1. November 2015 LeadingAge National A Cross Continuum Collaborative: Working Together to Improve Outcomes www.abramsoncenter.org

2. Introductions Staci Warsaw, VP Transitional Services- Abramson Center for Jewish Life North Wales, PA Cathy Benner, Executive Director of Rehab and Case Management-Doylestown Health Doylestown, PA

3. Objectives Learn about an effort to create a regional cross continuum network of acute and post-acute providers Consider the processes used to identify partners to include in the collaborative and work toward mutual goals Examine how mutual goals were established to improve quality of care, patient experience, and efficiencies in care delivery

4. Regional Health Care Market Northeastern suburbs of Philadelphia Population approximately 1.6 million 5 hospital systems 15 mile radius 92 SNFs/CCRCs 58 home care agencies 3 major health insurers for seniors Among highest cost of health care in the country

5. Why? Hospital systems were trying to collaborate through SNF consortiums Care transitions/care coordination beginning to emerge as primary contributors to quality patient care and experience Hospital systems and post-acute providers sharing patients across levels of care

6. The Issues Coordination of care Communication Follow-up processes post discharge Duplication of services Increasingly educated consumers Changing healthcare landscape

7. Know your Market Hospital systems Post acute providers-all levels Role of primary care ACOs/BCPIs Referral patterns

8. Regional Health Care Market

9. Decide on Partners Location Referral patterns Affiliations Star ratings Non-profit

10. Decide on Participants COOs Executive Directors Administrators Business Development specialists VPs Clinical Leaders

11. Explanations and Invitations Vet your idea with colleagues Determine message you want to portray as you invite partners to join Use the phone Follow with email

12. Eye on the Prize Outcome and quality reporting is done in a consistent way that ensures that information being used to make transition decisions is accurate and reliable Identify and initiate the aspects of care transitions that contribute to the quality of the patient experience as they travel through the health care continuum Create a network of providers that are focused on providing high quality, patient-centered care transitions

13. First meeting Agenda Ground Rules Introductions Organizational and personal reasons for participating Potential barriers

14. Rules of Engagement Everyone has to answer Keep them guessing-change up the order Follow the ground rules Stick to the agenda Finish in time

15. Outcome of first meeting Medication Reconciliation Understand what one another does (restrictions, clinical capabilities, regulations) Universal transfer form Sharing of data and essential data elements Measurement tools for sharing data Uniform definition of re-admission Group discussion of adverse outcomes Information and Referral Guide access Research/evaluation of best practices

16. Outcome of first meeting Improvement of chronic disease management ED Visit Evaluation (between SNF/hospital) Palliative Care discussions (POLST) Understanding definitions ie observation, healthcare Consideration of community assets Incorporation of physician into care continuum Awareness/monitoring of physician conditions Families Understand capabilities

17. Next Meeting One month later Hired a facilitator Each partner brought in at least one additional person-25 people in room Much buzz and excitement from participants

18. Next Meeting Goals Determine top three priority goals Draft action plans for top three priority goals Choose sub-teams for each goal Draft goals Draft action plans for goals Date of completion for goals should be within 2 – 3 months

19. Challenges Topics too big Team realized they did not have enough information about how each organization approached these things to create effective action plans

20. Decisions Decided to carry over action planning process to next meeting Goals to fine tune topics and action plans Intended to begin working on 2-3 topics –Medication reconciliation –Universal transfer form –Communication with PCPs

21. In the meantime…. QIO heard about the collaborative Spoke with someone from QIO She wanted to use the collaborative to create a “Health Care community” focused on decreasing re-hospitalizations Invited her to speak ant next meeting

22. Third Meeting QIO introduced health care community Group had to decide whether we wanted to participate Decided against it Tried to work further on action plans….

23. Third Meeting cont Began to struggle Refined our purpose/mission statement Decided to reduce frequency of meetings

24. Next meeting 2 Months later Major changes in the regional market –Mergers –ACO –MCO –HIE

25. Forks in the Road New people at the table New regional landscape New issues to work through Needed to redefine again

26. New Direction Clear communication at time of transition was still of key importance Needed to decide what is included in transition communication Decided we needed additional people around the table (physician services representaives )

27. Now What? Pilot the use of the interact transfer tool for communication between any level of care; not just hospital and SNF. Develop and pilot communication process with PCPs and/or practice/ACO based care managers when people transition between levels of care

28. Lessons Learned Have Vision Communicate clearly Be flexible Don’t let your ego get in the way

29. Next Steps Continue Quarterly meetings Pilot transitions projects to enhance collaboration across different service lines Information sharing Best practice sharing

30. How Partnerships Benefit Patients Case Study

31. Questions