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Lessons from the Care Transitions Theme. Jane Brock, MD, MSPH Alicia Goroski, MPH.

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lessons from the care transitions theme

Lessons from the Care Transitions Theme

Jane Brock, MD, MSPH

Alicia Goroski, MPH

This material was prepared by CFMC (PM-4010-070 CO 2010), the Medicare Quality Improvement Organization for Colorado, 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.

objectives
Objectives
  • Methods used by QIOs for analyzing root causes of readmissions
  • Drivers of readmission
  • How to plan for success
14 qios with 14 target communities
14 QIOs with 14 Target Communities

Community Names

  • Tuscaloosa AL • Omaha NE
  • NW Denver CO • Southwest NJ
  • Miami FL • Upper Capital Region NY
  • Metro Atlanta East GA • Western PA
  • Evansville IN • Providence RI
  • Baton Rouge LA • Harlingen TX
  • East Lansing MI • Whatcom County WA
results cy 2007 compared to cy 2009
Results*: CY 2007 compared to CY 2009

14 Care Transitions Communities vs. the Nation

*Results were developed to help guide the Care Transitions Theme. These are not formal findings about the success of the QIO Program (individual QIOs or collectively) in relation to QIOs’ obligations under their CMS contracts.

root cause analyses
Root Cause Analyses
  • Medical record review
    • First hospitalization discharge
    • Other services provided
    • Readmission admission
  • Process assessment
    • Direct observation
    • Process owner interviews
  • Group discussion
why do hospitals have unwanted readmissions
Whydo hospitals have unwanted readmissions?

Provider-Patient interface

unmanaged condition worsening, use of suboptimal medication regimens, return to an emergency department

Unreliable system support

Lack of standard and known processes

Unreliable information transfer

Unsupported patient activation during transfers

why do hospitals have unwanted readmissions7
Why do hospitals have unwanted readmissions?

Provider-Patient interface

unmanaged condition worsening, use of suboptimal medication regimens, return to an emergency department

Unreliable system support

Lack of standard and known processes

Unreliable information transfer

Unsupported patient activation during transfers

No Community infrastructure for achieving common goals

why do hospitals have unwanted readmissions8
Why do hospitals have unwanted readmissions?
  • Provider-Patient interface
      • unmanaged condition worsening, use of suboptimal medication regimens, return to an emergency department

Unreliable system support

Lack of standard and known processes

Unreliable information transfer

Unsupported patient activation during transfers

No Community infrastructure for achieving common goals

handing over medical responsibility
Handing Over Medical Responsibility

Real time communication to PCPs SNF needs functional status

<20% at time of discharge High refusal rates

33% unaware of discharge 3-day stay rule

Communication to HHAs Discharge Summaries

No direct conversation 86% in 48 hours

Need signature from PCP 33% prior to follow up visit

cms s table of interventions
CMS’s Table of Interventions

http://www.cfmc.org/caretransitions/files/Care_Transition_Article_Remington_Report_Jan_2010.pdf

building community ness four models of community engagement
Building Community-ness: Four Models of Community Engagement
  • Multi-representative steering committee
  • Aggregate providers vertically in clusters, then merge
  • Aggregate providers by setting then vertically integrate
  • Individual improvement projects, with information and data-broker

Make it visibly a community effort

where a motivated community could start
Where a motivated community could start
  • Figure out who you share patients with
  • Forum for routine exchange/discussion
    • Utilization
    • Quality
  • Routine discussion of readmission cases among all involved providers
    • Multi-institution ‘transitional care’ rounds
  • Review hospice/palliative care providers/utilization/referral processes
where a motivated community could start13
Where a motivated community could start
  • Require routine cross site visits –
    • Include CEOs
  • Map/create handover management processes with your partners
    • Form a ‘receiver’s group’
    • Form receiver’s coalitions
  • Call/visit your AAA to see what they can do for you
  • Value/promote informal social networking
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