1. PUTTING THE PIECES TOGETHER: REDUCING AVOIDABLE READMISSIONS

2. The Medicare Quality Improvement Organization for Florida Care Transitions Goals Improve 30-day rehospitalization rates Improve AMI, PNE, and HF readmission rates Improve the number of physician follow-up visits among the patients who have been readmitted to the hospital Improve hospital performance of patient satisfaction (HCAHPS) for patients receiving information about discharge and medications

3. The Medicare Quality Improvement Organization for Florida The Miami Opportunity “Making the health care delivery system work reliably for very sick Medicare beneficiaries requires linking all clinical care providers and ensuring that transitions are thoroughly reliable. This work can only succeed when all of the community is engaged and working together, so the QIOs will serve to catalyze and coordinate the work across all care settings in the community.” Barry M. Straube, M.D. Director & Chief Clinical Officer Office of Clinical Standards & Quality for CMS

4. Community Readmission Rates NOTE: Lower better. 30-day readmission rates are unadjusted, weighted averages and are based on a 6-month reporting period ending the specified quarter. Florida’s 30-day unadjusted readmission rate for the 6-month period ending May 2009 = 19.04%.

5. Disease-Specific Readmission Rates: AMI NOTE: Lower better. AMI results are unadjusted, weighted averages and are based on a 3-month reporting period ending specified quarter. The AMI “unadjusted to risk-adjusted difference” at baseline = - 2.83%. Florida’s weighted, unadjusted AMI rate for the 6-month period ending May 2009 = 20.50%.

6. Disease-Specific Readmission Rates: CHF NOTE: Lower better. CHF results are unadjusted, weighted averages and are based on a 3-month reporting period ending specified quarter. The CHF “unadjusted to risk-adjusted difference” at baseline = - 2.48%. Florida’s weighted, unadjusted CHF rate for the 6-month period ending May 2009 = 24.90%.

7. Disease-Specific Readmission Rates: PNE NOTE: Lower better. PNE results are unadjusted, weighted averages and are based on a 3-month reporting period ending the specified quarter. The PNE “unadjusted to risk-adjusted difference” at baseline = - 2.71%. Florida’s weighted, unadjusted PNE rate for the 6-month period ending May 2009 = 17.80%.

8. Physician Follow-Up Visit NOTE: Higher better. Results are unadjusted, weighted averages and are based on 6-month reporting periods ending the specified quarter.

9. Improved Patient Satisfaction: Meds NOTE: Results are unadjusted averages and are based on 12-month reporting periods ending the specified quarter. Based on number of HCAHPS questions answered “always or usually” to question # 16 (Before giving you any new medicine, how often did the hospital staff tell you what the medicine was for? And question # 17 (Before giving you any new medicine, how often did the hospital staff describe possible side effects in a way you could understand?)

10. Improved Patient Satisfaction: D/C Info NOTE: Results are unadjusted averages and are based on 12-month reporting periods ending the specified quarter. Answered “yes” to HCAHPS question # 19 (During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?) And question # 20 (During this hospital stay, did you get information in writing about what symptoms or heath problems to look out for after you left the hospital?)

11. The Medicare Quality Improvement Organization for Florida Based on beneficiaries' claims 2007-2008 Tests patient characteristics to determine non-diseased based disparities Tests the impact of: –Primary discharge diagnosis –Services utilized during hospital stay –Co-existing conditions defined during index hospitalization Risk Modeling NOTE: All diagnoses fields were classified using the CMS-HCC risk-adjustment model. Revenue & procedure codes were classified using utilization flags developed for the Healthcare Cost & Utilization Project (H-CUP), sponsored by the Agency for Healthcare Research & Quality (AHRQ). –Age –Gender –Race/ethnicity –Dual eligibility –ESRD –Length of stay

12. The Medicare Quality Improvement Organization for Florida Dual eligible ESRD Longer length of stays (>5.65) Males (slight) African American (slight) Results: Patient Characteristics

13. The Medicare Quality Improvement Organization for Florida Congestive heart failure* Major psych disorders* Cardio-respiratory failure / shock* Metastatic cancer / acute leukemia # Chemotherapy / benign neoplasm # Artificial openings for feeding / elimination * Impacts greatest number of patients # Greatest risk for readmission Results: Primary Discharge Diagnosis

14. The Medicare Quality Improvement Organization for Florida Emergency department* EKG* Coronary care* Respiratory therapy* Ultrasound Renal Dialysis # Mental Health & Substance Abuse # * Impacts greatest number of patients # Greatest risk for readmission Results: Service Utilization

15. The Medicare Quality Improvement Organization for Florida Cardiac / Respiratory / Vascular* GI / GU Mental Health # Nutrition / Skin / Blood Disorders Cancer # * Impacts greatest number of patients Results: Co-existing Conditions

16. The Medicare Quality Improvement Organization for Florida Community QI Activities

17. The Medicare Quality Improvement Organization for Florida Adapted Coleman’s Care Transitions Intervention SM (CTI) Addresses patient empowerment through Coleman’s 4 Pillars: –medication reconciliation, –physician follow-up, –disease management, –maintaining personal health record Framework’s greatest strength - it is an intervention that is standardized and replicable, but flexible enough to adapt to organizational and patient needs. CTI is not designed to be disease-specific, but it can easily be applied to patients with a variety of chronic illnesses, more specifically, those driving high readmission rates. Stresses patient empowerment by increasing the patient’s knowledge and self-care management skills Project’s Conceptual Framework

18. The Medicare Quality Improvement Organization for Florida Coaching

19. The Medicare Quality Improvement Organization for Florida Provider-Specific Interventions

20. The Medicare Quality Improvement Organization for Florida Collaboratives

21. The Medicare Quality Improvement Organization for Florida Fifth Pillar: QIO & Alliance for Aging Partnership (Area Agency on Aging for Miami-Dade and Monroe Counties) –The Community Living Program Sixth Pillar: QIO & Department of Elder Affairs (DOEA) Partnership –Nutritional support program Additional Activities

22. The Medicare Quality Improvement Organization for Florida Contact: Susan Stone, MSN, RN Project Director – Care Transitions Direct: 813.865.3526 Fax: 813.865.3546 Email: sstone@flqio.sdps.org This material was prepared by FMQAI, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. FL2009T2F72T20611018