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The Problem: Hospitalized older adult diabetics w/Medicare are 72% more likely to be readmitted within 30 days than non- diabetics (19% vs. 11%). Further, this group’s length of stay is 5.4 days longer on average than the Medicare Geometric Mean Length of Stay.  Quality reputation and vision vs. public data  LOS cost opportunity: $3.4 million annually 4

Results of Environmental Scan  What I learned: We are learning more every year about diabetes Do WITH and not TO the patient Care transitions: start somewhere 5

Target Population  Hospitalized diabetics (primary or secondary diagnosis) age 65+ with Medicare  Admitted by hospitalist or internal medicine resident  Returning to community after D/C  Multicultural/multilingual population: Caucasian Latino (Spanish-speaking) African American Chinese (Mandarin/Cantonese-speaking) Armenian 6

Approach to the Problem Older Hospitalized Diabetic Identified Transition Coach (TC) Hospital Bedside; T/C; H/V <4 days post D/C Weekly Follow-up phone calls x 3 Diabetes Education in- home or community Hospitalists, Residents, Chief Care Coordinators, D/C Planners, Dietitians Coleman Transition Intervention SM MSW & RN Transition Coaches Four Pillars of CTI: ::Medication Management ::Use of Personal Health Record ::Knowledge of Red Flags ::MD Appointment Scheduled Link to community resources Stanford chronic disease program Healthy Eating Lifestyles Program Health/Diabetes Educator in-home 7

Process and Outcome Measures  Process Measures: Patients referred vs. eligible and not referred Care transitions – service dates vs. standards  Outcomes Measures: Collected at completion of service delivery: ○ Coleman’s Care Transitions Measure (CTM-3) ○ Lorig’s Chronic Care Self Management Scale Collected ongoing: ○ 30-day readmissions ○ Length of stay 8

Program Timeline 12/2009-6/2010—Planning period 7/2010-6/2011—Pilot program Implementation Quarterly/ongoing: ::Work group meetings ::Data Collection & reporting 8/2011: Final Report 9

Implementing the Program  Leveraging: CTI statewide pilot participant Strategic Operating Plan: care transitions Related care transitions initiatives Pursuit of Magnet Designation by American Nurses Credentialing Center (ANCC) Health Care Reform 10

Implementing the Program (cont’d)  Engaging the Stakeholders: Patients & Families: feedback (surveys) Professionals—Strategic communications, periodic interim outcomes reports: ○ Nursing ○ Physician Groups ○ Social Work / Discharge Planning / UM ○ Ambulatory Care & Senior Care Network 11

Perceived Facilitators/Barriers  Facilitators: Initiative Champions Risks of doing nothing: ○ Quality and patient satisfaction ○ Threat of payment penalties ○ Cost opportunity  Barriers: Identifying patients timely Cultural norms & scope of practice concerns Potential for confusion—related initiatives 12

Preliminary Data 13

Preliminary Data 14

Sustaining the Program  Outcomes measures: quality improvement and return on investment  Develop business case for continuation  Plan next steps to expand program 15

What I Have Learned  Leading means… Focusing on the goal and remaining flexible Maintaining hope Helping the group find and cross bridges  We have the privilege to serve and the obligation to improve 16

Question…  What wisdom can you share with me about implementing care transitions in an environment that expects medical interventions? 17