1. Option D ADRC Evidence Based Care Transitions Grant Program Evaluator Workgroup Call August 15, 2011 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL aoainfo@aoa.gov | WEB www.aoa.govaoainfo@aoa.gov

2. Agenda Welcome and Introductions Calculating Cost Avoidance Associated with Care Transitions Efforts (Lisa Alecxih) Spring 2011 SART Resources U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3523 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

3. Overview Cost Avoidance = # of Readmissions avoided x $Dollars Readmissions How do you measure something that does not happen? Where can I find data?

4. Measuring Reduced Readmissions Unless you have a crystal ball, not every patient touched by your program would have been readmitted – On average, about 20% of Medicare discharges are readmitted – Worst readmission rate was for 32.3% among individuals with heart failure (Georgiana Hospital, AL) – Best readmission rate was for 18.2% among individuals with pneumonia (Northern Navajo FHS, NM) Therefore, counting all of the people in your program as avoiding readmission (even if they did not get readmitted) will overstate the cost avoidance

5. Fundamental Questions Need to be able to measure readmission rate before the intervention relative to after OR in comparison to a similar hospital without an intervention Best if you can get data directly from the hospital – More timely and more flexible in what you can measure

6. Where Can I Find Data? CMS Medicare dollars/discharge by state – http://www.cms.gov/dashboard/downloads/ partAdash.asp?agree=yes&next=Accept http://www.cms.gov/dashboard/downloads/ partAdash.asp?agree=yes&next=Accept CMS readmission rate by hospital – http://www.cms.gov/DemoProjectsEvalRpts/ downloads/CCTP_FourthQuartileHospsbyStat e.pdf http://www.cms.gov/DemoProjectsEvalRpts/ downloads/CCTP_FourthQuartileHospsbyStat e.pdf

7. Questions for Lisa? U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

8. Hawaii * Alaska * MT ID* WA † CO † WY NV CA *† NM AZ MN TX † KS * IA WI IL † KY TN † IN † OH MI ALMS AR LA FL † SC * WV VA NC* PA † VT RI † NH † OR * UT SD ND MO * OK NE NY † CT † MA † DC Care Transitions Activities DE Guam Northern Mariana Islands 34 States with ADRC program sites currently conducting care transitions through formal intervention (Total of 82 active sites with an additional 61 sites within active states currently planning to conduct care transitions) 11 States with ADRC program sites currently planning to conduct care transitions through formal intervention ( Total of 13 sites currently planning care transitions activities within states with no active sites) GA 9 States not reporting current or planned care transition activities Puerto Rico * Indicates state with current CMS Hospital Discharge Planning Model grant † Indicates state with 2010 ADRC care transitions grant MD *† NJ ME †

9. Spring 2011 SART: Option D Grantee Challenges Staffing, high turnover, and a lack of resources Delays in getting the program up and running due to delays in executing contracts, hiring staff, implementing data sharing agreements, or establishing IRBs Working through cultural differences to build relationships with hospitals and providers

10. Spring 2011 SART: Option D Grantee Lessons Learned Build relationships first before you start the process The coach needs to be part of the hospital discharge team to allow for a successful transition After the initial training, it is important to provide follow-up support, including ongoing mentoring of the coaches Proactive and frequent communication with all transition staff at all locations is beneficial to promote team building and share problem solving U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV

11. Care Transitions Resources and Upcoming Events AoA’s Aging Network & Care Transitions Toolkit Defining Communities: Care Transitions Partnerships between QIOs and the Aging Network Webinar – August 23, 2:00-3:30 pm (EST) – Register for the webinar Register for the webinar Next Evaluator Work Group Call: – September 19, 2011 at 1:00 p.m. (EST)

12. Resources Exchange: Helpful Resources from Grantees Flow Chart from Colorado Hospital to Home: Enhancing Safe Transitions through Innovative Community Partnerships in Maine Hospital to Home: Enhancing Safe Transitions through Innovative Community Partnerships in Maine Navigating Across Care Settings Discharge Materials from Massachusetts – Brochure, Patient Letters, Family Letters, and Inclusion Exclusion Criteria BrochurePatient Letters,Family Letters, Inclusion Exclusion Criteria Email resources to: adrc-tae@lewin.comadrc-tae@lewin.com U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, ADMINISTRATION ON AGING, WASHINGTON DC 20201 PHONE 202.619.0724 | FAX 202.357.3555 | EMAIL AOAINFO@AOA.GOV | WEB WWW.AOA.GOV