1. Alice Bonner, PhD, RN Executive Director Massachusetts Senior Care Foundation

2.  Poor care transitions disproportionately affect frail older adults and other vulnerable populations (Counsell et al, 2007)  Lack of coordination during transitions can lead to adverse events, poor clinical outcomes and rehospitalizations (Forster, 2003; Jencks, Williams & Coleman, 2009)  Efforts to improve care transitions in MA are underway, but lack planning and integration (Care Transitions Forum, Presentation to the MA Health Care Quality and Cost Council, May, 2009)

3.  Multiple projects are underway  State Action to Avoid Rehospitalizations (STAAR)  Interventions to Reduce Acute Care Transfers (INTERACT II)  Medical Orders for Life Sustaining Treatment (MOLST)  Medical Home pilots with Community Health Centers  MA Division of Health Care Finance and Policy Potentially Preventable Readmissions (PPR) project  RWJ Aligning Forces grant (new – Boston only)

4.  Multiple MA government entities are involved:  Administration and Finance (Health Care Payment Reform Commission)  Health Care Quality and Cost Council (HCQCC)  State Quality Improvement Institute (SQII)  Elder Affairs (ADRCs, Long Term Care Financing Task Force)  Masshealth (pilots such as Senior Care Options (SCO), transforming care of dual eligibles, case management of certain high risk populations, P4P for nursing homes)  MA Commission on HIT

5. 1. Work with MA team to write Care Transitions strategic plan for the state (3-4 months; target completion date December 1 st, 2009)  Use strategic plan to guide integration of multiple care transitions projects and align goals/objectives  Examine whole systems measures (statewide) 2. Use process and outcome measures for a specific care transitions project (INTERACT II) in selected communities to focus the PCF proposal

6.  INTERACT II (Interventions to Reduce Acute Care Transfers) www.interact.geriu.orgwww.interact.geriu.org  Goal: reduce avoidable transfers of nursing home residents back to the acute care setting  Intervention: a toolkit for nursing home staff ▪ Clinical Care Paths and Resources ▪ Communication tools (Stop & Watch; SBAR; Resident Transfer Form; Envelope Checklist) ▪ Advance Care Planning tools ▪ QI Review Tool  Critical component: establish a cross-continuum team (relationship building)

7.  Currently: 10 demonstration homes in MA, NY, FL  Implement INTERACT II tools and processes in at least 10 additional communities in Massachusetts  Reduce avoidable acute care transfer rates from nursing homes in those communities by 20%  Insure that at least 80% of the time, nursing home patients will arrive in the emergency department with 100% of the essential data required to manage the patient (or nursing homes using INTERACT II will improve by 10%)

8.  State-level project  All citizens in the Commonwealth (broadest sense)  Consider health disparities  Consider unique aspects of rural health regions  Focus on nursing home population (primarily older adults)  But keep other vulnerable populations in mind for future dissemination (lifespan approach)

9.  Outcome measures  Medicare 30-day readmission rates by facility (all cause and CHF) ▪ We want to track readmissions at every point in time (many SNF patients return within a short period of time). Working with DHCFP on data quality. ▪ Berkowitz measure (unplanned discharge back to the hospital= number of discharges back to the hospital/number of SNF admissions)  Process measures under consideration  Resident/family experience with transfer (adaptation of CTM-3 or NH-CAHPS items)  Survey of implementation of INTERACT II by cross-continuum teams in communities (Are you using the tools? Which ones? How has it changed the way you are able to deliver care?)  Did essential data accompany the patient to the next setting of care, e.g., nursing home to ED?

10.  Statewide Strategic Plan finished by December 1 st  Rollout to other project teams by January 1 st, 2010  INTERACT II demonstration sites complete data collection and analysis by April, 2010  Implementation of INTERACT II beyond the ten demonstration homes (additional Partners post-acute facilities) beginning in January, 2010  Data collection on Partners homes and hospitals begins April, 2010

11.  Strategic plan needs to tie into health care payment reform initiatives, including cost containment  Plan (blueprint or roadmap) must guide us from isolated centers of excellence to effective statewide health policy and wider dissemination  My problem: I wasn’t in the right place to effect these changes

12.  Director, Bureau of Health Care Safety and Quality, Department of Public Health  Oversees licensing and certification of hospitals, nursing homes, clinics, dialysis centers, home care agencies, ambulatory surgery centers  Includes the Division of Professional Licensure  Includes Office of Emergency Management Services (OEMS)  Includes Drug Control Programs  Includes Determination of Need Program  Includes Betsy Lehman Center for Patient Safety

13.  Massachusetts has some unique politics  Massachusetts Hospital Association has a history of voluntary reporting and working with government entities  Massachusetts Senior Care Association (nursing home trade group) has a history of wanting to play a significant role in improving care transitions  Massachusetts has several current funded care transitions projects to build on for dissemination  New Director of BORIM also interested in quality improvement

14.  State-level opportunities for program sustainability:  Regulatory channels (e.g., DPH sanctions)  Legislative channels (MA Chapter 305 of Health Care Reform legislation)  Financial incentives (P4P, other)  Payment Reform (Healthcare Payment Reform Commission)

15.  There is a lot of networking to be done  There is a lot of politics to understand

16.  Has anyone been part of a similar initiative in other states or regions?  Do you think it makes sense to move ahead with this agenda, or wait until national health care reform legislation is passed?  Suggestions for how to focus on specific project goals and metrics with INTERACT II