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Finger Lakes Health Systems Agency
April 18, 2023 1
CMS Community-Wide Care Transitions Intervention
Overview
• 1. How we got here
• 2. What we are doing
• 3. What is important to support success
April 18, 2023 2
FLHSA: Vision, Mission & Strategy• Vision: A local health-care system that makes people
healthier and saves money, by delivering the right care, in the right place, and at the right time for everyone in the community.
• Mission: We are an independent organization working to improve health care in Rochester and the Finger Lakes region, by analyzing the needs of the community, bringing together stakeholders and organizations to solve health problems, and measuring results.
April 18, 2023 3
FLHSA Community Health 2020 Commission
April 18, 2023 4
Shifted focus from individual CON applications to a determination of the aggregate community need
Recognized the unsustainable trend in growth driven by failure of optimal care in the community
Bed approvals scaled back and a commitment to “community investment” to alter the trend by improving care in the community
FLHSA 2020 Commission
April 18, 2023 5
The 2020 Commission recommended FLHSA convene the 2020 Performance Commission “to engage all stakeholders in a process that will result in community initiatives and requisite investments to improve access to care, avoid unnecessary hospital use, and eliminate disparities in health status across the region.”
Interactive Components
HS/PlanOrganization of Health Care
Self-management
support
Delivery system design
Decision support
Clinical information
systems
Provider’s Job
Prepared, proactive practice
team
Productive Interactions
Quality and value outcomes; ROI; engaged, satisfied participants
HS/Plan’s Job
Informed, activatedpatient
HS = health system; ROI = return on investment.Wagner EH. Effective Clinical Practice. 1998;1(1):2-4.
Community
Resources and policies
Community Investment Goals
• The 2020 Commission created specific goals for the community– A decrease of 15% in the number of low acuity
(non-urgent) visits to emergency rooms– A decrease of 25% in the number of admissions for
Ambulatory Sensitive Conditions that are manageable in outpatient settings – 2350 admits in 2011
– A decrease of 20% in the number of low acuity admissions to Monroe County hospitals of residents from outlying communities
• Recommended creation of the 2020 Performance Commission to guide community activities to reach the established goals
April 18, 2023 7
Three Dimensions of Value
PopulationHealth
Experienceof Care
Per CapitaCost
• Readmissions
• ED use• PQI admissions• Admissions from
outlying communities
• Access• CAHPS surveys
8April 18, 2023April 18, 2023 8
Measures Defined by 2020 Performance Commission
• Agreed Upon Measures for 2014:– PQI admissions: goal to decrease by 25% – Low acuity ED visits: goal to decrease by 15%– Low acuity admissions to Monroe County hospitals:
goal to decrease by 20%
• Implied goal: have the right bed available 99% of the time (this was the measure used to calculate the beds needed to determine bed need)
April 18, 2023 9
Reducing Avoidable Admissions:
Disease Condition as a Variable Hospitalizations
per 100,000 population, Percent of age adjusted All PQI Admissions
• Respiratory Condition 657.7 (<US) 43%• Heart Conditions 439.3 (<US) 29%• Diabetes 153.7 (<US) 10%• Other 278.0 18%
• All Adult PQIs 1,528.7 (<US) 100%
April 18, 2023 10
Reducing Avoidable Admissions:Insurance Status as a Variable
April 18, 2023 11
Reducing Avoidable Admissions: Geography as a Variable
April 18, 2023 12
Reducing Avoidable Admissions:Ethnicity as a Variable
April 18, 2023 13
Reducing Avoidable Admissions: SES as a Variable
April 18, 2023 14
PQI – Finger Lakes Region
• Adult Respiratory and Circulatory conditions account for over 70% of all PQI Admissions in the six county Finger Lakes Region.
• Between 2004-2006, 13% of all hospital discharges were PQI discharges.
• Each day 295 hospital beds in the region were filled by patients who potentially could have avoided hospitalization.
• This equates to 10% of Hospital charges for these admissions (charges not costs).
April 18, 2023 15
Conclusions from FLHSA Data
• Patients with PQI admits are generally older and insured
• Rochester’s inner city has significantly higher rates of PQI admits
• African-Americans and to a lesser degree Latinos experience increased PQI admits
• Lower socioeconomic status is an important contributor to PQI admits
• Reaching the target reduction in PQI admits requires decreasing PQI admits in the white population as well as in underserved minority populations
April 18, 2023 16
Conclusions from National Data
• Rehospitalization is the low hanging fruit of PQI hospitalization reduction
• Most admissions are related to cardiovascular and respiratory diseases
• Major factors in reducing Medicare re-hospitalizations are:– Having a primary care practitioner– Seeing that practitioner often post
discharge– Having a team to coordinate care
April 18, 2023 17
CMS Community-Wide Care Transitions Program Goals
• Improve transitions of Medicare FFS beneficiaries from the inpatient hospital setting to home or other care settings
• Improve quality of care
• Reduce readmissions for high risk beneficiaries
• Document measurable savings to the Medicare program and expand program beyond the initial 5 years
April 18, 2023 18
The Care Transition Intervention
Coaching models, when applied to transitions in care, have been shown to reduce readmissions by 20-40%.
Patient/family coaching actively engages patients and their families to be full partners in insuring improved health and decreasing unnecessary dependence on hospitals and emergency departments.
Community organizations and home care agencies will lead the effort, fulfilling Wagner’s model of optimally treating chronic conditions.
April 18, 2023 19
Our Phased Approach to a Community-wide Care Transition Intervention
• Insurers pilot Commercial and Medicare Advantage • Monroe Plan for Medicaid Services pilot for
Medicaid HMO
• HEAL 19 funds the uninsured and Medicaid FFS patients
• CMS CTTP grant for Medicare FFS patients target launch June 2012
April 18, 2023 20
Self – Reported Aggregate Coaching Data
Measure Oct – Dec 2010 Jan – March 2011 Totals through March 2011
Patients agreeing to coaching in hospital
219 351 670
Patients who Accepted Coaching - (Defined as patient seen at home)
130 230 360
Acceptance rate 59% 65% 62%
# completing program 104 195 299
% completing 80% 84% 82%
# readmitted to hospital with in 30 days
15 Incomplete
% readmitted in 30 d
14.4 Incomplete
#/% T&R from ED in 30 d*
6/6 Incomplete
April 18, 2023 21
*Based on coaching organizations data tracking, not health plan data
Initiatives at Hospitals
1. Identify and Track Reasons for Readmissions2. Risk Assessment Stratification3. Medication Reconciliation4. Provider Checklist for High Risk Patients5. Teach backs6. Community Standards for Discharge Planning7. Timely PCP Follow up Appointments8. Hospitalist to SNF Communication
April 18, 2023 22
FLHSA CMS Community-wide Process
• Coordinated community meeting: 60 regional representatives
• Agreed to scope of work: Build upon previous experience; expand & spread
• Defined work • Determined patient eligibility criteria based on data
review• Designed and Clarified hospital integration with CTI• Integrated Community based services• Calculated costs of intervention and ROI• Designed tracking and reporting processes• Talked, talked, talked, and…… talked more!
April 18, 2023 23
Our CMS Community - Wide Care Transitions Intervention
• Lifespan ; an AOA –funded non-profit organization
• Five hospitals:– Rochester General, Unity, Strong Memorial, Highland and Newark-
Wayne
Target Population:
Medicare FFS beneficiaries with an active PQI diagnosis having
2 or more characteristics at risk of re-hospitalization:– 3 co-morbid chronic illnesses– 5 prescription medications– 2 hospital admissions within the last 12 months– Failure to teach back– Special Circumstances subject to interdisciplinary judgment
April 18, 2023 24
Putting your plan into Action
• Secure and maintain leadership commitment• Form multi-disciplinary workgroups• Analyze root cause analysis• Understand processes• Anticipate and confront resistance / barriers• Identify improvement opportunities• Develop a measurement plan• Estimate ROI• Employ and Commit to Continuous Quality
Improvement• Establish Trust• Go for it!!!
April 18, 2023 25
April 18, 2023 26
Establish and Maintain Trust
Clearly define and agree to your goals
Explicitly define guiding principles and adhere to core values
Use data to guide and inform your work
Anticipate concerns, encourage and solicit input, and provide a feedback loop
Finger Lakes Health Systems Agency
Thank You!!!
Melissa Wendland
Associate Director, Planning and Research
Finger Lakes Health Systems Agency
1150 University Avenue
Rochester, New York 14607-1647
April 18, 2023 27
April 18, 2023 28
Finger Lakes Health Systems Agency
The triangle represents our agency’s role as a fulcrum—the point on which a lever pivots—boosting the community’s health by leveraging the strengths of all stakeholders. The fulcrum is also a point of equilibrium, reflecting our ability to balance the needs of consumers, providers and payers on complex health matters. The inner triangle also evokes the Greek letter delta—used in medical and mathematical contexts to represent change—with a forward lean as we work with our community to achieve positive changes in health care.
Give me a lever long enough and a fulcrum on which to place it, and I shall move the world. —Archimedes
1150 University Avenue • Rochester, New York • 14607-1647585.461.3520 • www.FLHSA.org
