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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

Care Transitions : Are You in the Game?

Naomi Hauser RN, MPA

Director Care Transitions

Quality Insights of Pennsylvania

May 16, 2012

  • 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
why are we here
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
integrated care for populations and communities
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

30 day readmissions the problem
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.
339 days in the life of mrs b
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
timeline for payment penalty for hospitals
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.

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
targeted community
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
9th sow overview
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
structure of the project
Structure of the Project
  • Cross-setting
  • Community-based
  • Collaborative
the shift to
The Shift to…
  • Chronic illness management
  • Self-care management
    • Empowerment
    • Responsibility
    • Accountability
    • Patient activation
cross setting goal
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
the role of agencies
The Role of Agencies
  • Home Health
  • Hosicpe
hospital elements
Hospital Elements
  • Leadership buy-in
  • Operational level leadership
  • Education
  • Silos
  • Bureaucracy/slow to change
  • Competitive
  • Non-transparent
hospital interventions
Hospital Interventions
  • Self reported readmission rate
  • Discharge process
  • Discharge instructions
  • End of life options
  • 48-hour follow-up call
  • Schedule follow-up PCP visit
snf elements
SNF Elements
  • Education
  • Eager to learn
  • Eager to share
  • Share competence levels
  • Family
  • Physicians
  • Turnover
snf interventions
SNF Interventions
  • SBAR
  • Communication transfer form
  • Chart reviews
  • End of life options/education
  • Coach CTI
home health elements
Home Health Elements
  • Focus on ACH vs. readmissions
  • Medication management
  • Low referral rates
  • Educate on referral criteria
  • Coaching
  • Hands on in home care
drivers of hospital readmission
Drivers of Hospital Readmission
  • Same for home care as other health care providers:
    • Patient activation
    • Standard, known processes
    • Transfer of information
home health compare
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
home health compare24
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%

intervention hha
Intervention HHA
  • Communication transfer sheet
  • Front load visits
  • Telehealth
  • Phone monitoring
  • Life line
  • Chronic care education
  • Coaching/partnering
  • Depression screening
  • Chart reviews
best practices
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:
bpips include
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
learn more coach hh nurse
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
lessons learned
Lessons Learned
  • Community focus
  • Root cause analysis
  • Communication
  • Transparency
  • Leadership buy-in
  • Collaboration
  • Patient-centered
  • Ongoing monitoring
  • Community outreach
  • Sustainability
lessons learned30
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)
aims and goals
AIMS and Goals

Strategic Aims

“What will be done”

  • Integrate Care for Populations
    • Care Transitions that reduce re-admissions by 20% within 3 years.
cms 10th sow for qios
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
cms 10th sow for qios34
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
the importance of communities to improve health care

The Importance of Communities to Improve Health Care

Integrating Care for Populations and Communities

cms defines a community
CMS Defines a Community
  • Defined by contiguous zip codes
    • Medicare beneficiaries that live in those zip codes
    • Committed providers and stakeholders
community essentials
Community Essentials
  • Developed around collaborative care delivery
    • Shared vision
    • Shared mission
    • Shared resources
    • Shared decision making
    • Environment of trust
a community
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
4 recruited communities
4 Recruited Communities
  • Western Pennsylvania
  • Lehigh Valley
  • York
  • Chester County
building community
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.

community development
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
provider responsibilities
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
stakeholder support
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
community intervention selection

Intervention Selection

standard known process
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
drivers of readmissions
Drivers of Readmissions

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


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
end of life
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
root cause analysis
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.
intervention selection
Intervention Selection
  • Derived from root cause findings
  • Monitor & Measure
    • Process Measures
      • System Components
    • Outcome Measures
      • Effect of change on patient
intervention selection by driver
Intervention Selection by Driver
  • Patient Activation
  • Standard/Known Process
  • Transfer of Information
project red reengineered discharge
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
transfer of information
Transfer of Information
  • Communication Re-design
  • HIT
  • SBAR
  • Beneficiary and community outreach
patient activation
Patient Activation
  • RED (Re-engineered Discharge)
  • Medication Reconciliation
  • Coaching
  • Teach-Back

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

~Henry Ford

the community based care transitions program cctp
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.
cctp program goals
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
eligible applicants
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
cctp definition of cbo
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
cctp key points
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
cctp application guidance
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
cctp conclusion
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:

cctp website
CCTP Website
  • Visit the program website for daily updates on program status at

Do not forget to note Frequently-Asked Questions

On the Site

what actions can you take
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
10th scope of work the opportunity for you
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!
qio technical assistance
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
resource sharing
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


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.