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Care Transitions : Are You in the Game?
Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012
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Welcome What we’ll cover today:
Introduction of Care Transitions Program The Role of HCA in the Community Discuss Evidence Based Interventions to reduced avoidable readmissions Share Lessons Learned form 3 Year Pilot Open Discussion
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Why Are We Here? To learn about and promote safe/effective transitions of care as patients navigate from one provider setting to another – or one caregiver to another Develop partnerships
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Integrated Care For Populations and Communities
GOAL To promote safe/effective transitions of care as patients navigate from one provider setting to another – or one caregiver to another
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30 Day Readmissions: The Problem
Nationally – 17.6% of Medicare beneficiaries discharged from the hospital are readmitted within 30 days. More than 85% of these re-hospitalizations are unplanned. 20-40% of re-hospitalizations are possibly preventable. 64% of Medicare beneficiaries who are readmitted within 30 days do not receive any post-discharge care before readmission.
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Mrs. B’s Story
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339 Days in the Life of Mrs. B Day 1 – New internal medicine physician, poorly controlled diabetes with neuropathy, HTN, osteoporosis. To see physician q. 2 wks Day 15 – Sees physician, fully functional, assists with care of grandchild and husband Day 60 – Mrs. B falls on the ice, to ER, no fractures but abrasions. Referred to home health Day 68 – Not feeling well Day 69 – Hospitalized with Staph Septicemia, dehydration, ARF, CHF, A-Fib, PN and uncontrolled diabetes Day 82 – Transferred to SNF for short-term rehab and wound care Day 182 – Discharged to home, depressed, abrasions healed, diabetes under good control Day 183 – Nauseated, can’t find her teeth, dgt intends to call home health Day 184 – Readmitted to the hospital for dehydration, CHF, A-Fib and diabetes Day – Admitted to in-pt rehab then to nursing home Day 338 – Readmitted to hospital w/ ARF, CHF, ARF Day 339 – Mrs. B dies
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Timeline for payment penalty for hospitals
Beginning October 2012 Medicare will apply penalties and will withhold payment for avoidable 30 day acute care readmissions with a progressively increasing scale for certain DRGs.
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July2008-August 2011 Pilot Project
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14 QIOs with 14 Target Communities
AL: Tuscaloosa CO: Northwest Denver FL: Miami GA: Metro Atlanta East IN: Evansville LA: Baton Rouge MI: Greater Lansing area NE: Omaha NJ: Southwestern NJ NY: Upper capital PA: Western PA RI: Providence TX: Harlingen HRR WA: Whatcom county 10
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Targeted Community Higher than state average re-admission rate
Located in southwestern PA, in a community surrounding the southern Pittsburgh metropolitan area Community spans most of Westmoreland County and small portions of Allegheny, Washington, and Fayette counties
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9th SOW Overview CMS SWPA 14 states Community cross-setting
Transparent Remove silos SWPA 5 hospitals 8 home health agencies 15 nursing homes 2 AAAs 32 interventions 14% relative improvement
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Structure of the Project
Cross-setting Community-based Collaborative
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The Shift to… Chronic illness management Self-care management
Empowerment Responsibility Accountability Patient activation
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Cross-Setting Goal Develop a practical, cross-setting approach
Unite providers from all settings Share vision of improved health care quality Equal voices Identify provider strength
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The Role of Agencies Home Health Hosicpe
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Hospital Elements Leadership buy-in Operational level leadership
Education Silos Bureaucracy/slow to change Competitive Non-transparent
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Hospital Interventions
Self reported readmission rate Discharge process Discharge instructions End of life options 48-hour follow-up call Schedule follow-up PCP visit CTI-AAA
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SNF Elements Education Eager to learn Eager to share
Share competence levels Family Physicians Turnover
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SNF Interventions SBAR Communication transfer form Chart reviews
End of life options/education POLST/AD Coach CTI
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Home Health Elements Focus on ACH vs. readmissions
Medication management Low referral rates Educate on referral criteria Coaching Hands on in home care
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Drivers of Hospital Readmission
Same for home care as other health care providers: Patient activation Standard, known processes Transfer of information
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Home Health Compare Top 20% for this measure has maintained an unplanned hospitalization rate of 21% since last quarter While stakeholders are focusing on reducing unnecessary hospitalizations, the data tells us that we still have work to do and… What about those 30-day readmissions? Low-hanging fruit for home care to determine root cause and intervene in real-time—win-win for everyone
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Home Health Compare The latest Home Health Compare (HHC) scores were published on October 13th and reflect a data collection period of July June Overall, the results have improved. Hospitalization result has had a setback Hospitalization worsened from 26% last quarter to 27%
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Intervention HHA Communication transfer sheet Front load visits
Telehealth Phone monitoring Life line Chronic care education Coaching/partnering Depression screening Chart reviews
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Best Practices Home Health Quality Improvement National Campaign Best Practice Intervention Packages (BPIPs) Focus on reducing ACH, improving management of oral medications and cross-setting collaboration Simplified approach to use packages Standardized steps to follow for each publication Flexible for HHA implementation BPIPs free to download at:
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BPIPs Include Hospitalization Risk Assessment Emergency Care Planning
Medication Management Fall Prevention Care Transitions Coaching Patient Self-Management Disease Management Telehealth Introduction to new ideas/topics: Patient Centered Medical Home; Accountable Care Organizations and others
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Learn more…Coach/HH nurse
Coaching and home health service Increase Medicare HH referrals Oasis takes time Coach non-clinical Different role Medication review… patient driven Complementary/respectful
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Lessons Learned Community focus Root cause analysis Communication
Transparency Leadership buy-in Collaboration Patient-centered Ongoing monitoring Community outreach Sustainability
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Lessons Learned Re-Engineers the discharge process (Project Red, Project Boost, Medication reconciliation) Change the paradigm of patient education (Teach Back) Improve information transfer (Cross setting transfer form) Increase community outreach (Collaboration with community resources, Handover) Increase post discharge process and support (PHR, Medication management, PCP f/u appointment and coaching)
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August 2011-July 2014 10th SOW
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AIMS and Goals Strategic Aims “What will be done”
Integrate Care for Populations Care Transitions that reduce re-admissions by 20% within 3 years.
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CMS 10th SOW for QIOs Form a community coalition to ensure community-wide adoption of improved practices in care transitions Assist communities in applying for the CMS 3026 CCTP funding opportunity Form a Learning and Action Network (LAN) and provide evidence-based interventions associated with known drivers of hospital readmissions (Jan. 26, 2012) Host quarterly LAN sessions; one in-person each year Benefit to Qio community recruitment Expertise in community building Assist with self reporting of real time re-admission data TA with application for CCTP If application denied still supported by QIO /Lan
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CMS 10th SOW for QIOs Provide the community with a template for coalition charters to help the partners formalize structure and procedures Assist the community with root cause analysis to identify community-specific causes for poor transitions and develop data reports to monitor progress Assist in the selection of the most appropriate evidence-based interventions
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The Importance of Communities to Improve Health Care
Integrating Care for Populations and Communities
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CMS Defines a Community
Defined by contiguous zip codes Medicare beneficiaries that live in those zip codes Committed providers and stakeholders
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Community Essentials Developed around collaborative care delivery
Shared vision Shared mission Shared resources Shared decision making Environment of trust
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A Community Social network analysis for Medicare beneficiaries in 2009
Allows visualization of relationships between providers through network diagrams Shows flow of transitions among providers Senders, receivers, provider type and strength of relationship
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4 Recruited Communities
Western Pennsylvania Lehigh Valley York Chester County
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Building Community Leaders reach to other leaders
Expand the circle of support Grow more resources Develop/sustain commitment Recruit people The more volunteers or members who find purpose in the community -the more they will commit resources that you may never have known existed.
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Community Development
CMS suggested communities Hospitals in contiguous Zip Codes Overlap of beneficiaries/penetration Desire to reduce re-admission rates Agree to collaboration/relationship Transparency Downstream Providers
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Provider Responsibilities
Leadership commitment Active involvement of provider teams including leadership in meetings, conference calls, webinars and coalition activities Implement improvement strategies using rapid cycle testing Create new strategies that maximize improvement for all participants Track, monitor and share real time data
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Stakeholder Support Are the cornerstone for the community
Learn from the community Inform members of CT strategies Support/provide community education sessions Participate in quarterly calls Provide publications via newsletter Post information/links of CT on Web sites
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Expand the Circle of Support… Motivating Call to Action
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Community Intervention Selection
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Standard/Known Process
BOOST (Better Outcomes for Older adults through Safe Transitions) TCM (Transitional Care Model) F/U appointment made at discharge Pharmacy Telephone F/U Document standardization
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Drivers of Readmissions
Based on discharges from Clinical Classification Software (CCS) 2008 downloadable from .
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Key drivers of 30 day readmission
Lessons Learned Key drivers of 30 day readmission Low patient activation Lack of standard processes Inadequate transfer of information across care settings Key strategies for 30 day readmission reduction Community organization Patient activation Multi-provider process improvement
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End of Life Of discharges of CT residents from the five targeted hospitals that result in a 30-day readmission to any acute care hospital during the last six months of life 35% are discharges to a SNF 33% are discharges to home under the care of a HHA 23% are discharges to home or self-care 28% of all readmissions occur during the last six months of life
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Root Cause Analysis Simply stated RCA is a process designed to help identify not only What and how BUT Why Leads to interventions selection and ongoing identification of gaps in care delivery across settings.
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Intervention Selection
Derived from root cause findings Monitor & Measure Process Measures System Components Outcome Measures Effect of change on patient
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Intervention Selection by Driver
Patient Activation Standard/Known Process Transfer of Information
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PROJECT RED (ReEngineered Discharge)
Evidenced based toolkit. Developed by Boston University Medical Center Addresses key factors identified in RCA Delayed Transfer of Discharge Summary Unknown Test Results Patients Failure to Follow-up Medication Interactions and Adverse Events
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Transfer of Information
Communication Re-design HIT SBAR Beneficiary and community outreach
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Patient Activation INTERACT RED (Re-engineered Discharge)
Medication Reconciliation Coaching Teach-Back
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Coming together is a beginning. Keeping together is progress
Coming together is a beginning. Keeping together is progress. Working together is success. ~Henry Ford
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Community Care Transitions Program
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The Community–based Care Transitions Program (CCTP)
The CCTP, mandated by section 3026 of the Affordable Care Act, provides funding to test models for improving care transitions for high risk Medicare beneficiaries. •Increasing rates of avoidable hospital readmissions will result in negative health outcomes for Medicare beneficiaries impacting their levels of safety and quality of care. •The CCTP seeks to correct these deficiencies by encouraging communities to come together and work together to improve quality, reduce cost, and improve patient experience.
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CCTP: Program Goals Improve transitions of beneficiaries from the inpatient hospital setting to other care settings •Improve quality of care •Reduce readmissions for high risk beneficiaries •Document measureable savings to the Medicare program
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Eligible Applicants Are statutorily defined as: Acute Care Hospitals with high readmission rates in partnership with a community based organization Community-based organizations (CBOs) that provide care transition services •There must be a partnership between the acute care hospitals and the CBO
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CCTP: Definition of CBO
Community-based organizations that provide care transition services across the continuum of care through arrangements with subsection (d) hospitals−Whose governing bodies include sufficient representation of multiple health care stakeholders, including consumers
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CCTP: Key Points CBOs will use care transition services to effectively manage transitions and report process and outcome measures on their results. •Applicants will not be compensated for services already required through the discharge planning process under the Social Security Act and stipulated in the CMS Conditions of Participation. •Applicants will be required to participate in ongoing learning collaboratives
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CCTP: Application Guidance
Applicants are required to complete a root cause analysis The proposals must specify how the root causes will be addressed The proposal will describe how they will work with accountable care organizations and medical homes if applicable The proposal will describe how they will align their care transition programs
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CCTP: Conclusion The program solicitation was announced in the Federal Register and is now available at: The program will run for 5 years with the possibility of expansion beyond 2015 If community progress is not occurring within 2 years of receiving funding, funding will be stopped Please direct CCTP questions to:
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Do not forget to note Frequently-Asked Questions
CCTP Website Visit the program website for daily updates on program status at Do not forget to note Frequently-Asked Questions On the Site
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What Actions Can You Take?
Look at your process What do you already have in place? What strength do you bring to the community? Be a good team player How can you collaborate to Improve care delivery across the continuum Reduce errors and avoidable re-admissions Share resources and reduce cost Improve communication and information transfer Improve Care Transitions
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10th Scope of Work: The Opportunity for You….
Communities are developing Position yourselves Promote cross setting best practices you have implemented Integrate with upstream and downstream providers Be part of the discussion and strategic planning Let everyone know the role of home care and the services are critical to decreasing the rate of 30-day readmissions Be part of the solution!
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Patients cross many settings for health care
Patients cross many settings for health care. Our handovers must be consistent, detailed and appropriate to each setting. Transitional care coordination is like putting pieces of the puzzle together to improve patient health care and to reduce avoidable acute care hospitalizations. Home care needs to assist patients and caregivers to connect the care provided back and forth across the settings. The care transitions intervention by Dr. Coleman’s team has been built on four pillars or conceptual domains. The illustration on the next slide adapts the four pillars concepts into the home health arena.
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QIO Technical Assistance
Learning and Action Networks (LAN) on a state-wide level Webinars provided and recorded Connect to downstream providers Provide current Medicare data to providers
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Resource Sharing Upcoming conferences or meetings E-newsletters
Share with us/success stories Or how can we share an article with you? Contact Krista Davis at or
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You must be the change you wish to see in the world
MahatmasGandhi
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This material was prepared by Quality Insights of Delaware, the Medicare Quality Improvement Organization for Delaware, 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. Publication number 10SOW-DE-ICP-KD A. App. 1/12.
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