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A Three Year Retrospective: Reflecting Back as we Evolve Forward. FLHSA 2020 Performance Commission Meeting November 26, 2012. 2020 Performance Commission. 2009 Community Investment Goals: Reduce potentially preventable hospitalizations by 25% by 2014

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a three year retrospective reflecting back as we evolve forward

A Three Year Retrospective:Reflecting Back as we Evolve Forward

FLHSA 2020 Performance Commission Meeting

November 26, 2012


2020 Performance Commission

2009 Community Investment Goals:

Reduce potentially preventable hospitalizations by 25% by 2014

2. Decrease avoidable ED visits by 15% by 2014

3. Create sustainable plan for Central Finger Lakes region hospitals



2020 Performance Commission: Status

  • Preventable Hospitalization and ED VisitDeveloped targeted work groups
  • Discharge planning
  • Embedded care managers
  • Care Transitions Intervention - Coaching
  • Telemedicine
  • Primary care support
  • Parent education



Discharge Planning: Goal

  • Reduce the 30-day Medicare readmission rate through the adoption of four (4) discharge/transition standards
  • Enhance patient safety
  • Ensure the safe transition from hospital to home and thecommunity-based setting



Discharge Planning: Status

  • 10 Regional Hospitals committed to standard discharge components:
  • Patient/family participation
  • Medication reconciliation
  • Information transfer
  • Post discharge follow-up
  • Readmissions from nursing homes
  • Sharing hospital experiences
  • Patients and families included in change of shift
  • Hospitals and home-care agencies using improveddischarge packets specific to diseases
  • Hospital provider-primary care physician call center
  • Rounds with hospitalists and care managers
  • Sharing opportunities
  • Coachestrained through teach-back training fromthe Community Health Foundation



Embedded Care Managers: Goal

  • Incorporate care managers into primary care practicesto reduce hospital readmissions by:
  • Identifying patients at risk of PQI readmissions and ED visits
  • Ensuring patients receive timely follow-up care
  • Medication reconciliation/management
  • Arranging for necessary community services to support thepatient and caregivers
  • Coordination with other providers



Embedded Care Managers: Status

  • Staffing
  • 9 care managers hired and working in selected primary care practices until March 2013
  • 6 Care Managers will remain in the practice after HEAL 19
  • Program evaluation
  • Developed tracking tools
    • Care manager encounter log
    • Hospital admissions andER utilization
    • Risk assessment tool
  • Measuring impact on PQI admissions
  • Insurers’ claims data received
  • Waiting next update



Care Transition Intervention: Goals

  • Engage patients and their families to be full partners in ensuring improved health and decreasing dependence on hospitals/EDs
  • Based on the nationally recognizedCare Transitions Program
  • Shown 20% to 40% lower hospital readmission rates (Medicarebeneficiaries receiving coaching)
  • 2011 Goals
  • 18 active patient-care coaches
  • 5 active hospitals accepting coaches
  • 2,500 people will have received coaching
  • Readmission rates and ED rates of coached patients compared with community
  • Physician follow-up visit within 0-7 daysof discharge


care transitions intervention status
Care Transitions Intervention: Status
  • 21 trained coaches (social workers, nurses, educators)
  • 2 Trainers
  • Over 3300 patients offered CTI from October 2010 – June 2012
  • 5 hospitals actively partnering with home care agencies and accepting coaches on patient floors(Strong, RGH, Unity, Highland, Newark-Wayne with Lifetime Care and VNS)
  • Lifespan awarded $3.2M from the Centers for Medicare and Medicaid Services to expand CTI for Medicare FFS patients

Our region is the nation’s first community-based, multi-payer all beneficiary coaching program to demonstrate an impact on reducing hospital readmissions and ED visits


emergency room goal
Emergency Room: Goal

Reduce avoidable ER visits through:

  • Telemedicine in pediatric practices
  • Primary care support
  • Parent education


emergency room status
Emergency Room: Status


  • Expanded use of pediatric telemedicine in the Rochester city schools (189 more telemed visits in Q4 2010 than in Q4 2009)

Primary care support

  • Utilizing care managers in PCP offices (providing care management support)

Parent education

  • Implemented health-literacy pilot in OB-practice setting to impact ER use in the0-1 age group
  • Distributed 500 health-care books to expectant parents during 3rd trimester (English and Spanish)


2020 pc regional work group goals
2020 PC / Regional Work Group: Goals
  • Sustain and improveaccess to care forresidents in the CentralFinger Lakes region
  • Understand regional hospital challenges
  • Integrate clinical care resources and deliveryin the region


regional work group status
Regional Work Group: Status
  • Work group unanimously voted to move forward with implementation strategies, define next steps
  • Formed Implementation Committee to select, developand implement strategic options
    • Composed of hospital CEOs, chairs, and medical professionals
  • Met with CFL hospital boards and the medical communities of each hospital to discuss work group’s findings and opportunities to work together


partnership with nys
Partnership with NYS

Strong and historic partnership

HEAL 9 and 19 funding

Strengthened by Cuomo Administration

DOH Commissioner Shah visitto Rochester

Fran invited to speak to North Country hospital CEOs in July

Medicaid Redesign Team


partnerships at the federal level
Partnerships at the Federal Level

U.S. Senator Schumer

Dr. Jaime Torres, HHS Region II Director

Dr. Richard Gilfillan, Acting Director, HHS Center for Medicare and Medicaid Innovation



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 • 14607-1647

585.461.3520 • www.FLHSA.org