1. Improving Care Transitions in Northwest Denver Risa Hayes, CPC Program Manager, CFMC Integrating Care for Populations and Communities AHRQ Annual Conference September 21, 2011 1

2. Our Equation 2 ( ) Readmissions and Admissions ( )

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4. Who is the Community? 4 Acute Care Hospitals LTACs SNFs Home Health Agencies Non-medical Home Care companies Senior Resource Centers Physician Offices Patient Advocates Hospice providers Palliative Care providers Medical Society Mental Health AAA QIO Hospitalists Physician management group

5. 5 Provider-Patient interface Unmanaged condition worsening Use of suboptimal medication regimens Return to an emergency department Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers No community infrastructure for achieving common goals Why are people readmitted?

6. The Project 6 Goal : Improve care transitions for Medicare beneficiaries in 44 zip codes in NW Denver As evidenced by: –2% reduction in 30 day all-cause readmission rate What we did: Community Action Teams Standardized Community PHR Post-acute Care Options Tool Coaching PAM ® -tailored CTI SM Volunteer Advocates

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8. Community Unity – A true NW Denver Partnership – Involved a large group of community providers – 21,000 printed copies – Available online for future use 8

9. 9 Post Acute Care Decision Support Tool Community Developed Tools

10. Timeline: Care Transitions in NW Denver 10

11. Outcomes: Care Transitions Intervention ℠ & Patient Activation Measure ® 11 Coleman CTI ℠ model 1 >300 patients coached Measurement –Patient Activation Measure ® (PAM ® ; Insignia Health) 2 NW Denver longitudinal data (sample size: 49) http://www.insigniahealth.com/solutions/patient-activation-measure

12. “I feel that I must tell someone about how greatly I benefited from and appreciate the services of the nurse who follows up on patients discharged from your hospital. She comforted me and helped make several forceful phone calls, and soon all was well. What a great help! What a relief! Thanks.” 12 Mr. H: A patient story

13. Results 13

14. 14 Outcome: Reduce hospital readmissions and improve patient activation Evaluation & Next Steps: Apply for CCTP funding AND… Peak: Create PHR, PAC tool, Palliative/Hospice curriculum and community talks Peak: Form Action teams Kick off: Community meeting Foundation: Determine community Peak: Celebration meeting – June 21st Northwest Denver: Campaign

15. NORTHWEST DENVER CONNECTED FOR HEALTH: STORY OF NOW 15 Inspiration

16. Questions? Risa Hayes, CPC Program Manager, Integrating Care for Populations and Communities CFMC risah@cfmc.org risah@cfmc.org Find your QIO and Access the Toolkit: http://www.cfmc.org/caretransitions/ http://www.cfmc.org/caretransitions/ 16