West TN - Alliance for Care Transitions (WTN-ACT) Community Meeting Location: Qsource office Lesley Armishaw Hays August 18, 2017

The QIN-QIO Program’s Approach to Clinical Quality Goals Make care safer Strengthen person and family engagement Promote effective communication and coordination of care Promote effective prevention and treatment Promote best practices for healthy living Make care affordable

Promote Effective Communication and Coordination of Care 35 million** 1 in 5* $17.4 billion** Approximate proportion of Medicare patients readmitted within 30 days of discharge - 75%* There were over 35 million hospital discharges in 2010. 20% of all Medicare patients were readmitted within 30days. It was estimated that 5.25 million of the readmissions could’ve been prevented. These readmissions cost over $17 billion. ******************************************************** Ensuring safe care transitions requires a systematic approach. Three key areas must be addressed prior to discharge: Medication reconciliation: The patient's medications must be cross-checked to ensure that no chronic medications were stopped and to ensure the safety of new prescriptions.  Structured discharge communication: Information on medication changes, pending tests and studies, and follow-up needs must be accurately and promptly communicated to outpatient physicians.  Patient education: Patients (and their families) must understand their diagnosis, their follow-up needs, and whom to contact with questions or problems after discharge. Approximate cost of readmissions Approximate percentage of Medicare readmissions that could have been prevented Number of US hospital discharges in 2010 * Improving Care Coordination. Retrieved from http://www.qioprogram.org/our-priorities/improving-care-coordination ** Alper, O’Malley, & Greenwald. Hospital discharge and readmission. In: Up-to-date, Post, TW(Ed), Up-to-date, Waltham, MA, 2016

Promote Effective Communication and Coordination of Care Reduce 30-day hospital readmissions by 20% by 2019 Increase number of nights spent at home post discharge by 10% Reduce number of Adverse Drug Events resulting from uncoordinated transitions of care The QIO Program helps communities with high readmission rates form local coalitions, identify the factors driving avoidable hospital readmissions in their area, and find ways to better coordinate care and activate patients to manage their health more actively. Next meeting: Knoxville – April 27th 11:00am – 1:00 pm EST. Corley Roberts croberts@qsource.org -9 Communities- Knoxville - Building a Bridge to Better Health Coalition Chattanooga – Chattanooga Regional Health Innovation Coalition Tri Cities – Appalachian Transitions Home Community Coalition Jackson – Readmission Connections Memphis – West Tennessee Alliance for Care Transitions Nashville – Transitioning Patients Across the Care Continuum Columbia – Community Partnership with Post Acute Providers Upper Cumberland – Upper Cumberland Transition of Care ** New**Morristown – Morristown Community Readmissions Coalition (Satellite community of Knoxville)

TN Community Zip Code Areas

What’s driving improvement? Hospital Readmissions Reduction Program Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act requiring CMS to reduce payments to IPPS hospitals with excess readmissions beginning October 1, 2012. Began with 1% penalties and now up to 3% of total Medicare DRG base MI Heart Failure (CHF) Pneumonia COPD Total Hip and Total Knee Replacement CABG IMPACT ACT Focused on Post Acute Care Transformation Hospital Readmissions Penalties Home Health Value Based Payment Tied to Performance Skilled Nursing Facility Readmissions Penalties

What’s driving improvement? (cont.) September 7, 2016 By Patrick Conway, M.D., principal deputy administrator and chief medical officer, CMS; and Tim Gronniger, deputy chief of staff, CMS

SNF Payment Adjustments Tied to Quality Skilled Nursing Facilities (VBP) Value Based Purchasing Adjustments made based on performance: penalties/incentives Public reporting of readmissions October 1st 2017 (FY 2018) CMS will withhold 2% payment (give back 50-80% based on reporting) Penalties or incentives applied October 1st 2018 (FY 2019) for performance scores from October 1st 2017. (Previous Year Data)

HH Payment Adjustments Tied to Quality Home Health Value-Based Purchasing Program (HHVBP) Nine (9) state pilot with payment adjustments tied to performance Tennessee included Incentive to provide higher quality and more efficient care

Social Network Analysis Where we are sending patients Social Network Analysis Where we are sending patients. Where we are receiving patients from.

Community Snapshot

30-Day Referral Source for Admission

Referral Source for Readmission

Top 10 Discharge Diagnoses

Psychosis DRG 855 Principal Diagnosis Codes F200 Paranoid schizophrenia F201 Disorganized schizophrenia F202 Catatonic schizophrenia F203 Undifferentiated schizophrenia F205 Residual schizophrenia F2081 Schizophreniform disorder F2089 Other schizophrenia F209 Schizophrenia, unspecified F22 Delusional disorders F23 Brief psychotic disorder F24 Shared psychotic disorder F250 Schizoaffective disorder, bipolar type F251 Schizoaffective disorder, depressive type F258 Other schizoaffective disorders F259 Schizoaffective disorder, unspecified F28 Other psychotic disorder not due to a substance or known physiological condition F29 Unspecified psychosis not due to a substance or known physiological condition F3010 Manic episode without psychotic symptoms, unspecified F3011 Manic episode without psychotic symptoms, mild F3012 Manic episode without psychotic symptoms, moderate F3013 Manic episode, severe, without psychotic symptoms F302 Manic episode, severe with psychotic symptoms F303 Manic episode in partial remission F304 Manic episode in full remission F308 Other manic episodes F309 Manic episode, unspecified F310 Bipolar disorder, current episode hypomanic F3110 Bipolar disorder, current episode manic without psychotic features, unspecified F3111 Bipolar disorder, current episode manic without psychotic features, mild F3112 Bipolar disorder, current episode manic without psychotic features, moderate F3113 Bipolar disorder, current episode manic without psychotic features, severe F312 Bipolar disorder, current episode manic severe with psychotic features F3130 Bipolar disorder, current episode depressed, mild or moderate severity, unspecified

Psychosis Principal Diagnosis Codes, continued F3131 Bipolar disorder, current episode depressed, mild F3132 Bipolar disorder, current episode depressed, moderate F314 Bipolar disorder, current episode depressed, severe, without psychotic features F315 Bipolar disorder, current episode depressed, severe, with psychotic features F3160 Bipolar disorder, current episode mixed, unspecified F3161 Bipolar disorder, current episode mixed, mild F3162 Bipolar disorder, current episode mixed, moderate F3163 Bipolar disorder, current episode mixed, severe, without psychotic features F3164 Bipolar disorder, current episode mixed, severe, with psychotic features F3170 Bipolar disorder, currently in remission, most recent episode unspecified F3171 Bipolar disorder, in partial remission, most recent episode hypomanic F3172 Bipolar disorder, in full remission, most recent episode hypomanic F3173 Bipolar disorder, in partial remission, most recent episode manic F3174 Bipolar disorder, in full remission, most recent episode manic F3175 Bipolar disorder, in partial remission, most recent episode depressed F3176 Bipolar disorder, in full remission, most recent episode depressed F3177 Bipolar disorder, in partial remission, most recent episode mixed F3178 Bipolar disorder, in full remission, most recent episode mixed F3181 Bipolar II disorder F3189 Other bipolar disorder F319 Bipolar disorder, unspecified F320 Major depressive disorder, single episode, mild F321 Major depressive disorder, single episode, moderate F322 Major depressive disorder, single episode, severe without psychotic features F323 Major depressive disorder, single episode, severe with psychotic features F324 Major depressive disorder, single episode, in partial remission F325 Major depressive disorder, single episode, in full remission F328 Other depressive episodes F330 Major depressive disorder, recurrent, mild F331 Major depressive disorder, recurrent, moderate F332 Major depressive disorder, recurrent severe without psychotic features F333 Major depressive disorder, recurrent, severe with psychotic symptoms F3340 Major depressive disorder, recurrent, in remission, unspecified F3341 Major depressive disorder, recurrent, in partial remission F3342 Major depressive disorder, recurrent, in full remission F338 Other recurrent depressive disorders F339 Major depressive disorder, recurrent, unspecified F348 Other persistent mood [affective] disorders F349 Persistent mood [affective] disorder, unspecified F39 Unspecified mood [affective] disorder F845 Asperger's syndrome F848 Other pervasive developmental disorders F849 Pervasive developmental disorder, unspecified

Discharge Status-30 Day Readmits

Patient Status at Discharge

Discharge and Readmit Status

10 Highest Readmission Zip Codes

Community – Days to Readmission 2016Q1-2016Q4

Memphis Impact Statement 2017 January 1st – December 31st sample Charter Community Timely Initiation of Care - HHA PCP Appointment prior to D/C - Hospital Fall Prevention - SNF

Strategies for Reduction Partnering and leading effectively in our communities Use SNN to identify PAC providers that need to be involved in community and reach out to them; Use various CMS data to determine hospital specific opportunities for improvement and how community can be leveraged to work toward goals; Assist the communities beyond the walls of the hospital to start TOC conversations across the continuum to develop (or tap into existing efforts) to drive reductions  Intervene timely as needed based on data monitoring; Recognize diversity of community population and design interventions around that (ex. SCD project or diabetes or whatever specific disease) Engage the voice of patients and families in community discussions to develop approach for broadening education on importance of right setting vs ED over-utilization

How do these strategies for reductions overlap with root causes for healthy lifestyles (accessibility, food security, safety, etc.). Where are the gaps? Fill healthy lifestyle gaps by identifying disease and population specific tools and resources (or enhance existing) that can be used in educating patient and families about diet, activities, exercise, etc. necessary to maintain a healthy lifestyle; Work with community partners to identify accessibility resources to ensure patients are getting key follow-up care post-hospital discharge to keep them out of the hospital Involve patients and/or families in health conversations to build knowledge capacity in managing chronic condition(s) Share patient success stories to promote spread

What Are You Doing in Your Organization? To reduce readmissions? Improve medication safety? Are you meeting with Acute Care and/or Post-Acute Care?

What’s Next? Sepsis Focus Opioid Reduction

2017 Community Schedule Meeting Frequency Discussion… Quarterly Meetings: 3rd Friday 8:30 am – 10:00 am August 18 ** Qsource Offices November 17 – TBD

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Connect with Us Reminders Facebook www.facebook.com/atomalliance Twitter www.twitter.com/atom_alliance LinkedIn www.linkedin.com/company/atom-alliance Pinterest www.pinterest.com/atomalliance/ May name is Beth Hercher, I serve as a quality advisor for Qsource and will be your facilitator for today’s session. we have posted the link for you to download today’s slide presentations… My atom Alliance colleague, Scott Gibson will serve as our phone audio monitor and chat monitor for today…scott will you provide our audience instructions on how to utilize the chat feature? Find exclusive content by connecting with atom Alliance on Social Media. Facebook postings of blogs, Twitter postings of latest news, LinkedIn posts of in-depth articles and Pinterest post of infographics, tools and resources. 37

Thank You! This presentation was prepared by atom Alliance, the Quality Innovation Network-Quality Improvement Organization (QIN-QIO), coordinated by Qsource for Tennessee, Kentucky, Indiana, Mississippi and Alabama under a contract with the CENTERS for MEDICARE & MEDICAID SERVICES (CMS), a federal agency of the U.S. Department of Health and Human Services. Content does not necessarily reflect CMS policy. 17.HIIN.09.004