COALITIONS

Arkansas Medicare Readmissions

Overall Goals by 2019: Reduce Medicare Hospital Readmission Rates by 20% Reduce Medicare Hospital Admission Rates by 20% Increase community tenure by increasing the days Medicare FFS Beneficiaries spend at home by 10% Reduce Adverse Drug Events, Emergency Department Visits, Observation Stays occurring as a result of the care transitions process.

A Community-Based Approach:

Case Management Quality Program Manager Med. Mgmt / Referral Nurse Director of Community Relations RN/ Patient Intake Coordinator Sales/Marketing Director of Pharmacy In Home Services Specialist Grant Coordinator Director of Quality VP of Quality & Patient Safety Quality Specialist Director Quality Home Health Director Director of Nursing Nursing AASN Coordinator General Manager Director of Clinical Services MBA, RN, RNP Volunteer Caregiver Advocate RN Director Care Manager RN Care Coordinator Director Community Liaison RN Care Management Supervisor Director of Client Services Manager Marketing Director Administrator Director of Marketing Physician Sales Representative Pharmacist Director Quality and Case Management Director of Behavioral Health/Senior Care Director Case Management Supervisor MRC, CRC Marketing Caregiver Marketing Manager Senior Area Business Specialist Marketing Director/Admission Director Patient Services Director RN Discharge CNO/Quality Director ADON DON SW/CM Quality LCSW COMMUNITY EDUCATOR & MEDICAL CONSULTANT Community Education Coordinator LPN Administrator Intake Coordinator Clinical Specialist Office Manager Business Developer Consultant Pharmacist Community Relations Consultant RN, MSN Behavioral Health Director Director Home Health Business Development Manager Patient Safety Officer Manager, bundled payments Director of Pharmacy Quality Health Coach Director Manager Care Transitions Vice President Marketing Assistant Administrator Sales/Marketing Community Outreach Administrator Nurse Manager QI Coordinator Administrative Coordinator Director of Corporate Marketing Arkansas sales Manager Admissions/Marketing Director Account Executive Director, Office of Rural Health and Primary Care Community Relations Specialist Director of Quality & Patient Safety Quality Specialist VP of Quality & Patient Safety Regional Account Director Patient Care Coordinator Billing RN, Manager of Clinical Services Customer Relations Executive, Care Transition Nurse Director of clinical services Director of Nursing Social Services Director Administrator Clinical Transition Nurse Case Manager Director Quality Team Lead - Transitions of Care Community Resource Specialist RN-Hospice Specialist Patient Care Manager RN, Care Transition Liaison Director of Clinical Services Area E.D. Social Director Director Mktg & Business Development Clinical Consultant for Remote Pt Monitoring Community Education Specialist Clinical Manager Population Health State Coordinator Admissions RN Clinical Assessment Coordinator Director of Community Education Manager of Clinical Practice Medical Director Director RN Program Director

Cohort A: ACT Delta/ACT East Cohort B: ACT North Central/ACT Northwest Cohort C: ACT Ozarks, ACT Southwest, ACT Central, ACT South Central, ACT River Valley

What do we do first? DATA Root Cause Case Studies Readmission Interviews

What causes a PREVENTABLE Readmission/Admission? The four factors “most strongly associated with potentially preventable readmissions”: Premature discharge from the index hospitalization Failure to relay important information to outpatient health care professionals Lack of discussions about care goals among patients with serious illnesses Emergency department decision-making to admit a patient who may not have required an inpatient stay The four most common factors affecting potentially preventable admissions: Emergency department decision-making Inability to keep appointments after discharge Premature discharge from the hospital Patient lack of awareness of whom to contact after discharge “Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients” JAMA Internal Medicine doi:10.1001/jamaintermed.2015.7863 (published online, March 7, 2016), http://archinte.jamanetwork.com/article.aspx?articleid=2498846.

Arkansas 30-day Hospital Readmissions by Care Setting

Arkansas 30-day Readmissions by Diagnosis CHF (24.2%) COPD (19.1%) Average 138/month (4-5/day) Average 76/month (2-3/day) Diabetes (24.4%) Average 42/month (1-2/day)

When do most readmissions occur? 0-7 Days 8-14 Days 15-21 Days 22-30 Days Number % 7,149 38% 4,909 26% 3,533 19% 3,203 17%

Expectations for Coalition Work: Workgroup Name Badges at the Door Buy-in/Participation FOCUS Measurable Goals Patient-Driven Change

What do our patients say? Better communication = face to face. Adjust your message to fit your audience. Connect the thread for all services involved in a patient’s care. Don’t overwhelm the people that are sick. See the patient as an individual. Explain things at a lower level that they might normally meet. Ask them to repeat back to you what they understood. St. Bernards Medical Center Patient Family Advisory Council

1 Year = 365 Opportunities 9 Coalitions 68 Counties 96% Medicare Population 96% State Population 255 Unique Providers 17 Critical Access Hospitals 43 Acute Care Hospitals 70 Nursing Homes 15 Home Health Agencies 8 Hospice Agencies 30 Coalition Meetings 2 Care Transitions Conferences 1 Coalition Leader Conference 100+ Subcommittee Meetings 18,422 Miles 68 Ongoing Projects 9 Statewide Projects 8/9 Coalitions with significant RIR in last quarter (Range from 2.4% to 17.1%) 7.87% combined decrease in readmissions across coalitions

And…1 Aunt Bertha

Numbers – Names – Processes - Validation

AFMC Care Transitions Outreach Specialists: Melodie Zipfel MSN, RN mzipfel@afmc.org Jo Whitmore MPH, RN jnycum@afmc.org