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

2. 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

3. 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 % 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 ** Alper, O’Malley, & Greenwald. Hospital discharge and readmission. In: Up-to-date, Post, TW(Ed), Up-to-date, Waltham, MA, 2016

4. 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
-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)

5. TN Community Zip Code Areas

6. 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

7. 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

8. 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 (Previous Year Data)

9. 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

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

15. Community Snapshot

16. 30-Day Referral Source for Admission

17. Referral Source for Readmission

19. Top 10 Discharge Diagnoses

20. 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
F Delusional disorders
F Brief psychotic disorder
F 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
F 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

21. 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

22. Discharge Status-30 Day Readmits

23. Patient Status at Discharge

24. Discharge and Readmit Status

25. 10 Highest Readmission Zip Codes

26. Community – Days to Readmission 2016Q1-2016Q4

27. 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

28. 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

29. 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

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

31. What’s Next?
Sepsis Focus
Opioid Reduction

32. 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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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?
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Facebook postings of blogs, Twitter postings of latest news, LinkedIn posts of in-depth articles and Pinterest post of infographics, tools and resources. 37

38. 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