1. Care Transitions in Georgia: Partnering with your community to move readmissions Jennifer Hodge RN MSBA Aim Lead, Integrating Care for Populations Communities Alliant Georgia Medical Care Foundation

2. Objectives ► Participants will be able to articulate 2 changes in the QIO program ► Participants will be able to discuss 2 advantages to partnership with other community stakeholders to improve care delivery ► Participants will be able to name the community health care connections meeting nearest to their home

5. Georgia’s Strategy ► Change focus of established regional meetings ► Engage wide variety of providers ► Grow local leaders ► Spread interventions that work ► Identify links in other CMS quality work ► Partner with others

6. Georgia Performance by ZIP Code GA Score Card. LEFT: Report Date: 12/31/11 RIGHT: Report Date: 10/31/13

7. What’s The impact of all our work in Georgia? ► In the yellow communities, readmissions have been reduced by 21.60% ► Statewide readmissions have fallen 20.79% ► In Georgia 7292 fewer readmissions occurred in 2013 than in 2010

9. 16.45%18.65% 11.54% 19.65% 15.50% 20.65%

10. Traveling to Georgia for Care

12. Readmissions Penalties

13. QIN Statement of Work: 4 Key Roles for QIO 1.Results-Oriented: A Multi-State and Local Change-Agent Champion ► Data driven ► Active engagement of patients and other partners ► Proactive, intentional innovation spread that improves and “sticks” 2.Learning and Action Networks: A Facilitator of Learning and Action ► Implement an “all teach, all learn” approach to share clinical QI expertise

14. QIN Statement of Work: 4 Key Roles for QIO (cont’d) 3.Technical Assistance: A Teacher and Advisor ► Consultation and education in QI science and process improvement ► Knowledge management so learning is never lost 4.Communication: A Highly Effective Communicator and Trusted Partner ► Optimal learning, patient activation and sustained behavior change ► The “Go To” for health care transformation

15. Clinical Focus of 11 th SOW Activities Improve Cardiac Health and Reduce Disparities Improve Coordination of Care Reduce Disparities in Diabetes CareReduce Adverse Drug Events Collaborate with Regional Extension Centers and Promote Meaningful Use of HIT Support Quality Reporting with an Emphasis on Improvement Reduce Healthcare-Associated Infections in Hospitals Perform Quality Improvement Initiatives as Requested Reduce Healthcare-Acquired Conditions in Nursing Homes Opportunity to Propose Projects That Meet Regional Needs

16. How They Want the Work Done (cont’d) ► Beneficiary engagement – Included as component of every aim – Work directly with beneficiaries and include beneficiaries in meetings – Target racial and ethnic minority beneficiaries, dual- eligible beneficiaries, rural beneficiaries and the community providers who serve them

17. How They Want the Work Done (cont’d) ► More focus on physician and physician practices ─Technical assistance for quality reporting ─Promote use of EHRs and electronic data reporting ► Leverage “virtual” activities such as learning and action networks ─Work with communities that cover 60% of beneficiaries ─Work with 75% of nursing homes ─Integrate efforts across aims ► Plan for sustainability from the start

18. Note to Self: Supporting individuals in their communities as they age will take more effort than any single entity can provide.

19. Different Communities, Different Discharge Plans

20. Promising Interventions Right here in Georgia

21. This material was prepared by Alliant GMCF, the Medicare Quality Improvement Organization for Georgia, 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 No.