National Initiative, Local Implementation—Improving Care Transitions

Health Services Advisory Group of California, Inc.–1–

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National Initiative, Local Implementation—

Improving Care Transitions

Mary Fermazin, MD, MPA &

Jennifer Wieckowski, MSG

Health Services Advisory Group of California, Inc.

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What We Will Cover Today

Present on current Centers for Medicare & Medicaid Services (CMS) national initiatives and local implementation efforts. Discuss the importance of coordinated care

transitions to reduce hospital readmissions. Introduce the Community-based Care

Transitions Program (CCTP) funding opportunity.

(c) Eric A. Coleman, MD, MPH

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National Initiatives

National Initiative, Local Implementation—Improving Care Transitions

Health Services Advisory Group of California, Inc.–2–

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Better Health forthe Population

Better Carefor Individuals

Lower CostThrough 

Improvement

National Strategy for Quality Improvement in Health Care (National

Quality Strategy) “Three-Part Aim”

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“Three-Part Aim”

National Quality StrategyNational Quality StrategyBetter Care:

• Reduce harm caused by care.

• Increase patient engagement.

• Improve communication and coordination of care.

Healthy People and Communities:

• Promote prevention and treatment of leading causes of mortality, starting with cardiovascular disease.

Affordable Care:

• Make quality care more affordable by developing and spreading new health care delivery models.

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National Partnership for Patients

•• by 20 20

Reduce healthcare-associated

infections by 40%

••

Reduce avoidable

readmissions by 20%

by2013

National Initiative, Local Implementation—Improving Care Transitions

Health Services Advisory Group of California, Inc.–3–

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Health Care ReformAccountable Care Act Initiatives

Hospital Reducing Readmission Program

Medicare Shared Savings Program – Accountable Care Organizations

National Pilot on Payment Bundling

Hospital Value-Based Purchasing Program

CCTP

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Local Implementation of National Initiatives:

The Quality Improvement Organizations’ New Work

August 1, 2011, to July 31, 2014

Bold improvement goals

Transformation at the systems level

Patient-centered approach

All improvers welcome

“All teach, all learn”

The Quality Improvement Organization Program Has Evolved

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National Initiative, Local Implementation—Improving Care Transitions

Health Services Advisory Group of California, Inc.–4–

When you work with the Quality Improvement Organization, you are: Tapping into the largest federal network dedicated

to improving health quality at the community level.

Focusing on three critical aims to make care better for everyone.– Better patient care

– Better population health

– Lower health care costs through improvement

Driving Improvement

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National Quality Strategy– Safer care

– Coordinated care

– Person- and family-centered care

– Preventive care

– Community health

– More affordable care

CMS Aligns With National Priorities

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Partnership for Patients– Quality Improvement Organization initiatives can

support and advance your commitment.

– Areas of focus include:• Adverse drug events.

• Catheter-associated urinary tract infections (CAUTIs).

• Central-line associated bloodstream infections (CLABSIs).

• Patient and family engagement.

CMS Aligns With National Priorities (cont’d)

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National Initiative, Local Implementation—Improving Care Transitions

Health Services Advisory Group of California, Inc.–5–

Partnership for Patients

Hospital Engagement Contractors

Regional Extension Centers

Institute for Healthcare

Improvement

Aligning Forces for

Quality

National Priorities

Partnership

Quality Improvement Organizations

Improvement Synergies

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Make Care Beneficiary- and Family-Centered.

Improve Individual Patient Care.

Integrate Care for Populations.

Improve Health for Populations and Communities.

Four Program Aims

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Empower beneficiaries and families to be more engaged in health care decision making.

Contribute to safer, more effective care as a result of quality improvement work with local health care providers.

Provide a streamlined process for making and reviewing quality-of-care complaints.

Beneficiary- and Family-Centered Care

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Reduce Healthcare-Associated Infections (HAIs).– Hospitals: CLABSIs, CAUTIs, Clostridium

difficile (C. diff), Surgical Site Infections (SSIs)

Reduce Healthcare-Acquired Conditions (HACs) by 40 percent.– Nursing homes: pressure ulcers, physical

restraints, CAUTIs, falls

Improve Individual Patient Care

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Reduce Adverse Drug Events.– Communities/outpatient providers: better care

coordination for patients taking multiple medications

Assist with Quality Reporting – Hospitals: CMS inpatient and outpatient

measures

Improve Individual Patient Care (cont’d)

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CLABSIs: Comprehensive Unit-based Safety Program (CUSP) methodology

Adverse Drug Events: HRSA Patient Safety and Clinical Pharmacy Services Collaborative (PSPC)

Proven Interventions for Improving Care

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National Initiative, Local Implementation—Improving Care Transitions

Health Services Advisory Group of California, Inc.–7–

Work with physician practices to:– Use electronic health records (EHRs) to coordinate

preventive services, increase utilization rates, and report data to CMS’ Physician Quality Reporting System.

• Screening mammography, colorectal screening, influenza, and pneumonia immunizations

– Reduce cardiac risk factors.• Hypertension, cholesterol control, smoking cessation,

and aspirin therapy

– Integrate health IT into clinical practice.• Coordination with RECs and Beacon communities

Improve Health for Populations

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Work with communities to:– Form effective care-transition coalitions.

– Reduce avoidable hospital readmissions.

– Build capacity to qualify for funding through Section 3026 of the Affordable Care Act.

– Conduct Learning and Action Networks (LANs) to reduce statewide readmissions.

Integrate Care for Populations

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Three Drivers of Change

Technical Assistance

LANs

Care Reinvention through Information and Innovation Spread (CRISP) Model

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Limited and focused. Examples: – Assist providers having difficulty interpreting

data extracted from their EHR to monitor immunizations.

– Help critical access hospitals enter data for the Hospital Inpatient Quality Reporting Program.

Technical Assistance

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Moving Toward Different Models

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Providers and other health care stakeholders, including beneficiaries, work together to implement change and spread best practices through peer-to-peer learning and solution sharing.– Improvement collaboratives

– Online interaction, tools, resources

– Educational opportunities

LANs

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National Initiative, Local Implementation—Improving Care Transitions

Health Services Advisory Group of California, Inc.–9–

Provides a strategic communication/social marketing foundation for building will to improve, engage, and sustain participation in initiatives.

Informs all segments of Quality Improvement Organization work.

CRISP Model

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Identify and engage multiple stakeholders to impact improvement for patients and providers.

Emphasize understanding stakeholder needs, barriers, and motivators.

Collaborate, create synergy, and reduce duplication of effort.

Commitment to “Boundarilessness”

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Reach out to and involve stakeholders:State and local health departments

Health plans

Federally qualified health centers (FQHCs)

Provider organizations

Major purchasers: Medicaid, commercial insurers, large employers

Beneficiary advocacy organizations

Others

Commitment to “Boundarilessness” (cont’d)

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It takes a community to solve this problem!

LANs are open to all with a vested interest in resolving the readmission problem in their community:– Hospitals, nursing homes, home health agencies,

area agencies on aging, community-based organizations, clinics, dialysis facilities, etc.

– C-Suite, quality improvement directors, nurses, discharge planners, case managers, social workers, etc.

Join California’s Care TransitionLearning and Action Network

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Join California’s Care TransitionLearning and Action Network (cont’d)

At least two project leaders from each hospital community will attend each session consistently!

It’s time to share!

Use resident- and family-engaged story telling.

Identify best practices and spread as widely as possible (Plan, Do, Study, Act).

High performers/mentors will assist their peers.

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Issues with Care Transitions

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20 Percent Are Readmitted Within 30 Days 90 Percent of Readmissions Are Unplanned

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Care Coordination

A function that helps ensure that the patient’s needs and preferences for health services and information sharing across people, functions, and sites are met over time.

—National Quality Forum

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Hospice

Hospital

HomeAmbulatory Care Clinic

Skilled Nursing Facility

SNF

Rehabilitation Facility

Hospice

Care Transitions

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Definition of “Transitions of Care”

The movement of patientsfrom one health care practitioner or setting to another as their condition and care needs change

(c) Eric A. Coleman, MD, MPH

Occurs at multiple levels– Within settings– Between settings– Across health states

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Group Activity

In your opinion, what are the current problems with care transitions and causes

of high readmissions?

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Where Are We Now?Where Are We Now?

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The Evolving Health Care System

Aging population

Increase in the incidence and prevalence of chronic conditions

Increasing focus on value and efficiency

Yet today’s health systems remain overly devoted to dealing with acute, episodic care, with little focus on continuity or transitions of care.

38© Eric A. Coleman, MD, MPH

Our healthcare system operates in “silos,” is setting centered―notpatient centered―and is incapable of reciprocal operation between organizations.

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Silos in Our Health Care System

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No Provider Takes Responsibility

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Affordable Care Act and

Improving Care Transitions

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The CCTP

Section 3026 of the Affordable Care Act

Provides funding to test models for improving care transitions and reducing avoidable readmissions for high-risk, fee-for-service (FFS) Medicare beneficiaries

$500 million available—applications are being accepted on a rolling basis

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Eligible Grant Applicants

Hospitals with high readmission rates in partnership with an eligible community-based organization (CBO).

CBOs that provide care transition services, in partnership with multiple hospitals (may not have high readmission rates).

CBOs must have governing bodies that include sufficient representation of multiple health care stakeholders, including consumers.

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Entities That May Be a CBO

Area Agencies on Aging

Aging and Disability Resource Centers

Federally Qualified Health Centers

A coalition representing a collaboration of community health care providers—if a legal entity is formed

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CCTP Grant Preferences

Hospitals whose 30-day readmission rates on at least 2 of the 3 Hospital Compare measures (AMI, HF, PNEU) fall in the 4th quartile

Proposals that provide services to medically underserved populations, small communities, and rural areas

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CCTP Grant Preferences (cont’d)

Proposals that target patients with multiple chronic conditions, depression, cognitive impairments, and a history of multiple admissions

All-payers approach; work closely with Accountable Care Organizations

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Application Requirements

Strategy and implementation plan Includes a community-specific root cause

analysis (RCA)

Organizational structure and capabilities for the applicant and its partners

Previous experience

Budget proposal

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Strategy Describe a comprehensive community-

specific RCA.

Show how the RCA results drove selection of the target population and the interventions.

Identify a clear process for identifying high-risk Medicare FFS beneficiaries to be targeted.

Describe an intervention implementation strategy, including how the intervention will be integrated into the discharge process without duplicating it.

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Previous Experience

Description of previous experience implementing care transitions interventions

Training completed in any of the evidence-based interventions

Description of other efforts to reduce readmissions

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Payment Methodology

CBOs will be paid a per-eligible-discharge rate.

The rate is determined by:– Target population.

– Proposed intervention(s)

– Anticipated patient volume.

– Expected reduction in readmissions (cost savings).

The rate will not support ongoing disease management or chronic care management, which generally require a per member per month fee.

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Budget Guidance

CBOs will not be paid for discharge planning services already required.

This is not a grant program.

CBOs may only include the direct-service costs for the provision of care transition services to high-risk Medicare beneficiaries.

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National Coordinating Center (NCC) http://www.cfmc.org/caretransitions/toolkit.htm

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Common Application Errors

The applicant CBO does not meet the eligibility requirements to be a CBO, or the documentation of CBO status is unclear.

There is lack of a community-specific RCA.

The RCA is present, but the methodology for targeting high-risk beneficiaries and the selected interventions proposed are not tied back to the community-specific RCA.

Budget errors.

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Group Activity

How would you go about conducting an RCA to identify why

your hospital has a high readmission rate?

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Community-Specific RCA Methods

Medical record reviews: review randomly sampled hospital discharges and 30-day readmissions.

Process assessment: directly observe discharge and admission processes, interview process owners, and map the processes.

Conduct group discussion and individual interviews with providers and patients.

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Using RCA to Drive Intervention Selection—Good Example

RCA Technique: Process Mapping

Hospital Discharge

Key Findings: No standard process,

discharge is chaotic, varies based on staff

Intervention Selection: Project

RED

Intervention improves hospital discharge process

Intervention directly addresses root cause

identified

National Initiative, Local Implementation—Improving Care Transitions

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Using RCA to Drive Intervention Selection—Poor Example

RCA Technique: Process Mapping

Hospital Discharge

Key Findings: No standard process,

discharge is chaotic, varies based on staff

Intervention Selection: CTI

Intervention improves patient

activation and engagement

Intervention does not address root cause

identified

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Using RCA to Drive Intervention Selection—Good Example

RCA Technique: Patient interview for all patients during one month who are currently in hospital for 30-day readmission

Key Findings: (1) Patients did not understand/did not correctly take

medications, and (2) Patient condition worsened; unsure of

what to do, patients called 911 or came to ED

Intervention Selection: CTI

Intervention improves patient activation and engagement—addresses 4 pillars (PHR, red

flags, medication management, and follow-up)

Intervention directly addresses root cause

identified

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Getting StartedPatient Centric, Community Based Approach

Establish relationships with the community of providers who care for patients in your area.

Recruit and convene relevant partners.

Conduct an RCA of the causes of readmissions or adverse events surrounding hospital discharge.

Choose evidence-based care transition interventions to address these causes.

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Common Elements of Effective Care Transitions

“Rocket science is helpful, but not required.”

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Common Elements of Effective Care Transitions (cont’d)

Standardized processes to ensure that critical information (standardized elements) is communicated timely

Patient/caregiver engagement/education

Early recognition of warning signs and early intervention

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However, none of these will work,

unless . . .

. . . an important element is present.

What is it?

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HUDSON RIVER PLANE LANDINGJanuary 15, 2009

SHARED Accountability

P r o v i d e d b y N a n c y S k i n n e r

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Shared Accountability (cont’d)

Transition is a period of shared accountability:– The sending provider has to ensure that key

information has been appropriately received and acknowledged by the receiving provider.

– The receiving provider has to understand and execute a care plan based on the key information received.

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Patient Outcome

Collaboration Coordination

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Thank You!

Mary Fermazin, MD, MPAChief Medical Officer, HSAG-California

Jennifer Wieckowski, MSGProgram Director, Care Transitions, HSAG-California

700 North Brand Blvd., Suite 370

Glendale, CA 91203

818-265-4650

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www.hsag.comThis material was prepared by Health Services Advisory Group of California, Inc., the Medicare Quality

Improvement Organization for California, 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. Publication No. CA-10SOW-8.0-091511-01

We convene providers, practitioners, and patients to build and share knowledge, spread best practices, and achieve rapid, wide-scale

improvements in patient care, increases in population health, and decreases in health care

costs for all Americans.