Mission

To improve the effectiveness and efficiency of

care and the quality of life of people

receiving long-term services and supports

by fostering person- and family-centered

quality measurement and advancing

innovative best practices.

2011-04-11 2

Strategic Agenda (2010-2012)

Care transitions; impact on people’s health and QoL; effects

on potentially avoidable hospitalizations, re-hospitalizations

and total health care costs.

Quality

Measurement

Key Strategy: Address a national health

challenge, TRANSITIONS IN CARE,

affecting people receiving LTSS in order to

produce demonstrable improvement in

quality and cost reductions

Person- and family-centered, effective

transitional care practices Quality

Improvement

Information and policies that advance high quality,

person- and family-centered transitional careOutreach/Public

Awareness

2011-04-11 3

LTQA Strategic Framework

2011-04-11 4

Quality Measurement

» Goal. Advance the use of key person- and family-

centered quality indicators specific to adults who

require long-term services and supports (LTSS) that

are focused on improvement in care transitions and

health related quality of life, and reductions in

potentially avoidable hospitalizations, re-

hospitalizations and total health care costs.

2011-02-25 5

Members

6

» Gregory Pawlson, Co-Chair

– National Committee for Quality

Assurance

» Heather Young, Co-Chair

– UC Davis

» Bruce Chernof

– SCAN Foundation

» Lynn Feinberg

– AARP

» Marty Ford

– ARC and UCP Disability Policy

Collaboration

» Joe Francis

– Department of Veterans Affairs

» James Gardner

– The Council on Quality

Leadership

» David Grabowoski

– Harvard Medical, Dept of

Health Care Policy

» Jennie Chen Hansen

– American Geriatrics

» Taylor Harden

– NIH/NIA

» William Hartung

– Agency for Health Care

Administration

» Ellen Kurtzman

– GWU Medical Center

Members

7

» Dave Kyllo

– National Center for Assisted

Living

» Michelle Litchman

– University of Utah College of

Nursing

» Katie Maslow

– Alzheimer's Association

» Mark McClellan

– Brookings Institution

» Paul McGann

– CMS

» Diane Meier

– Center to Advance Palliative

Care

» Vince Mor

– Brown University

» Susan Reinhard

– AARP

» Alan Rosenbloom

– Alliance for Quality Nursing

Home Care

» Dr. Di Shen

– CARF/CCAC

» Tom Valuck

– NQF

» Martina Roes

– 2010-11 Harkness Fellow

Progress to Date

» Achieved consensus on key

measurement domains

» Assembled focused list of measures

relevant to care transitions for adults

receiving LTSS

» Surveyed workgroup members re:

importance of measures to advancing

quality

2011-04-11 8

Deliverables

» Endorsement of initial core measurement

set and strategy by LTQA board and

members, Summer, 2011

» Collaboration with multiple stakeholders in

promoting:

– Selection of key measures

– Implementation of measurement strategy

– Development of measures to address gaps

2011-04-11 9

Next Steps

» Engage LTQA members and other key

stakeholders in prioritizing available

measures

» Identify measurement gaps

» Develop dissemination strategy to

promote use of important measures

» Propose strategy to address

measurement gaps

2011-04-11 10

How You Can Help

» Participation in setting strategies and

measure prioritization

» Identifying and influencing critical

opportunities to include focus on long

term care interventions and measurement

in major health care reform mandates

and innovations

2011-04-11 11

“Innovative Communities”

» A collaborative effort between the Quality

Improvement and Outreach/Public

Awareness Workgroups

» Amy Boutwell and Larry Minnix,

» Co-Leaders

2011-04-11 12

Community-BasedApproach

» Communities across the US are

beginning to consider transitions of

care as a community –based

challenge that requires shared

ownership and close collaboration

across settings.

» (Institute for Healthcare Improvement)2011-04-11

13

Innovative Communities

Why?

“Without the involvement of long-term services and

supports, ACO’s or other new collaborative

models of service delivery will not be able to

achieve sustained quality improvements and

reduced costs.”

-Mark McClellan, MD, Ph.D

CAST Chair

Director, Engelberg Center for Health Care Reform

Leonard D. Schaeffer Chair in Health Policy Studies

Brookings Institution, Washington DC

Innovative Communities

Why?

“…LTQA is convinced that the most important

health reform victories will take place at the

local level, in cities and towns… A broad range

of community stakeholders…is needed to help

older people and people with disabilities

remain healthy and independent…”

- “Innovative Communities: Breaking Down Barriers for the Good

of Consumers and their Family Caregivers.” p.3

Innovative Communities

Summit

Philosophical Principles

“Large-scale social change requires broad

cross-sector coordination, yet the social

sector remains focused on the isolated

intervention of individual organizations.”

-John Kania, Mark Kramer, “Collective Impact,” Stanford Social

Innovation Review, Winter, 2011, p.36

Innovative Communities

Summit

Kania and Kramer*

Five Conditions of Collective Success*

» Common Agenda

Shared vision for change. Common understanding

of the problem. Joint approach to solution.

» Shared Measurement Systems

Agreement for success measures. Consistent data

collection and indicators. Group accountability.

Shared learning for success and failure.

Innovative Communities

Summit

Kania and Kramer*

Five Conditions of Collective Success*

» Mutually Reinforcing ActivitiesEach party plays their unique role. Coordination of efforts. Mutual

support.

» Continuous CommunicationsTrusting relationships. Common motivation regardless of sector.

Regular meetings. Best solutions instead of self-interest.

» Backbone Support OrganizationSeparate organization of stakeholders. Coordination of leadership

talent.

Background

» Summit – December, 2010

» Sponsored by SCAN Foundation

» Case studies of best transitional care

practices stimulated dialogue and action

steps

» 140 representatives from >20

communities joined leaders of public and

private health organizations and federal

and state policy leaders in discussion 19

SUMMIT OBJECTIVES

» To share and learn from what is already underway in communities present

» To explore what is possible

– What would it take to build a 3-5 year collaboration of multi-sector communities that will advance innovative practices in line with the mission of LTQA?

– Is it possible? Is there commitment to make it so?

» To identify next steps2011-04-11 20

2011-04-11 21

North Carolina: Community Connections

Patricia Sprigg| Carol Woods Retirement Community

Description of Community

» Developed by active group of local residents

in 1970s

» Goal, establish a desired place to live after

retirement

» Community Spirit lead Carol Woods to

spearhead a community-wide collaborative

designed to bring primary, acute, and long-

term care providers, community-based

organizations, and consumers together

2011-04-11 23

Nursing Home

Assisted Living

RehabilitationContinuing Care

Retirement Community

Home

County Council/

Department on Aging

Area Agency

on Aging

Cooperative Extension

Mental Health

Provider

Community Resource Connection

Home Health Care

Senior Center

Adult Day Services

Faith Community

County Social

Services

?

How does our community navigate this transition?

Community Health Goals

» North Carolina and counties concerned about impact that the Baby

Boom population would have on their communities

» 2004, development of Master Aging Plan

» 2006, One-year planning grant to support a formal assessment of

the factors impacting the health and safety of older citizens in their

community

» create a community infrastructure

– educate consumers

– foster better communication

– decrease fragmentation

– improve innovative transitional

care supports

The Challenge“If re-hospitalizations are frequent, costly, and able to be reduced,

why haven’t they been?”

Hospital-level barriers

» Financial disincentives, no financial incentives, not high on priority list, limited knowledge / sharing of disease-specific efforts & care transition interventions among hospitals.

Community-level barriers» Not common to engage organizations across continuum of services to

collaborate on improving care, lack of IT connectivity, no reimbursement for coordination & systems and organizations working in silos.

State-level barriers» Lack of population-based data, lack of understanding costs of poor

quality on systems, effect of fragmented payer market and lack of CMS participation.

2011-04-11 25

Primary Strategies

» Community Engagement Event

Participants mapped community’s current services, identified

barriers, set priorities for community action, and established

workgroups to address priority areas.

» Aging and Disability Resource Center

Provides infrastructure to engage and unite health and service

providers. CRCs connects older consumers and people with

disabilities to information referrals to host of long-term services

and supports.

» Matching Funds and Seed Money

Funds helped implement and expand evidence-based

programs that address hospital transition, chronic disease self-

management, and falls prevention.

Results to Date

» Discharge planners trained through Community Connections and the

Chatham-Orange CRC are now better equipped to guide consumers to

services that can ease their transition from hospital to home

» Consumers experience a smoother transition to those services, thanks

to the CRC, workgroup activities, the annual resource fair, and efforts

within local agencies to cross-train staff

» 89% of the respondents said they have learned something new about

available programs and services as a result of their involvement in

Community Connections.

» 94% of the respondents reported increasing their own connections with

their colleagues in other agencies.

» Two-thirds said that they had begun or increased their focus on

transition issues (64%) and that they had increased their partnerships

with health care providers to improve transitions (66%).

Lessons Learned

» Identify a Change Agent

» Stakeholders: Consumers: Make the Case

» Encourage Collaboration: Public & Private

Partnerships

» Build Synergy: But Keep Alignment

» Demonstrate Impact (Now vs. Future)

» Choose Intervention –Find the Fit-Don’t Duplicate

» Capture the Data – who/what/how/why

» Sustainability is Critical!

2011-04-11 28

Next Steps

» Carol Woods received an additional

$296,000 from the Duke Endowment to

continue Community Connections for

another two years

– Will focus on developing best practices

around transitions from hospital to home

– Help CCRCs throughout the state

implement evidence-based care transitions

interventions

2011-04-11 29

2011-04-11 30

Vermont: Support And Services at Home: A Care Partnership

Nancy R. Eldridge | Cathedral Square Corporation

Description of Community

» 2005, Vermont adopted Section 1115 Medical Waiver

allowing consumers to stay in their home for as long

as possible

» Citizens aged without system of home- and

community-based services to support

» Resident assessments by Cathedral Square showed

increased frailty, cognitive decline, and complex

conditions

– 47% able to pass cognitive screening

– 37% reported fallen in past year

– 50% reported taking six or more medications

Community Health Goals

» Produced housing-with-services model:

Support And Services at Home,(SASH)

» Reduce avoidable costs to Medicare and

Medicaid

» Provide essential services to housing

residents

» True transformation of long-term care

system, and full integration with acute

and primary care delivery systems

The SASH Team

» Non-Profit Housing

» Visiting Nurse Association

» PACE

» Area Agency on Aging

2011-04-11 33

Primary Strategies

» One year pilot test, involving 60 elderly residents

» Implementation of SASH site team led by full-time

SASH coordinator and nurse who serves as liaison

between site teams and community health teams

» Team carries out two consumer-centered planning

process:

– Individual Healthy Aging Plan

– Community Healthy Aging Plan

» Each team connects to umbrella group called “The

Local Table”

How Our Collaboration Impacted

Our Community

Better Health

Better Care Coordination

Quality of Life improvements

Reduced Hospital Admissions

Reduced Costs

New Relationships

Framework for scalable & sustainable system

2011-04-11 35$10,000,000

$20,000,000

$30,000,000

$40,000,000

$50,000,000

$60,000,000

$70,000,000

1 2 3 4 5

AN

NU

AL

CH

AN

GE

IN

H

EA

LT

HC

AR

E E

XP

EN

DIT

UR

ES

YEARS

IMPACT OF INTEGRATED HEALTH SYSTEM-POTENTIAL COST AVOIDANCE ACROSS TOTAL MEDICARE

POPULATION-ANNUAL CHANGE IN HEALTHCARE EXPENDITURES

INCREMENTAL EXPENDITURES WITHOUT INTEGRATED HEALTH SYSTEM OR SASH

INCREMENTAL EXPENDITURES WITH INTEGRATED HEALTH SYSTEM PLUS SASH

66.1%

Results to Date

» Results from one-year testing stage:

– 19% reduced hospital admissions

– Not one SASH participants discharged from

hospital experienced readmission

– 22% decrease of fall reduction

– Percentage of physically inactive residents

was reduced by 10%

» Vermont's health reform initiative combined

with SASH projects savings of $40 million in

Medicare

Next Steps

» The SASH initiative will receive $10.2

million in Medicare Funds

– Represents a capitated amount of $700 per

participant per year

– Will be rolled out to 112 housing sites in

July 2011

– 75 new jobs

• 60 SASH coordinators

• 15 wellness nurses

2011-04-11 37

What We Learned

• Just because it is simple, doesn’t mean its easy!

• Housing setting provides efficiency and access

• Quality providers hampered by system

• Consumer Designed Model challenges assumptions

• Value of integrating primary, acute and long term care

in one coordinated system

• Improving outcomes while lowering costs requires

fundamental transformation

2011-04-11 38

2011-04-11 39

Michigan: Detroit Community Action

to Reduce Rehospitalizations

Nancy Vecchioni| MPRO- Michigan’s Quality

Improvement Organization

Description of Community

» City’s Medicare hospital readmission rate stands at 25%, highest in

Michigan

» Population decreased from 1.8 million to 871,000 in the past 50

years

» City’s Median income is $29,500 compared to $37,000 for the

nation as a whole

» 34% poverty rate, highest among nation’s cities

» 30% unemployment, 17% uninsured, and almost 20,000 residents

are homeless

» Over 28% residents have a disability, and are more likely to suffer

from heart disease and diabetes

» One fifth of population has no transportation

» Though diet is a major risk factor, half of food stamp retailers are

liquor stores, gas stations, and bakeries

Community Health Goals

» Forming of cooperative initiative by five hospitals in

Detroit aimed specifically at reducing

rehospitalizations

» Four state pilot program (State Action on Avoidable

Rehospitalizations, STAAR)

» Directed by the Institute for Healthcare Improvement,

with support from The Commonwealth Fund

» Detroit Initiative, Detroit Community Action to Reduce

Rehospitalizations (Detroit CARR)

Primary Strategies

» Creation of local healthcare/community

cooperatives

» Each MI STA*AR hospital built its own

transition team

» Focus on STAAR strategies: enhanced

admission assessment, enhanced

learning, patient and family-centered

handover communication, post-acute

care and follow up

Primary Strategies (con’t)

Teams test strategic interventions including:

Before discharge. Begin discharge planning upon

admission to educate patients on discharge

instructions

After discharge. Provide 3-to-30 day supply of

medication and follow up appointments with

patients. Follow up calls after discharge.

Working closely with post-acute providers. Develop

working relationships with post-acute providers to

ease transitions. Introduction of two-page transition

form

Results to Date

» 20% reduction of rehospitalization since

Detroit CARR initiative began

» City rehospitalization in city decreased

5% among adult patients

Next Steps

» Detroit CARR is gearing up to introduce

additional interventions to reduce

hospitalizations

– Including the development of a person-

centered discharge planning initiative that

will be implemented with the Office of

Services for the Aging.

2011-04-11 45

Innovative Communities Summit

Findings

“POWER OF COMMUNITY”

COLLABORATION IS KEY

»Holistic approach

»Emphasis on teamwork

»Tapping existing resources

»Dedicated infrastructure

Collective Lessons

Learned» Identify a champion.

» Made the case for change.

» Learn about the health world.

» Bring consumers to the table.

» Don’t duplicate existing services.

» Focus on sustainability.

» Celebrate small victories.

» Get people talking.

» Don’t forget about the workforce.

» Be Patient.

Innovative Communities

Common Vision for the Future

» Features…

– Consumer empowerment

– Team mentality

– Equal partners

– Independent and invested leadership

– Free flowing information

– Aligned incentives and flexible funds

Innovative Communities

Common Vision for the Future

» Features (con’t)…

– Reinvestment of savings

– Cutting edge technology

– Robust work-force

– Strong volunteer network

– Public education

Quality Improvement/Best

Practices

» Goal. Achieve wider dissemination and

adoption of person and family-centered,

effective transitional care practices that are

focused on improvement in care transitions

and health related quality of life, and

reductions in potentially avoidable

hospitalizations, re-hospitalizations and total

health care costs.

2011-04-11 50

Members

» Amy Boutwell, Co-Chair

– Institute for Healthcare

Improvement

» Mathy Mezey, Co-Chair

– NYU School of Nursing

» Maureen Amos

– National Pace Association

» Carolyn Clancy

– AHRQ

» Mary Tess Crotty

– Genesis Health Care

» Penny Hollander Feldman

– Center for Home Care Policy

and Research

» Kathy Greenlee

– HHS/AoA

» Robert Hornyak

– HHS/AoA

» Gail Hunt

– National Alliance for

Caregiving

» Robert Jenkens

– The GreenHouse Project

» Donald Kennerly

– Baylor University

51

Members

» Mary Jane Koren

– The Commonwealth Fund

» Mark Leenay

– UnitedHealth Care

» Carol Levine

– United Hospital Fund

» Karen Love

– Center for Excellence in

Assisted Living

» Diane Ordin

– Department of Veterans

Affairs

» Joseph Ouslander

– Florida Atlantic University

» Martha Roherty

– National Association of States

United for Aging and

Disabilities

» Marisa Scala-Foley

– HHS/AoA

» Jeanette Takamura

– Columbia University

» Nancy Thaler

– National Association of State

Directors of Developmental

Disabilities Services

» Nancy Vecchioni

– MPRO

52

Progress to Date

» Proposed and received LTQA board

endorsement of a set of principles and

recommendations to guide the development,

implementation, and evaluation of programs

and policies aimed at improving care for

people receiving LTSS.

2011-04-11 53

LTQA Principles

» Include individuals who are recipients of LTSS in

multiple settings

» Adopt a community-based, culturally sensitive,

approach

» Incorporate measures of person- and family-

centered experience

» Support payment mechanisms that promote better

integration of clinical care and LTSS by aligning

incentives

» Encourage implementation of evidence-based

transitional care practices.

2011-04-11 54

Specific Recommendations

» Integrate individuals, caregivers, and

direct care workers as essential

members of the care team;

» Focus efforts on eliciting individual and

caregiver preferences and goals and

address these goals in care delivery;

» Adopt a longitudinal, cross-setting

perspective of health care and LTSS

needs for individuals and families;2011-04-11 55

Specific Recommendations

» Invest in a workforce capable of integrating health

care and LTSS that enables teams of health care

professionals, direct care workers, community

workers, informal caregivers, families and recipients of

care to work together to deliver optimal care.

» Create an infrastructure, using technology where

appropriate, that accelerates quality improvement by

systematizing practices and protocols based on

empirical evidence, and improves coordination and

timely and effective communication among and

between care providers, patients, and families.2011-04-11 56

Next Steps

» Perform a targeted scan of evidence-based and better

practices for improving care for the LTQA population

of interest

– To complement the existing compendia

– Bring focus specifically to approaches for

populations requiring LTSS

» Perform a community-based scan of cross-sector

efforts to improve care across settings and over time

for individuals requiring LTSS

– Understand not only who is developing innovative

models, but who is actually trying to serve

individuals in a better way2011-04-11 57

Next Steps

» Engage and Build

– Engage members of LTQA in identifying

practices/models for QI/BP scan

– Engage national stakeholders in indentifying

practices/models for the scan

» Analyze

– Identify practice areas with strong evidence and/or

relevance to LTQA population

– Identify areas where innovation and further

research is needed

2011-04-11 58

Next Steps

2011-04-11 59

» Disseminate and Apply

– Craft results of scan into user-friendly

resource

– Disseminate through LTQA membership,

innovative communities, and communities

identified in national scan

– Use as foundation for LTQA Innovative

Communities Learning Community

Deliverables

» Principles

» Targeted Scan

» Analysis of areas for development

» Disseminate

» Apply to build a foundation for Innovative

Communities

2011-04-11 60

How You Can Help

» Consider using the LTQA Statement of

Principles when describing priorities

– Provide Feedback to LTQA

» Contribute to targeted scan

– Models of care

– Communities collaborating across settings

and sectors

– Participate, provide feedback to LTQA

2011-04-11 61

Outreach/Public Awareness

Goal. Achieve engagement and

“buy in” for policies and

mechanisms that advance effective

person- and family-centered

transitional care and contribute to

improved health related quality of

life, and reductions in potentially

avoidable hospitalizations, re-

hospitalizations and total health

care costs.

2011-04-11 62

Members

» Larry Minnix, Co-Chair

– LeadingAge

» Heather Altman, Co-Chair

– Carol Woods Retirement

Community

» Rachelle Bernstecker

– American Seniors Housing

Association

» Maribeth Bersani

– Assisted Living Federation

of American

» Janet Firshein

– Burness Communications

» Nadine Grosso

– Maine Health Care

Association

» Joanne Hardy

– Aging Services of

California

» Martha Hayward

– Partnership for Healthcare

Excellence

» Gail Kass

– NewCourtland

63

Members

» Randy Linder

– National Association of

Long Term Care

Administrator Boards

» Sandy Markwood

– National Association for

Area Agencies on Aging

» Mary Naylor

– University of Pennsylvania

» Tricia Nueman

– Kaiser Family Foundation

» Carol Raphael

– Visiting Nurse Service of

New York

» Carol Regan

– PHI

» Jeanette Takamura

– Columbia University

» Leonila Vega

– Direct Care Alliance

64

Progress to Date

» Burness Communications developed blueprint

for LTQA communication plan in collaboration

with suggestions from the workgroup

» Workgroup members overseeing LTQAs staff in

implementing plan

» Promoting members for participation in major

policy making groups

» Created opportunities to spread the word (e.g.,

“Innovative Communities” Summit and report,

enhance LTQA website)2011-04-11 65

Next Steps

Internal messaging

– Develop communications toolkit (e.g., fact

sheets, case studies) to promote

understanding of LTQAs mission among

members

– Initiative inventory of members’ affiliations

to facilitate partnerships between LTQA and

other LTSS initiatives

2011-04-11 66

Next Steps

» External messaging

– Identify key external stakeholders

– Initiate outreach activities (e.g.,

webinars)

• To inform key consumer groups,

providers and policy makers about

strategic issues

• To suggest solutions

2011-04-11 67

2011-02-25 68

LTQA Dissemination Work Plan

(January-June 2011)

Communication Priorities Strategies / Activities Timeline (Lead)

Cultivate Media Relationships

External Audience Outreach

Create Communications Toolkit

Refine Message Platform

TBD, for discussion with

Executive Committee and

Burness Communications

1/1/2011 – 3/1/2011

(Burness)

Enhance LTQA website domain Disseminate “news”

Best Practices exemplars:

Call for narratives to

Alliance members

Internal Audience

Outreach: generate

automatic updates to

membership when new

News is posted to site

Video Blog

Ongoing (S. Naylor)

January 2011

January 2011

Interviews to begin

late January 2011

2011-02-25 69

Quarterly e-newsletters Alliance news: synopsis of

Workgroup activity, profile a

couple of board

members/member

organizations; events

April 2011, 1st issue

Leverage use of established

Social Networks

Twitter

Facebook (determine if this

is an additional outlet that is

needed)

December 2010

April 2011

Special Events Annual Meeting

Workgroup Initiatives:

o Innovative Communities

Other Major Events (e.g.,

panel or presentations at

national meetings)

Ongoing (individualized

event plans to be

developed)

Communication Priorities Strategies / Activities Timeline (Lead)

Deliverables

» Communication toolkit

» LTQA will be recognized as forum for

generating dialogue, problem solving and

innovative ideas among major stakeholders

involved in solving challenges re: transitions of

this vulnerable population

» LTQA will inform delivery system innovation

and implementation

2011-04-11 70

How You Can Help

» Become and be active members,

partners, and collaborators

» Disseminate the “Innovative

Communities” Report

» Use the communications toolkit

» Provide your reactions

» Help use all of your communication

channels2011-04-11 71

Role of LTQA

» Repository of information

» Common language

» Catalyze Innovative Communities

» Fund Innovative Communities development

» Public education campaign

» Educate policy-makers

» Advocate for policy change that support

consumers

» Identify and address barriers to success

2011-04-11 73

Doug Pace

Executive Director

2519 Connecticut Ave NW

Washington, DC 20008

dpace@ltqa.orf

202-508-9454

www.ltqa.org