1. Lessons from the Care Transitions Theme Jane Brock, MD, MSPH Alicia Goroski, MPH This material was prepared by CFMC (PM-4010-070 CO 2010), the Medicare Quality Improvement Organization for Colorado, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

2. Objectives Methods used by QIOs for analyzing root causes of readmissions Drivers of readmission How to plan for success

3. 14 QIOs with 14 Target Communities Community Names Tuscaloosa AL Omaha NE NW Denver CO Southwest NJ Miami FL Upper Capital Region NY Metro Atlanta East GA Western PA Evansville IN Providence RI Baton Rouge LA Harlingen TX East Lansing MI Whatcom County WA 3

4. Results*: CY 2007 compared to CY 2009 14 Care Transitions Communities vs. the Nation *Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts. 4 MeasureCT Theme (National) Absolute ChangeRelative Change % readmitted-0.08% (+0.05%)-0.39% (+0.24%) Readmissions/1000-2.96/1000 (-1.93/1000)-4.75% (-3.34%) Admissions/1000-15.23/1000 (-11.8/1000) -4.59% (-3.77%)

5. Root Cause Analyses Medical record review – First hospitalization discharge – Other services provided – Readmission admission Process assessment – Direct observation – Process owner interviews Group discussion

6. Why do hospitals have unwanted readmissions? Provider-Patient interface unmanaged condition worsening, use of suboptimal medication regimens, return to an emergency department Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers

7. Why do hospitals have unwanted readmissions? Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers No Community infrastructure for achieving common goals Provider-Patient interface unmanaged condition worsening, use of suboptimal medication regimens, return to an emergency department

8. Why do hospitals have unwanted readmissions? Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers No Community infrastructure for achieving common goals Provider-Patient interface unmanaged condition worsening, use of suboptimal medication regimens, return to an emergency department

9. Handing Over Medical Responsibility Real time communication to PCPsSNF needs functional status <20% at time of discharge High refusal rates 33% unaware of discharge 3-day stay rule Communication to HHAsDischarge Summaries No direct conversation 86% in 48 hours Need signature from PCP 33% prior to follow up visit 9

10. CMS’s Table of Interventions http://www.cfmc.org/caretransitions/files/Care_Transition_Article_Remington_Report_Jan_2010.pdf

11. Building Community-ness: Four Models of Community Engagement 1.Multi-representative steering committee 2.Aggregate providers vertically in clusters, then merge 3.Aggregate providers by setting then vertically integrate 4.Individual improvement projects, with information and data-broker Make it visibly a community effort

12. Where a motivated community could start Figure out who you share patients with Forum for routine exchange/discussion – Utilization – Quality Routine discussion of readmission cases among all involved providers – Multi-institution ‘transitional care’ rounds Review hospice/palliative care providers/utilization/referral processes

13. Where a motivated community could start Require routine cross site visits – – Include CEOs Map/create handover management processes with your partners – Form a ‘receiver’s group’ – Form receiver’s coalitions Call/visit your AAA to see what they can do for you Value/promote informal social networking