Partnership for patients reducing readmissions and hospital acquired conditions
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Partnership for Patients: Reducing Readmissions and Hospital Acquired Conditions . Dennis Wagner & Paul McGann, MD Co-Directors, Partnership for Patients US Department of Health & Human Services and Centers for Medicare & Medicaid Services AHRQ Annual Conference September 10, 2012.

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Partnership for patients reducing readmissions and hospital acquired conditions

Partnership for Patients: Reducing Readmissions and Hospital Acquired Conditions

Dennis Wagner & Paul McGann, MD

Co-Directors, Partnership for Patients

US Department of Health & Human Services

and Centers for Medicare & Medicaid Services

AHRQ Annual Conference

September 10, 2012

Questions to run on

Questions to Run On

  • Why is the Partnership for Patients Different and How will it Make a Difference?

  • How can you benefit from the Partnership?

  • What actions and contributions might you, your organization, AHRQ’s network make?

  • What are your insights and advice about how CMS and AHRQ can be most helpful in achieving these bold aims?

    …we want your answers too

Breakthrough aims of the partnership for patients

Breakthrough Aims of the Partnership for Patients

40% Reduction in Preventable Hospital Acquired Conditions

  • 1.8 Million Fewer Injuries

  • 60,000 Lives Saved

    20% Reduction in 30-Day Readmissions

  • 1.6 Million Patients Recover Without Readmission

    Up to $35 Billion Dollars Saved

3 partnership for patients engines to generate better health better care at lower cost

3 Partnership for Patients Engines to Generate Better Health & Better Care at Lower Cost

  • CMS Innovation Center Investments, up to $1 billion

    • Technical Assistance to Hospitals (Hospital Engagement Networks)

    • Community Based Care Transitions Program

  • Programs and platforms of the Department of Health & Human Services – AHRQ, CDC, ACL, HRSA, CMS, ONC, OASH, IHS – VA and DoD

  • Programs and platforms of Partners: AMA, ABMS, AFL-CIO, AHA, NAPH, ANA, N4A, many more

If we always do what we ve always done we ll always get what we ve always got

If we always do what we’ve always done, we’ll always get what we’ve always got.

Partnership for Patients is About All of Us Doing Things Differently

We have unprecedented Federal action and coordination.

We have an unprecedented CMMI Investment in taking proven practices to scale.

We are calling for continued unprecedented action and alignment by CBOs, hospitals, clinicians, private partners and others.

26 hospital engagement networks hens achieving results through 3 700 hospitals

26 Hospital Engagement Networks (HENs)Achieving Results through 3,700+ Hospitals

American Hospital Association

Premier Healthcare Alliance


NC Hospital Assoc

Intermountain HealthCare

GA Hospital Assoc

TX Hospital Assoc

MN Hospital Assoc

Healthcare Assoc of NY State

IA Healthcare Collaborative

PA Hospital Assoc

WA Hospital Assoc

DFWHC Foundation

OH Hospital Assoc

NJ Hospital Assoc

Ascension Health

TN Hospital Assoc

MI Health & Hospital Assoc

National Public Hospital & Health Institute

LifePoint Hospitals, Inc

Joint Commission Resources

OCHSPS National Children’s Network

Dignity Healthcare

NV Hospital Assoc

Carolinas Health Care


Joint commission resources reduces heart failure readmissions 3 hospital system pilot

Joint Commission Resources Reduces Heart Failure Readmissions: 3-Hospital System Pilot

Hosp A Hosp B Hosp C System

Baseline, Prior Year:

Oct. 2009 – May 2010

NO intervention

Oct. 2010 – May 2011


Oct. 2010 – May 2011

Readmissions/total cases

Prior to Intervention: 159/515

Post Without Intervention :165/558

Post With Intervention: 36/184

Aha hret hen first focus results early elective delivery eed

AHA/HRET HEN First Focus Results: Early Elective Delivery (EED)

Aha hret eed reduction initiatives

AHA/HRET EED Reduction Initiatives

  • In May 2012, the AHA Board of Trustees approved the position of supporting policies to eliminate early-term non medically necessary deliveries.

  • Physician engagement

  • Patient education

  • March of Dimes toolkit implementation

  • Implementation of hard stop policies.

  • Hospitals submitted Early Elective Delivery baseline and monitoring data to the HRET Comprehensive Data System.

Aha hret reducing eed state activities

AHA/HRET Reducing EED:State Activities


  • Partnered with the Oklahoma State Department of Health-Maternal Services, University of Oklahoma Health Sciences Center Office of Perinatal Quality Improvement, Oklahoma March of Dimes, and the Oklahoma Health Care Authority to implement an approach to institute scheduling process changes in birthing hospitals for scheduled cesareans and inductions, asking OB providers to distribute March of Dimes patient education materials and broadcasting a public service announcement on the risks of scheduling a baby’s birth before 39 weeks gestation.


  • Worked with the Florida Perinatal Quality Collaborative (FPQC) and the Lawton and Rhea Chiles Center for Healthy Mothers and Babies at the University of South Florida. Hosted an EED kick-off webinar in July that provided the MoD toolkit, tips for engaging a hospital team, and resources available from the FPQC and FHA. FHA is promoting data submission to the HRET CDS, one-on-one coaching with OB hospitals, and development of OB/EED grand rounds.


  • LHA partnered with the Louisiana Department of Health and Hospitals (LDHH) in a comprehensive birth outcomes initiative. Every birthing hospital, in 2011, pledged to adopt a comprehensive 39-week gestation delivery prohibition policy by the end of 2012. Partnered with the IHI Perinatal Collaborative efforts in which 22 hospital are enrolled and actively participating in the second phase of the collaborative.

The community based care transitions program cctp aca section 3026

The Community-Based Care Transitions Program (CCTP, ACA Section 3026)


Improve transitions of beneficiaries from the inpatient hospital setting to home or other care settings

Improve quality of care

Reduce readmissions for high risk beneficiaries

Document measureable savings to the Medicare program

For more information, visit:

2010 readmission rates by payer

2010 Readmission Rates by Payer

The community based care transitions program cctp aca section 30261

The Community-Based Care Transitions Program (CCTP, ACA Section 3026)

Now 47 Sites: CBOs with 200+ hospitals serving 185,500 beneficiaries in 21 states

Quality improvement organizations qios work and results on partnership for patients

Quality Improvement Organizations (QIOs) Work and Results on Partnership for Patients

  • 202 Communities Recruited

  • 179 Community Coalition Charters Signed

  • 89 Communities Submitting Applications to Care Transitions Funded Programs

  • 32 Communities Accepted into Funded Care Transitions  Programs

  • Recruited communities across the country include 661 Hospitals, 1584 Skilled Nursing Homes, 532 Home Health Agencies, 118 Dialysis Facilities, and 273 Hospices

Partnership for patients reducing readmissions and hospital acquired conditions

PfP Readmissions Aim: A Network of Networks for Nationwide Results

QIO-Recruited Communities, CCTP Sites, & ADRC Option D Grantees

(as of July 31, 2012)

Partnership for patients reducing readmissions and hospital acquired conditions

CCTP Sites, QIO-Recruited Communities, ADRC Grantees

ZIP Code Level Readmissions per 1000 Medicare Beneficiaries

(January 1, 2011 – December 31, 2011)

30-day Readmissions per 1000 beneficiaries

Cctp and qio care transitions the approach

CCTP and QIO Care Transitions: The Approach

Convene community partners to improve transitions across the continuum of care, including social and HCBS providers, hospitals, pharmacy, nursing homes, home health, primary care, other post-acute care providers

Identify major drivers of readmissions and ideal target population through community-specific Root Cause Analysis

Select interventions best suited to address those drivers and implement for target population identified as at high risk of readmission (in CCTP, with monthly payment for services)

Use PDSA, rapid-cycle measurement for improvement (e.g., run charts), learning collaboratives and change packages to share successful practices, other continuous improvement tools to adjust target population and/or intervention strategy and improve along the way

Partner with multiple payers if possible, to serve more patients and reduce more readmissions

Community based care transitions your qio can help

Community-Based Care Transitions - Your QIO Can Help!

• Community Coalition Formation

• Community-specific Root Cause Analysis

• Intervention Selection and Implementation

• Assist with an Application for a Formal Care Transitions Program

Access a comprehensive Toolkit, Learning Sessions, and locate your QIO care transitions contact at: under “Contact Us”

Readmissions reduction keys to success

Readmissions ReductionKeys to Success

Build on and spread success within and across networks, including CCTP, QIO, HEN, private efforts, and so on

Hospitals team with the larger community

Work closely with QIOs and align with state/local efforts

Target patient-level interventions to highest risk patients

Conduct a thorough Root Cause Analysis (RCA) to determine major readmissions drivers, not just top diagnoses

Make greater patient engagement and enhanced role of family caregivers a core focus

Choose your interventions based RCA findings

Target High-Risk but Measure All-Cause Readmissions

Partnership for patients reducing readmissions and hospital acquired conditions

Federal Partners and Programs Are Aligned & Generating Results on Partnership for Patients

Ahrq alignment and action on partnership aims

AHRQ Alignment and Action on Partnership Aims

  • Led team that established the “Science Base” for PFP and developed national goals for reducing HACs and readmissions.

  • Worked with other agencies to establish methods and national baselines for the measured 2010 rates for HACs and readmissions that will be tracked through 2013.

  • Currently providing healthcare organizations with opportunities to implement proven tools and programs (e.g., CUSP for CLABSI, TeamSTEPPS® in partnership with DoD) and to join new projects (e.g., CUSP for CAUTI, for Safe Surgery and for Perinatal Safety).

  • A source for no-cost, stand-alone toolkits and guides, Webinars on available resources and implementation research findings, and related patient safety and quality improvement expertise.

Ahrq cusp for clabsi project central line associated bloodstream infections reduced in adult icus

AHRQ “CUSP for CLABSI” Project: Central Line-Associated Bloodstream Infections Reduced in Adult ICUs

* CLABSI rate calculated as sum of infections divided by sum of line-days for all reporting ICUs

40% Reduction (1.91 CLABSIs per 1,000 line-days

to 1.13)


Data are for six cohorts that started collecting baseline data from May 2008 to April 2009. Q1 varies from May-Jul 2009 to Apr-Jun 2010. Q1 to Q4 covers all six cohorts; Q5 to Q8 covers three to five cohorts.

Data are from 44 States, DC and PR; with a total of 1142 participating ICUs.

We estimate that 27 percent of hospitals with an adult ICU in the nation are participating in CUSP for CLABSI. See:

The project is led by HRET, Johns Hopkins’ Armstrong Institute, and Michigan’s Keystone Center.

Ahrq cms collaboration on pfp national results scorecard

AHRQ-CMS Collaboration on PfP National Results Scorecard

Pfp measured hacs 2010

PFP-Measured HACs (2010)

Pfp measured hacs 20101

PFP-Measured HACs (2010)

Adverse drug events measured in the pfp hacs

Adverse Drug Events Measured in the PFP HACs

  • The 1.621M and 34 percent of HACs measured in the PFP 2010 totals are as follows:

    • ADE Associated with Digoxin (12,000)

    • ADE Associated with Insulin and Hypoglycemic Agents (930,000)

    • ADE Associated with IV Heparin (170,000)

    • ADE Associated with LMW Heparin and Factor Xa Inhibitor (340,000)

    • ADE Associated with Warfarin (170,000)

  • These ADE HACs are 57 percent hypoglycemic agents, 42 percent anticoagulants, and 1 percent Digoxin.

    • The most important missing ADE-type is probably opiate-related ADEs.

  • Not counted in the ADE category, but related to ADEs and counted in the “all-other” HACs category:

    • Contrast Nephropathy Associated with Catheter Angiography (230,000)

    • C. difficile Infection after Inpatient Antibiotics (87,000)

Counting the 40 of preventable 44 of hacs nationwide goals for 2013

Counting the “40% of Preventable (44% of) HACs” Nationwide Goals for 2013

Health resources and services administration hrsa

Health Resources and Services Administration (HRSA)

  • HRSA’s Patient Safety & Clinical Pharmacy Collaborative (PSPC) and CMS’s QIOs partnered to have teams in all 50 states working on preventing medication errors and facilitating care transitions

  • Outreach to small rural hospitals for their participation in PfP, with over 900 CAHs now engaged by the HENs.

  • Providing leadership to the Rural Affinity group with 20 of the HENs participating.

  • Convened representatives of rural hospitals and PfP HENs in a special 2-day working event for the HEN Rural Affinity Group.

Partnership for patients reducing readmissions and hospital acquired conditions

ADRC Evidence Based Care Transition Program

  • ADRCs are implementing a variety of evidence based models:

    • Care Transitions Intervention®

    • Transitional Care Model

    • Project BOOST

    • Bridge

    • GRACE

    • Guided Care®

  • Current Status:

  • 93 ADRCs are partnering with 242 hospitals in 27states

  • 30 ADRCs are partnering with QIO’s

  • 74 ADRCs supported the transition of 10,314 consumers

Source: ACL Semi Annual Report Data October 2010- March 2012

Partnership for patients reducing readmissions and hospital acquired conditions

Success Story: Pennsylvania

  • Partnership between Delaware County ADRC and Crozer Keystone Health System

  • Mary Naylor Transitional Care Model

    • Partnership designed a team based approach: Hospital provides Nurse Assessor, ADRC provides Options Counselor

    • Original 2 year goal was to serve 235 participants

      • Served 355 participants within 13 months

  • ADRC Care Transition Program Readmission Rate = 7%*

    • 47% reduction from baseline

  • ACL investment of $400,000 yielded $3 Million in Savings*

  • State provided special funding to purchase supplies, equipment, and services for participants not covered by existing programs

    • Examples: Talking scale for a consumer with a visual impairment and CHF to monitor weight; Air Conditioner; Stair Rides

    • ADRC CT data was cited in successful CCTP application

*Data provided by Crozer Keystone Health System

Acl work on aca care transitions

ACL Work on ACA Care Transitions

  • AoA (now ACL) National and Regional Leadership Engagement

  • Technical assistance to Aging Network on evidence-based care transitions interventions.

    • 12 webinars on practical implications for the Aging Network; 10,000+ Attended / 100,000+ Downloaded

    • Care Transitions Online Toolkit

  • CMS Community Based Care Transition Program (Section 3026/CCTP)

    • 47 CCTP sites

      • 86% lead CBO is in the Aging Network

      • 92% have at least one Aging Network Partner

Care transitions resource development

Care Transitions Resource Development

  • Resource Development

    • Care Transitions Toolkit (41,000+ downloads from the AoA website)

    • ACL 2010 Evidence Based Care Transitions Program Webpage

    • ACL Affordable Care Act: Opportunities for the Aging Network Webpage

    • ADRC Care Transition Technical Assistance Exchange Webpage

Other examples of federal alignment on partnership aims

Other Examples of Federal Alignment on Partnership Aims

  • National Quality Strategy

  • Assistant Secretary for Health – Office of Healthcare Quality

    • HAI Action Plan, State-Based Partner Meeting, Data Summit, Partnering to Heal Computer-based Simulation, Do the WAVE Consumer Campaign

  • Centers for Medicare and Medicaid Services

    • Medicare and Medicaid EHR Incentive Programs (with ONC)

    • ACA Sec. 3008 - Payment Adjustment for Hospital Acquired Conditions

    • ACA Sec. 3025 - Hospital Readmissions Reduction Program

    • QIO work to reduce readmissions, ADEs, HAIs

    • Medicare Hospital Inpatient Value-Based Purchasing Program

    • CMS Innovation Center Models, including ACOs and Bundled Payment

Other examples of federal alignment on partnership aims1

Other Examples of Federal Alignment on Partnership Aims

  • Centers for Disease Control and Prevention

    • NHSN Measurement System, State HAI Coordinators, Healthcare Infection Control Practices Advisory Committee

  • Department of Defense

    • TeamSTEPPS, Patient Safety Research Center

  • Office of the National Coordinator for HIT

    • Beacon Communities, Improving Care Transitions Through HIT Meaningful Use, Innovator Challenges

Partners are contributing to pfp in major ways

Partners Are Contributing to PfPin Major Ways

  • “Buying Value” initiative to align purchasing with PfP Aims by large employers, unions, NBGH and many others.

  • Johnson & Johnson incentives to employees discharged from hospitals who call for guidance on health care follow up.

  • Joint Commission is educating surveyors through a video and at the annual training course on the goals of the PfP

  • NAPH push to get public hospitals teaming with CBOs on Care Transitions to reduce 30 day readmissions.

  • AHA has launched a Readmissions Race across 1600 hospitals within 31 states to achieve significant reductions in 30 day readmissions by 12/31/2012.

How can you benefit

How Can You Benefit?

Be a part of the largest public or private sector investment in patient safety & readmissions reduction

Access to real-time data and cutting-edge discoveries from hospitals and communities participating in the work of improvement

Opportunity to see your research used in real-time to influence community –based care and/or drive patient and family engagement

Become an important coordinator of care beyond hospital walls by establishing new cross-setting collaborations

Ease the burden of HACs and re-hospitalization on patients and the community

Build “communities of scale” by tapping into efforts already going on right in your backyard

Other ways?

How can you benefit1

How Can You Benefit?

Take 1 Minute

Talk to Your Neighbor

What are your answers?

Partnership for patients reducing readmissions and hospital acquired conditions

How Can You Contribute?

  • Make sure your hospital or other care setting is a part of this

    important initiative

  • Connect with leaders in your hospital to be part of improvement work

  • Make HACs and readmissions your area of focus

  • Connect with the Partnership’s Network of Networks, starting with

    efforts already going on in your own backyard

  • Show us what works. We want to spread your proven practices!

  • What HIT tools better enable good patient safety and care transitions?

  • What gaps are there, and how can you help to fill them?

Partnership for patients reducing readmissions and hospital acquired conditions

How Can You Contribute?

Make a note….30 Seconds

What is your answer

to this question?

How can cms and ahrq help

How Can CMS and AHRQ Help?

  • Work aggressively to bring proven practices to scale

  • Help to facilitate the connections among Partnership networks and results-getters

  • We want to broadcast your successes and results!

    • Have you submitted your QualityNet abstract?

    • Are you our next webinar keynote?

  • What more can CMS and AHRQ do to team with you and your networks and link you to other partners in the Partnership for Patients?

  • Other ways?

Partnership for patients reducing readmissions and hospital acquired conditions

Sharing Insight, Possibility and Action

AHRQ Annual Meeting

My biggest insight about how my organization can benefit from the Partnership for Patients initiative is: ___________________________________


The possibilities I see for our organization to act on or contribute to the Partnership for Patients are:




My main advice to CMS and AHRQ about how they can be most helpful in achieving the bold aims of the Partnership:_____________________________


Name, Organization, Email:_______________________________________

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