1. CMS National Conference on Care Transitions December 3, 2010 1

2. Coaching in Pennsylvania Naomi Hauser, RN, MPA, CLNC Quality Insights of Pennsylvania Tim Landrin, MPA Southwestern Pennsylvania Area Agency of Aging 2

3. Intro of Project Goal Why AAA? – Mission congruent – Sustained community support Coleman Model Approach AAA/hospitals Engage leadership QIO set culture for collaboration – Transparency – Equal playing field – Non-blame 3

4. Outcomes Potentially eligible discharges – 418 out of 5,531 (8%) Completed CTI for 30 days – 220 out of 418 (53%) Completed pre-post PPA – 177 out of 220 Of coached patients, 73% improved by a median score of 2 Discharge rate – Any hospital to any hospital – 20% – Participating hospital to any hospital – 18% – Receptive patient discharged from a participating hospital to any hospital – 14% 4

5. Collaboration/Relationship Improvement Hospital – 67% more contact with AAA than before project – 66% know more about service AAA can provide patient – 46% are more satisfied with contact with AAA AAA – 74% more satisfied with hospital contacts – 67% more AAA services provided now – 60% referrals are more appropriate – 53% have more contact about referrals – 60% more confident patients needs met 5

6. AAA Involvement AoA/AAA mission Provision of community services 6

7. Ground Work/Initial Process Start cross-setting conversation Develop workflow process Identify staff/roles Coleman training participation 7

8. Referral Process Implementation July 2009 Selection criteria – MFFS – Alert and oriented or caregiver – Diagnose CHF/COPD and other diagnoses – Within CTI Zip codes 8

9. Lessons Learned QIO role Enhanced relationship with hospital staff Administrative support Value of on-site hospital visitations Value of AAA involvement Patient empowerment 9

10. Limitations Resources 8% of discharged patients coached 10

11. Success Stories Referrals for HCBS Assisting special needs 11

12. Contact Us Naomi Hauser, Quality Insights of Pennsylvania – nhauser@wvmi.org Tim Landrin, Southwestern Pennsylvania Area Agency on Aging – landrin@swpa-aaa.org Ray DuCoeur, Westmoreland County Area Agency on Aging – rducoeur@co.westmoreland.pa.us This material was prepared by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania, 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 9SOW-PA-CT-KD-110510. App. 11/10. 12