Alice Bonner, PhD, RNExecutive Director Massachusetts Senior Care Foundation

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)

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)

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

1. Work with MA team to write Care Transitions strategic plan for the state (3-4 months; target completion date December 1st, 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

INTERACT II (Interventions to Reduce Acute Care Transfers) www.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)

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%)

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)

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?

Statewide Strategic Plan finished by December 1st

Rollout to other project teams by January 1st, 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

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

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

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

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)

There is a lot of networking to be done

There is a lot of politics to understand

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