1. Home Health Quality Improvement National Campaign II (2010-2011) Charles P. Schade, MD, MPH Medical Epidemiologist

2. Acknowledgements Co-authors of final report –Shanen Wright –Bethany Knowles –Karen Hannah –Eve Esslinger WVMI/QI analytic staff –Jill Manna –Yinghua Sun –John Bowers Cynthia Pamon, Government Task Leader Almost 5,000 participating HHAs

3. Disclaimer The analyses upon which this publication is based were performed under Contract Modification WV0005 to the West Virginia Quality Improvement Organization Contract, HHSM-500-2008-WV9THC, funded by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The content of this publication does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented. Publication number: 9SOW-WV- HH-BK-081811. App. 8/2011.

4. Objectives of this talk Describe the HHQI National Campaign II –Compare with first campaign (2007) Present results of evaluation of the campaign Discuss how the campaign’s success might inform future QI efforts involving home health and future national campaigns

5. Background >3 million recipients of Medicare-paid home health services in the United States each year, including: –Medical, nursing, social, or therapeutic treatment –Assistance with the essential activities of daily living Volume increasing over time Patients prefer to stay home when possible, but >25% of home health episodes end in rehospitalization First HHQI national campaign (2007) reduced rehospitalization

6. HHQI National Campaign II Focused on home health patient care quality as measured by ACH reduction Improvement in oral medication management Cross-setting initiative Special Project funded by Centers for Medicare & Medicaid Services Patient-centered focus Interdisciplinary Free tools, resources, networking

7. Call To Action HHQI Summit, January 13, 2010 National, state and local stakeholders –National Association for Home Care & Hospice (NAHC) –Alliance for Home Health Quality and Innovation –State associations, Quality Improvement Organizations (QIOs), and corporate leaders

8. Inter-Connected Movement

9. Cross-Setting Focus Efforts to Unite Providers Across Settings: –Communication and sharing tools –Campaign supporter designation –Campaign physician advisory panel –Collaboration opportunities at the state level –Cross-setting steering committee –Educational resources –Registration open to all providers -- October 2010

10. Comparison of Campaigns

12. What is a Best Practice Intervention Package? Educational package Top “best practices interventions” for themes of the campaign User-friendly collection of materials designed to be flexible and functional Downloadable from the campaign website (and still available)

13. How Participants Obtained BPIPs Login to http://www.homehealthquality.org to retrieve after registering http://www.homehealthquality.org Available as a complete package or individual sections –Leadership –Disciplines –Tools/Resources

15. BPIP Release Schedule Release DateTopic January 2010 Introduction Fundamentals of reducing ACH April 2010 Medication Management July 2010 Fall Prevention October 2010 Cross Setting I: Improving care transitions and aligning with other health care providers January 2011 Cross Setting II: Improving care transitions with chromic care patients through disease management, self-management support and telehealth April 2011 Cross Setting III: Innovative ideas to help prepare for health care changes

16. Fundamentals of Improving ACH January 2010 The Fundamentals “For me, the worst part of playing golf, by far, has always been hitting the ball.” Dave Barry

17. Hospitalization Risk Assessment Must know your ‘at risk’ population Target interventions accordingly Better use of resources

18. Emergency Care Planning Patient Emergency Plan (PEP) Customize for your agency Use on every patient –Modify as appropriate Reinforce

19. Compare Interventions Intensity Resources Appropriateness Patient Centered

20. Improvement in Management of Oral Medications April 2010  Accurate Assessment  Medication Reconciliation  Medication Simplification  High-Alert/High Hazard Drugs

21. Potentially inappropriate but commonly prescribed medications can contribute to falls, altered mental status, and gastrointestinal bleeding. Medication-induced complications in older adults account for 7% to 11% of their visits to the ED, and contribute to 12% to 17% of their hospital admissions (Fick, Mion, Beers, and Waller, 2008). A study by Dr. Eric Coleman and colleagues revealed that 14 percent of elderly patients admitted to the hospital experienced one or more discrepancies between their pre hospital medication regimen, post hospital medication regimen, and what the patient reported actually taking (Coleman, Smith, Raha, and Min, 2005). Do we have a medication problem?

22. Medication Quick Guide: Accurate Assessment

23. High-Alert Drugs

24. Medication Management: Issues and Opportunity Issues –Polypharmacy –Medication Adherence –Preventable hospitalizations from medication adverse events (overuse and underuse) Opportunities –OASIS-C comprehensive medication assessment –HHQI Campaign Medication management and reconciliation is key to patient safety and improving care between settings

25. Fall Prevention July 2010  Multifactorial and Standardized Assessment  AGS/BGS fall prevention guidelines

26. Fall Prevention Accurate Assessment Multifactorial and Standardized Assessment Direct interventions tailored to the identified risk factors, coupled with an appropriate exercise program. Evidence Based Interventions –AGS/BGS 2010 Prevention of Falls

27. The Impact of Falls One out of three adults age 65 and older falls each year. Among those age 65 and older, falls are the leading cause of injury death. They are also the most common cause of nonfatal injuries and hospital admissions for trauma. In 2007, over 18,000 older adults died from unintentional fall injuries. The death rates from falls among older men and women have risen sharply over the past decade. http://www.cdc.gov/HomeandRecreationalSafety/ Falls/adultfalls.html

28. Fall Prevention Resources: Multifactorial Assessment

29. Fall Prevention Resources: TUG

30. Cross Setting I October 2010 Coaching Care Transitions  Care Transitions SM  Transitional Care Model  Project RED  Project BOOST

31. Do we have a care transitions problem? Patients are at risk of medical errors during discontinuation of care from in patient to outpatient setting and this puts patients at risk of rehospitaliziation. (Moore, Wisnivesky, Williams, McGinn (2003). Almost one-fifth of the Medicare beneficiaries who had been discharged from an acute care facility were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days (Jencks, Williams, and Coleman, 2009).

32. Use Lessons Learned Care Transitions: Barriers and Strategies Read the success stories—what works? –Multi-provider meetings –Coaching –Educating staff –Best Practices “Focus on remedies, not faults.” Jack Nicklaus

33. Teach Back

34. SBAR

35. Cross Setting II January 2011 Care Transitions with Chronic Care Patients  Disease Management  Self-Management Support  Telehealth

36. The costs for hospital care and rehospitalizations increases with the number of different chronic conditions (Friedman et al., 2008). “In 2009, 145 million people—almost half of all Americans—lived with a chronic condition” (Robert Wood Johnson Foundation, 2010, p. 5). “Between 2000 and 2030 the number of Americans with chronic conditions will increase by 37 percent, an increase of 46 million people” (Robert Wood Johnson Foundation, 2010, p. 7). Do we understand the impact of chronic care issues?

37. Hospital Risk Assessment— For the Patient!

38. Top 10 Reasons for Follow-up

39. Cross Setting III April 2011 Innovative ideas to help prepare for health care changes –Patient-Centered Medical Homes (PCMH) –Accountable Care Organizations –Functioning as a provider community –Reducing readmissions while improving quality –Medication reconciliation and medication management from a community perspective –Communication of fall risk with the multi-provider community

40. Healthcare Priorities Center for Medicare & Medicaid Innovation Better healthcare Better health Reduced costs IHI’s Triple Aim Improve the health of the population Enhance the patient experience of care (including quality, access, and reliability) Reduce, or at least control, the per capita cost of care.

41. Deciding whether to play or not??? Since ACOs will be looking for partners to achieve this goal in the most effective and efficient manner, home health agencies must aggressively pursue these groups and convince potential ACOs that they can provide services needed for goal attainment. Mary St. Pierre, CS III BPIP As PCMH models become more widespread, I would expect they would seek close collaboration with Home Care Agencies to meet the needs of these vulnerable populations. Richard J. Baron, MD, MACP, CS III BPIP “You must play boldly to win.” Arnold Palmer

42. Best Practices “The game of golf would lose a great deal if croquet mallets and billiard cues were allowed on the putting green.” Ernest Hemingway

43. BPIP Downloads* by 6/29/2011 Topic (Date first available)Downloads ACH BPIP (Jan 2010)59,280 Med Management (April 2010)35,200 Falls (July 2010)14,757 Cross Settings I (Oct 2010)8,869 Cross Settings II (Jan 2011)6,054 Cross Settings III (April 2011)2,478 *Individual download of the BPIP or one of its components

44. Using Data to Motivate Staff HHQI Data Reports –Agency actual data –Current –Focus on ACH and Oral Medications Use HHQI Data Access System Resources –Description of Monthly Report –Data Reports Webinar

45. HHQI Data Reports Participating HHAs obtained individualized HHQI reports through a separate secure login on the HHQI Web site We required a secure ID from the agency’s CASPER Reports for login

47. HHQI Resources Social Networking HHQI STAR Free Webinars –Home Health and Care Transitons –Making Care Transitions a Reality Through Home Health –Conversations Across the Discharge Divide –Integrating Home Care into Primary Practice to Improve Patient Outcomes

48. Webinar Participation DateSpeakerTopicSites Page Hits* 06/30/2010 Dr. Stephen Landers (Cleveland Clinic) Hospital Readmissions and the Role of Home Care 1,3194,580 09/29/2010 Dr. Jane Brock (CFMC) Home Health and Care Transitions 1,0473,528 11/12/2010 Tasha Mears (Amedysis) Implementing the Coaching Model 9282,480 01/20/2011 Luke Hansen, MD, MHS; Jessica Soos Pawlowski; Robert Young, MD (Northwestern University) Conversations Across the Discharge Divide 852731 04/13/2011 Dr. Alan Goldblatt and Linda Murphy (Caretenders of Gainesville FL) Integrating Home Care into Primary Practice to Improve Patient Outcomes 1,025698 *Page hits to webinar site after webinar through 6/30/2011

49. Social Networking Opportunities Live Chat Discussion Forums Blogs Twitter, Facebook

50. Live Chat Participation

51. Other Social Media Use* Facebook –12 messages –332-1,447 impressions/view Blog –2,000 views Twitter –90 followers –83 tweets * through 6/7/2011

52. Project Evaluation Registered participants Uptake of materials/event participation BPIP evaluations Changes in quality measures Program participation linked to outcomes

53. Registered Participants 10,865 Medicare Home Health Agencies (HCIS, 2010) By 5/31/2011, 4,721 (43%) had registered for the campaign Of those, 3,075 had >=10 discharges/month (1/1/2010-6/30/2011) and were included in analysis Potentially impacted about 3 million patients

54. BPIP User Feedback E-mail inquiry (Zoomerang) sent to agencies downloading BPIP BPIP-specific questions, but similar structure –Use of relevant campaign materials –Taking recommended actions –Self-assessed impact 4 BPIPs evaluated

55. Recommended Tool Use

56. Actions Taken or Planned after Downloading BPIP

57. Posting Tables and Graphs Showing Medication Management Performance

58. Self-Reported BPIP Impact

59. Outcomes Quality measures generally improved Quality performance was better in groups of agencies with more intense participation in the campaign OASIS-B to OASIS-C transition appears to have impacted the medication management improvement measure

60. Agencies grouped by participation “Nonparticipants” did not sign up for the HHQI National Campaign “Participants” signed up for the campaign, but did not download related campaign materials “Downloaders” signed up and downloaded materials related to the BPIP “Respondents” responded to the user evaluation related to a BPIP

61. Acute Care Hospitalization Rate BPIP released

62. Medication Management Improvement No data due to OASIS-B to OASIS-C conversion BPIP released

63. Impact Assessment ACH outcome only Using item response theory, developed composite score for ACH evaluation responses Divided composite score into quartiles, which we believe represented increasing levels of intensity of participation in campaign

64. Changes in ACH and ALOS by Participation Intensity Quartile *Average length of service for home health patients in agency

65. Cost implications Project cost $1.4 million Average Medicare hospital admission cost $11,000 Project cost equivalent to 127 admissions 195 HHAs in top 2 partici- pation quartiles averaged 1,600 episodes/year These HHAs reduced hospital admissions 0.5% more than lower groups 1,560 fewer readmissions than expected

66. Limitations Observational study (pre-post) Small sample size Missing data Confounding ACH with ALOS Externalities

67. Conclusions Campaign was successful, engaging nearly 5,000 home health agencies Agencies used campaign materials and many adopted recommended practices Quality of care measures –Acute care hospitalization –Medication self-management Participation intensity linked with improvement

68. Future Challenges Understanding and addressing disparities Reaching smaller agencies Accelerating improvement

69. Questions? Comments? Thank you for coming to this presentation. Presenter e-mail: cschade@wvmi.org or see our website, www.HomeHealthQuality.org