It Takes a Village Community-Based Care Transitions Improvement
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It Takes a Village Community-Based Care Transitions Improvement Marian Boxer, RN Colorado Foundation for Medical Care February 22, 2012 This material was prepared by CFMC (PM-4010-031 CO 2011), the Medicare Quality Improvement Organization for Colorado, 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.
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It Takes a Village Community-Based Care Transitions Improvement. Marian Boxer, RN Colorado Foundation for Medical Care February 22, 2012. - PowerPoint PPT Presentation
Transcript of It Takes a Village Community-Based Care Transitions Improvement
It Takes a VillageCommunity-Based Care Transitions
Improvement
Marian Boxer, RNColorado Foundation for Medical Care
February 22, 2012
This material was prepared by CFMC (PM-4010-031 CO 2011), the Medicare Quality Improvement Organization for Colorado, 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.
Objectives
Reducing Readmissions4 Important things we learned from the Care Transitions ThemeWhere to start – Drivers and SettingsNew /Current opportunities
Walkers: just starting to think about care transitions
& reducing readmissions
Joggers: currently involved in efforts to
improve care transitions & reduce
readmissions
Marathoners: have a permanent structure in place to improve care transitions & reduce readmissions (Accountable Care Organizations)
A Variety of Opportunities
QIO Support
Community-Based Care Transitions Program (CCTP)
14 QIOs with 14 Target Communities AL: Tuscaloosa CO: Northwest Denver FL: Miami GA: Metro Atlanta East IN: Evansville LA: Baton Rouge MI: Greater Lansing area NE: Omaha NJ: Southwestern NJ NY: Upper capital PA: Western PA RI: Providence TX: Harlingen HRR WA: Whatcom county
Results
1. It’s not a hospital project
HHA
SNF
It’s a Community Problem
Why are people readmitted?
No Community infrastructure No Community infrastructure for achieving common goalsfor achieving common goals
Unreliable system supportLack of standard and known processesUnreliable information transferUnsupported patient activation during transfers
Provider-Patient interfaceUnmanaged condition worseningUse of suboptimal medication regimensReturn to an emergency department
CMS’ Table of Interventions
Available at: www.cfmc.org/caretransitions
Blah blah blah, blah blah. Any questions?
No I’m good to go. Whatever you say is what we’ll do Doctor
What’s he saying? I sure hope my wife is getting this..
2. Patient activation trumps all
PATIENT ACTIVATIONPATIENT ACTIVATION
The CMS Discharge Planning Checklist
http://www.medicare.gov/Publications/Pubs/pdf/11376.pdf
Knowledge, skills and confidence
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Sample Questions:#1: “When all is said and done, I am the person who is responsible for taking care of my health.”
#12: “I am confident I can figure out solutions when new problems arise with my health”
The PAM is scored on a 100 point continuum. Most patients score between 35 and 80
The Patient Activation Measurewww.insigniahealth.com
PATIENT ACTIVATIONPATIENT ACTIVATION
The PAM is very helpful to guide interventions
3. Local adaptation is inevitable
Adapt gold standard modelsDo not adapt others’ adaptations
4. Ask the community to help
• “Brought to you by your Community Partners”
To Organize a Community..
Tie participation to valuesInclude personal narrativesDevelop flexible tactics
DEVELOPING A COMMUNITY PROJECT TO REDUCE HOSPITAL READMISSIONS
Identify the communityDetermine drivers of readmissionSelect intervention strategiesDevelop a ‘backbone’ agency
I think it’s an elephant!
The ‘Zip Code Overlap’ Community Definition
FFS Medicare beneficiaries living in zip codes of interest
Target Population
Community identity supports both social and economic sustainability
FFS beneficiaries discharged from hospitals of interest
Social Network Analytic techniques for displaying the provider network
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Building Community Infrastructure
1. RCA Drivers1. Data2. Medical record review3. Process assessment
2. Drivers + Settings = Interventions
Intervention Packages
Intervention Reference Main tools Driver addressed #
SKP PAct InfCare Transitions Intervention
www.caretransitions.org Coaches, personal health record, medication discrepancy tool ? XXX X 13
Transitional Care Nursing www.transitionalcare.info/index.html Risk assessment , nursing training materials XX X XX 2
CMS Discharge Checklist www.medicare.gov Patient and family checklist of important items to address before discharge ? XXX X 9
BOOST www.hospitalmedicine.org/ResourecRoomRedesign
Screening/assessment , provider discharge checklist, transition record, teach-back instructions, data collection and tracking
XXX XX 2
Best Practices Intervention Package (BPIP)
www.homehealthquaqlity.org/hh/ed_resources/interventionpackages/default.aspx
Comprehensive manual for HHA process improvement includes CTI teaching XX XX XX 11
InterAct Interact.geriu.org Communication tools, clinical care paths, advanced care planning XX XX 10
Transforming Care at the Bedside (TCAB)
www.ihi.org/IHI/Programs/StrategicInitiatives/TransformingCareAt TheBedside.htm
(Re)Admission assessment, teach-back, pt and family communication, scheduled f/u XXX XX X 4
Re-Engineered Discharge (RED)
www.bu.edu/fammed/projectred/index.gtml Nurse discharge advocate, pharmacy f/u medication teaching, PCP f/u booklet XXX XX 4
1. RCA Drivers1. Data2. Medical record review3. Process assessment
2. Drivers + Settings = Interventions3. Backbone ‘agency’
EXAMPLES
Provider Pair:HHAs and hospital pharmacy (NY)
Butterfield, Stegel, Tartaglia. Improving outcomes through re-engineering care transitions: The New York Experience. Remington Report May/June 2010.
MULTI-PROVIDER INTERVENTIONSMULTI-PROVIDER INTERVENTIONS
Lateral Cluster:30day hospital readmission rate from SNFs in Harlingen
http://www.cfmc.org/caretransitions/files/Feb24_2011%20Learning%20Session_FINAL.pdfhttp://www.cfmc.org/caretransitions/files/Feb24_2011%20Learning%20Session_FINAL.pdf
Partnering for coached discharges:Improved activation (Co)
PATIENT ACTIVATIONPATIENT ACTIVATION
The HHS National Quality Strategy(http://www.healthcare.gov/center/reports/quality03212011a.html)
Three-Part Aimo Better Care: Improve the overall quality, by
making health care more patient-centered, reliable, accessible, and safe.
o Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care.
o Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.
o Goals: o Improve quality of care for Medicare beneficiaries as
they transition between healthcare settingso Reduce 30-day hospital readmission rates by 20% over
3 years for the nation
QIO technical assistance for all communities:
• Shared savings• ? Other TA
• Zip Code Overlap• Social Network Display• Community coalition formation• Root cause analysis• Intervention selection• Statewide Learning Networks• Assistance with CCTP applications• Quarterly data feedback if not in CCTP
• CCTP payment (http://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313)
• PAM, CTM, HCAHPS support• Collaborative Learning• Connection with best practices• Quarterly monitoring data
Technical Assistance
The Care Transitions Toolkit:
1. Getting Started2. Participants3. Community Engagement4. Root Cause Analysis5. Interventions6. Measurement
http://www.cfmc.org/caretransitions/toolkit.htm
Care Transitions Statewide Learning in Action Network
Care Transitions Learning in Action Network Quarterly Statewide sessions (3 calls & 1 in-person meeting) Mechanism by which large scale improvement is fostered, studied, adapted and rapidly spread regardless of the change methodology, tools, or time-bounded initiative used to achieve the aimAction orientedReal time learning/problem solving (Community Development)Transparent, flexible, interchangeable, purposeful
To pay for improved transitions of care for Mcare beneficiaries from the inpatient hospital setting to home or other care settings
Improve quality of careReduce readmissions for high risk beneficiariesDocument measureable savings to the Medicare program
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Community-Based Care Transitions Program:
ACA Section 3026
$500 Million
“IT’S CLEAR THAT SOMEBODY HAS TO DO SOMETHING AND IT’S INCREDIBLY
PATHETIC THAT IT HAS TO BE US”
Jerry Garcia
