2. National Association of Area Agency on Aging Conference July 2009

3.  Various models have evolved over the past few years ◦ Coleman’s Care Transition Intervention ◦ Chad Boult’s Guided Care Model  2006 – National Transitions in Care Coalition formed

5. Community-based AAAs, CILs, and ADRCs play critical role in helping people navigate both health and social support

6.  ADRC includes intervention in critical pathways (hospitals, NFs, physicians’ offices, ERs, etc.)  Many ADRCs have critical pathway providers on advisory boards  Some have developed formal referral protocols  New ADRC solicitation includes person centered hospital discharge planning as “key operational component”

7.  In 2008/2009 awarded grants for states to develop ADRCs as well as person-centered hospital discharge programs ◦ 1 st round - Alaska, Missouri, South Carolina, Kansas, Oregon ◦ 2 nd round - Maryland, North Carolina, Hawaii, California  Consumer Discharge Planning Checklist  Continuity Assessment Record and Evaluation (CARE)  QIOs 9 th Statement of Work (SOW) included care transitions

8.  CMS contracts (3 years) with one in every state to provide ◦ Beneficiary Protection ◦ Patient Safety, ◦ Prevention, and ◦ “Care Transitions”  “Improve quality of care for Medicare beneficiaries through a comprehensive community effort  Goal to reduce hospital re-admissions

9.  Alabama, Colorado, Florida, Georgia, Indiana, Louisiana, Michigan, Nebraska, New Jersey, New York, Pennsylvania, Rhode Island, Texas, Washington  http://www.cfmc.org/caretransitions/http://www.cfmc.org/caretransitions/

10.  Continued funding contingent on interim CMS evaluation of care transitions theme after 18 months  How to locate state QIO: http://www.ahqa.org/pub/uploads/SOW9_QIO_Co ntracts_List_0808.pdf  American Health Quality Association (AHQA). AHQA represents the national network of quality improvement organizations (QIOs) and other professionals working to improve health care quality and patient safety. http://www.ahqa.org

11.  Invite critical pathways providers to be part of ADRC advisory committees and councils  Provide consumers with information to empower themselves and family members through transitions in care  Contact state QIO to determine what initiatives they have going with community based organizations and if ADRC can be involved  Develop formal referral protocols with critical pathways providers  Assign specific ADRC staff to operate out of critical pathway locations  Implement a care transitions model

12.  2008 CMS Person centered hospital discharge grantee  Currently in planning phase (three county pilots)  Will target Medicaid eligible individuals with PD or chronic illness  Identified Measurable Outcomes ◦ Discharge of Medicaid patients to nursing facilities will be reduced by 35% (estimated $5.2 million savings). ◦ Home care services will be started within 24 hours of referral for 90% of patients discharged home. ◦ Customer satisfaction rating will be 90% or higher related to discharge planning process and caregiver education.

13.  2008 CMS Person Centered Hospital Discharge Planning Grantee  Care Transitions Task Force established ◦ Lane Council of Governments (AAA), ◦ Lane Independent Living Alliance (CIL), ◦ Sacred Heart Medical Center, ◦ Lane Individual Practice Association (Medicaid managed care plan  Two year planning process ◦ “Hospital Discharge Feedback” survey ◦ Health navigator model

14.  One of the 14 sites in the CMS QIO initiative  Georgia Medical Care Foundation (QIO)  http://www.gha.org/pha/Provider/TransofCa re/ToolsResources/index.asp (several resources related to care transitions) http://www.gha.org/pha/Provider/TransofCa re/ToolsResources/index.asp

15.  CMS Fact Sheet – QIOs and Care Transitions - http://www.ahqa.org/pub/uploads/CMS_SoW9_Sum mary_Care_Transitions_0807.pdf http://www.ahqa.org/pub/uploads/CMS_SoW9_Sum mary_Care_Transitions_0807.pdf  CMS list of state QIOs http://www.ahqa.org/pub/uploads/SOW9_QIO_Contr acts_List_0808.pdf  Oregon’s Hospital Discharge Feedback Questionnaire (available soon at www.adrc-tae.org)  Kansas Person Centered Discharge Fact Sheet (http://www.adrc- tae.org/tikidownload_file.php?fileId=28302)  CMS Consumer Discharge Planning Checklist http://www.medicare.gov/Publications/Pubs/pdf/113 76.pdf http://www.medicare.gov/Publications/Pubs/pdf/113 76.pdf

16. Technical Assistance Exchange  Technical Assistance Resources  Website www.adrc-tae.org  Resource Materials (e.g. Issue Briefs)  National Meetings  Regular Electronic Newsletters  Grantee Surveys  Examples from the Field  On-line Training Courses  Building a Grantee Community  Monthly Teleconferences/Web casts  Bi-monthly Workgroup Teleconferences  On-line Discussions  Electronic Bulletin Board