes
  will be addressed
• The proposal will describe how they will work
  with accountable care organizations and medical
  homes if applicable
• The proposal will describe how they will align
  their care transition programs

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CCTP Conclusion

• The program solicitation was announced in the
  Federal Register and is now available at
• http//www.cms.gov/DemoProjectsEvalRpts/M
  D/itemdetail.asp?itemIDCMS1239313
• The program will run for 5 years with the
  possibility of expansion beyond 2015
• If community progress is not occurring within 2
  years of receiving funding, funding will be
  stopped
• Please direct CCTP questions to
• http//www.cms.gov/DemoProjectsEvalRpts/MD/itemdet
  ail.asp?itemIDCMS1239313

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CCTP Website

• Visit the program website for daily updates on
  program status at http//www.cms.gov/DemoProjectsE
  valRpts/MD/itemdetail.asp?itemIDCMS1239313
• Do not forget to note Frequently-Asked Questions
• On the Site

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What Actions Can You Take?

• Look at your process
• What do you already have in place?
• What strength do you bring to the community?
• Be a good team player
• How can you collaborate to
• Improve care delivery across the continuum
• Reduce errors and avoidable re-admissions
• Share resources and reduce cost
• Improve communication and information transfer
• Improve Care Transitions

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10th Scope of Work The Opportunity for You.

• Communities are developing
• Position yourselves
• Promote cross setting best practices you have
  implemented
• Integrate with upstream and downstream providers
• Be part of the discussion and strategic planning
• Let everyone know the role of home care and the
  services are critical to decreasing the rate of
  30-day readmissions
• Be part of the solution!

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QIO Technical Assistance

• Learning and Action Networks (LAN) on a
  state-wide level
• Webinars provided and recorded
• Connect to downstream providers
• Provide current Medicare data to providers

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Resource Sharing

• Upcoming conferences or meetings
• E-newsletters
• Share with us/success stories
• Or how can we share an article with you?
• Contact Krista Davis at kdavis_at_wvmi.org or
• nhauser_at_wvmi.org
• www.qipa.org

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You must be the change you wish to see in the
world
MahatmasGandhi
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This material was prepared by Quality Insights of
Delaware, the Medicare Quality Improvement
Organization for Delaware, 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. Publication
number 10SOW-DE-ICP-KD-010612A. App. 1/12.