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Care Transitions : Are You in the Game?. Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012. Welcome . What we’ll cover today: Introduction of Care Transitions Program The Role of HCA in the Community

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Care transitions are you in the game l.jpg

Care Transitions : Are You in the Game?

Naomi Hauser RN, MPA

Director Care Transitions

Quality Insights of Pennsylvania

May 16, 2012

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  • What we’ll cover today:

    • Introduction of Care Transitions Program

    • The Role of HCA in the Community

    • Discuss Evidence Based Interventions to reduced avoidable readmissions

    • Share Lessons Learned form 3 Year Pilot

    • Open Discussion

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Why Are We Here?

  • To learn about and promote safe/effective transitions of care as patients navigate from one provider setting to another – or one caregiver to another

  • Develop partnerships

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Integrated Care For Populations and Communities


To promote safe/effective transitions of care as patients navigate from one provider setting to another – or one caregiver to another

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30 Day Readmissions: The Problem

  • Nationally – 17.6% of Medicare beneficiaries discharged from the hospital are readmitted within 30 days.

  • More than 85% of these re-hospitalizations are unplanned.

  • 20-40% of re-hospitalizations are possibly preventable.

  • 64% of Medicare beneficiaries who are readmitted within 30 days do not receive any post-discharge care before readmission.

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339 Days in the Life of Mrs. B

  • Day 1 – New internal medicine physician, poorly controlled diabetes with neuropathy, HTN, osteoporosis. To see physician q. 2 wks

  • Day 15 – Sees physician, fully functional, assists with care of grandchild and husband

  • Day 60 – Mrs. B falls on the ice, to ER, no fractures but abrasions. Referred to home health

  • Day 68 – Not feeling well

  • Day 69 – Hospitalized with Staph Septicemia, dehydration, ARF, CHF, A-Fib, PN and uncontrolled diabetes

  • Day 82 – Transferred to SNF for short-term rehab and wound care

  • Day 182 – Discharged to home, depressed, abrasions healed, diabetes under good control

  • Day 183 – Nauseated, can’t find her teeth, dgt intends to call home health

  • Day 184 – Readmitted to the hospital for dehydration, CHF, A-Fib and diabetes

  • Day 191-337 – Admitted to in-pt rehab then to nursing home

  • Day 338 – Readmitted to hospital w/ ARF, CHF, ARF

  • Day 339 – Mrs. B dies

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Timeline for payment penalty for hospitals

  • Beginning October 2012 Medicare will apply penalties and will withhold payment for avoidable 30 day acute care readmissions with a progressively increasing scale for certain DRGs.

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July2008-August 2011

Pilot Project

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14 QIOs with 14 Target Communities

  • AL: Tuscaloosa

  • CO: Northwest Denver

  • FL: Miami

  • GA: Metro Atlanta East

  • IN: Evansville

  • LA: Baton Rouge

  • MI: Greater Lansing area

  • NE: Omaha

  • NJ: Southwestern NJ

  • NY: Upper capital

  • PA: Western PA

  • RI: Providence

  • TX: Harlingen HRR

  • WA: Whatcom county

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Targeted Community

  • Higher than state average re-admission rate

  • Located in southwestern PA, in a community surrounding the southern Pittsburgh metropolitan area

  • Community spans most of Westmoreland County and small portions of Allegheny, Washington, and Fayette counties

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9th SOW Overview

  • CMS

    • 14 states

    • Community cross-setting

    • Transparent

    • Remove silos

  • SWPA

    • 5 hospitals

    • 8 home health agencies

    • 15 nursing homes

    • 2 AAAs

    • 32 interventions

    • 14% relative improvement

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Structure of the Project

  • Cross-setting

  • Community-based

  • Collaborative

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The Shift to…

  • Chronic illness management

  • Self-care management

    • Empowerment

    • Responsibility

    • Accountability

    • Patient activation

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Cross-Setting Goal

  • Develop a practical, cross-setting approach

  • Unite providers from all settings

  • Share vision of improved health care quality

  • Equal voices

  • Identify provider strength

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The Role of Agencies

  • Home Health

  • Hosicpe

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Hospital Elements

  • Leadership buy-in

  • Operational level leadership

  • Education

  • Silos

  • Bureaucracy/slow to change

  • Competitive

  • Non-transparent

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Hospital Interventions

  • Self reported readmission rate

  • Discharge process

  • Discharge instructions

  • End of life options

  • 48-hour follow-up call

  • Schedule follow-up PCP visit


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SNF Elements

  • Education

  • Eager to learn

  • Eager to share

  • Share competence levels

  • Family

  • Physicians

  • Turnover

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SNF Interventions

  • SBAR

  • Communication transfer form

  • Chart reviews

  • End of life options/education


  • Coach CTI

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Home Health Elements

  • Focus on ACH vs. readmissions

  • Medication management

  • Low referral rates

  • Educate on referral criteria

  • Coaching

  • Hands on in home care

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Drivers of Hospital Readmission

  • Same for home care as other health care providers:

    • Patient activation

    • Standard, known processes

    • Transfer of information

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Home Health Compare

  • Top 20% for this measure has maintained an unplanned hospitalization rate of 21% since last quarter

  • While stakeholders are focusing on reducing unnecessary hospitalizations, the data tells us that we still have work to do and…

    • What about those 30-day readmissions?

    • Low-hanging fruit for home care to determine root cause and intervene in real-time—win-win for everyone

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Home Health Compare

  • The latest Home Health Compare (HHC) scores were published on October 13th and reflect a data collection period of July 2010 - June 2011. Overall, the results have improved.

  • Hospitalization result has had a setback

    • Hospitalization worsened from 26% last quarter to 27%

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Intervention HHA

  • Communication transfer sheet

  • Front load visits

  • Telehealth

  • Phone monitoring

  • Life line

  • Chronic care education

  • Coaching/partnering

  • Depression screening

  • Chart reviews

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Best Practices

  • Home Health Quality Improvement National Campaign Best Practice Intervention Packages (BPIPs)

  • Focus on reducing ACH, improving management of oral medications and cross-setting collaboration

    • Simplified approach to use packages

    • Standardized steps to follow for each publication

    • Flexible for HHA implementation

  • BPIPs free to download at:

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BPIPs Include

  • Hospitalization Risk Assessment

  • Emergency Care Planning

  • Medication Management

  • Fall Prevention

  • Care Transitions

  • Coaching

  • Patient Self-Management

  • Disease Management

  • Telehealth

  • Introduction to new ideas/topics: Patient Centered Medical Home; Accountable Care Organizations and others

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Learn more…Coach/HH nurse

  • Coaching and home health service

  • Increase Medicare HH referrals

  • Oasis takes time

  • Coach non-clinical

  • Different role

  • Medication review… patient driven

  • Complementary/respectful

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Lessons Learned

  • Community focus

  • Root cause analysis

  • Communication

  • Transparency

  • Leadership buy-in

  • Collaboration

  • Patient-centered

  • Ongoing monitoring

  • Community outreach

  • Sustainability

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Lessons Learned

  • Re-Engineers the discharge process (Project Red, Project Boost, Medication reconciliation)

  • Change the paradigm of patient education (Teach Back)

  • Improve information transfer (Cross setting transfer form)

  • Increase community outreach (Collaboration with community resources, Handover)

  • Increase post discharge process and support (PHR, Medication management,PCP f/u appointmentand coaching)

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AIMS and Goals

Strategic Aims

“What will be done”

  • Integrate Care for Populations

    • Care Transitions that reduce re-admissions by 20% within 3 years.

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CMS 10th SOW for QIOs

  • Form a community coalition to ensure community-wide adoption of improved practices in care transitions

  • Assist communities in applying for the CMS 3026 CCTP funding opportunity

  • Form a Learning and Action Network (LAN) and provide evidence-based interventions associated with known drivers of hospital readmissions (Jan. 26, 2012)

  • Host quarterly LAN sessions; one in-person each year

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CMS 10th SOW for QIOs

  • Provide the community with a template for coalition charters to help the partners formalize structure and procedures

  • Assist the community with root cause analysis to identify community-specific causes for poor transitions and develop data reports to monitor progress

  • Assist in the selection of the most appropriate evidence-based interventions

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The Importance of Communities to Improve Health Care

Integrating Care for Populations and Communities

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CMS Defines a Community

  • Defined by contiguous zip codes

    • Medicare beneficiaries that live in those zip codes

    • Committed providers and stakeholders

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Community Essentials

  • Developed around collaborative care delivery

    • Shared vision

    • Shared mission

    • Shared resources

    • Shared decision making

    • Environment of trust

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A Community

  • Social network analysis for Medicare beneficiaries in 2009

    • Allows visualization of relationships between providers through network diagrams

    • Shows flow of transitions among providers

    • Senders, receivers, provider type and strength of relationship

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4 Recruited Communities

  • Western Pennsylvania

  • Lehigh Valley

  • York

  • Chester County

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Building Community

  • Leaders reach to other leaders

  • Expand the circle of support

  • Grow more resources

  • Develop/sustain commitment

  • Recruit people

    The more volunteers or members who find purpose in the community -the more they will commit resources that you may never have known existed.

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Community Development

  • CMS suggested communities

  • Hospitals in contiguous Zip Codes

  • Overlap of beneficiaries/penetration

  • Desire to reduce re-admission rates

  • Agree to collaboration/relationship

  • Transparency

  • Downstream Providers

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Provider Responsibilities

  • Leadership commitment

  • Active involvement of provider teams including leadership in meetings, conference calls, webinars and coalition activities

  • Implement improvement strategies using rapid cycle testing

  • Create new strategies that maximize improvement for all participants

  • Track, monitor and share real time data

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Stakeholder Support

  • Are the cornerstone for the community

  • Learn from the community

  • Inform members of CT strategies

  • Support/provide community education sessions

  • Participate in quarterly calls

  • Provide publications via newsletter

  • Post information/links of CT on Web sites

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Intervention Selection

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Standard/Known Process

  • BOOST (Better Outcomes for Older adults through Safe Transitions)

  • TCM (Transitional Care Model)

  • F/U appointment made at discharge

  • Pharmacy

  • Telephone F/U

  • Document standardization

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Drivers of Readmissions

Based on discharges from 2007. Clinical Classification Software (CCS) 2008 downloadable from .

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Lessons Learned

  • Key drivers of 30 day readmission

    • Low patient activation

    • Lack of standard processes

    • Inadequate transfer of information across care settings

  • Key strategies for 30 day readmission reduction

    • Community organization

    • Patient activation

    • Multi-provider process improvement

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End of Life

  • Of discharges of CT residents from the five targeted hospitals that result in a 30-day readmission to any acute care hospital during the last six months of life

    • 35% are discharges to a SNF

    • 33% are discharges to home under the care of a HHA

    • 23% are discharges to home or self-care

    • 28% of all readmissions occur during the last six months of life

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Root Cause Analysis

  • Simply stated RCA is a process designed to help identify not only

    • What and how BUT

    • Why

  • Leads to interventions selection and ongoing identification of gaps in care delivery across settings.

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Intervention Selection

  • Derived from root cause findings

  • Monitor & Measure

    • Process Measures

      • System Components

    • Outcome Measures

      • Effect of change on patient

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Intervention Selection by Driver

  • Patient Activation

  • Standard/Known Process

  • Transfer of Information

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PROJECT RED(ReEngineered Discharge)

  • Evidenced based toolkit.

  • Developed by Boston University Medical Center

  • Addresses key factors identified in RCA

    • Delayed Transfer of Discharge Summary

    • Unknown Test Results

    • Patients Failure to Follow-up

    • Medication Interactions and Adverse Events

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Transfer of Information

  • Communication Re-design

  • HIT

  • SBAR

  • Beneficiary and community outreach

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Patient Activation


  • RED (Re-engineered Discharge)

  • Medication Reconciliation

  • Coaching

  • Teach-Back

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Coming together is a beginning.Keeping together is progress.Working together is success.

~Henry Ford

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The Community–based Care Transitions Program (CCTP)

  • The CCTP, mandated by section 3026 of the Affordable Care Act, provides funding to test models for improving care transitions for high risk Medicare beneficiaries.

  • •Increasing rates of avoidable hospital readmissions will result in negative health outcomes for Medicare beneficiaries impacting their levels of safety and quality of care.

  • •The CCTP seeks to correct these deficiencies by encouraging communities to come together and work together to improve quality, reduce cost, and improve patient experience.

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CCTP: Program Goals

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

  • •Improve quality of care

  • •Reduce readmissions for high risk beneficiaries

  • •Document measureable savings to the Medicare program

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Eligible Applicants

  • Are statutorily defined as: Acute Care Hospitals with high readmission rates in partnership with a community based organization

  • Community-based organizations (CBOs) that provide care transition services

  • •There must be a partnership between the acute care hospitals and the CBO

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CCTP: Definition of CBO

  • Community-based organizations that provide care transition services across the continuum of care through arrangements with subsection (d) hospitals−Whose governing bodies include sufficient representation of multiple health care stakeholders, including consumers

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CCTP: Key Points

  • CBOs will use care transition services to effectively manage transitions and report process and outcome measures on their results.

  • •Applicants will not be compensated for services already required through the discharge planning process under the Social Security Act and stipulated in the CMS Conditions of Participation.

  • •Applicants will be required to participate in ongoing learning collaboratives

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CCTP: Application Guidance

  • Applicants are required to complete a root cause analysis

  • The proposals must specify how the root causes will be addressed

  • The proposal will describe how they will work with accountable care organizations and medical homes if applicable

  • The proposal will describe how they will align their care transition programs

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CCTP: Conclusion

  • The program solicitation was announced in the Federal Register and is now available at:

  • The program will run for 5 years with the possibility of expansion beyond 2015

  • If community progress is not occurring within 2 years of receiving funding, funding will be stopped

  • Please direct CCTP questions to:

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CCTP Website

  • Visit the program website for daily updates on program status at

    Do not forget to note Frequently-Asked Questions

    On the Site

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What Actions Can You Take?

  • Look at your process

  • What do you already have in place?

  • What strength do you bring to the community?

  • Be a good team player

  • How can you collaborate to

    • Improve care delivery across the continuum

    • Reduce errors and avoidable re-admissions

    • Share resources and reduce cost

    • Improve communication and information transfer

    • Improve Care Transitions

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10th Scope of Work: The Opportunity for You….

  • Communities are developing

    • Position yourselves

    • Promote cross setting best practices you have implemented

    • Integrate with upstream and downstream providers

    • Be part of the discussion and strategic planning

    • Let everyone know the role of home care and the services are critical to decreasing the rate of 30-day readmissions

    • Be part of the solution!

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QIO Technical Assistance

  • Learning and Action Networks (LAN) on a state-wide level

  • Webinars provided and recorded

  • Connect to downstream providers

  • Provide current Medicare data to providers

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Resource Sharing

  • Upcoming conferences or meetings

  • E-newsletters

    • Share with us/success stories

    • Or how can we share an article with you?

  • Contact Krista Davis at or


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This material was prepared by Quality Insights of Delaware, the Medicare Quality Improvement Organization for Delaware, 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 number 10SOW-DE-ICP-KD-010612A. App. 1/12.