Building the Cross Continuum Collaborative Baystate Medical Center

1. Building the Cross Continuum Collaborative Baystate Medical Center Stephanie Calcasola, RN, MSN, RN-BC Susana Hall, RN, BSN, MBA Ruth Odgren, RN, MS

2. 680 bed tertiary care referral center ( ~1M) Flagship of Baystate Health 42 k admissions/year Annual surgical volume: 29,043 Western Campus of TUFTS Member CoTH, 9 residency programs/244 PGs 1200 member medical staff, 206 faculty MDs Level 1 Trauma Center IHI Mentor Hospital (SCIP/AMI/HF/HAPU/VTE) Magnet facility –re designated 2010

3. Quality Accomplishments

4. STAAR CollaborativeAims • Reducing re-hospitalizations goal for 2010, 2011 • Threshold: Implement a standardized discharge process for heart failure patients • Target: Decrease heart failure re-hospitalizations by 15% • Maximum: reduce heart failure re-hospitalizations by 30% • Makes business sense to be proactive in light of: • Upcoming changes regarding healthcare • Throughput and capacity issues • Right thing to do for patients & families

5. Study Says US Hospitals Fail To Reduce Avoidable Readmissions. Bloomberg News (9/28, Wechsler) reports, "US hospitals risk cuts in Medicare payments next year after failing to reduce avoidable readmissions, a Dartmouth Atlas Project study showed." The study, by tracking "10.7 million discharges at 1,925 hospitals from 2004 to 2009,...found that readmissions of elderly patients within 30 days of a hospital stay have remained the same or increased." And "the Centers for Medicare and Medicaid Services in Baltimore plans to cut payments by 1 percent to hospitals with excessive rates starting in fiscal 2013."         The Pittsburgh Tribune-Review (9/28) reports, "Readmission rates for Medicare patients ages 65 and older within 30 days barely changed from 2004 to 2009." Study author Dr. David C. Goodman commented, "For a long-standing problem, not much progress has been made." National Journal (9/27, Fox) also covers the report.

6. Deb Hawkes RN -Unit Manager Springfield 3 Oncology Laurie Kaeppel RN / Deb Hawkes RN – Springfield 3 Medicine Carol Morrison RN – S4 Case Manager Brenda Krumpholz RN – S3 M Case Manager Bonnie Geld MSW - Director Care Management Maria Giordano, RN – Assistant Nurse Manager, Daly 5A Carlo Real RN /Jodi Kashouh RN - Splfd 4 Short Stay Cardiology Gini Staubach RN -Assistant Director Critical Care & Cardiology PCS Ann Maynard RN -Director ED John Santoro MD -Vice Chair, Chief Emerg Svcs Surinder Yadav MD - DHQ /Attending Hospitalist Carol Richardson MD - Associate Med Director Hospital Medicine Donna Borah RN Director Hospital Medicine Program Ruth Odgren RN President BVNA&H Aaron Michelucci PharmD, Assistant Director, Clin Pharm Regional Western Mass Cross Continuum Partners Stephanie Calcasola, RN Director of Quality Win Whitcomb,MD, Medical Director of Healthcare Quality Susana Hall, RN Director of Post Acute Care Services Cara Kenny, RN, S1 Clinical Educator

7. Cross Continuum Regional Meetings

8. Cross Continuum Invite

9. Planning for Cross Continuum Meetings Regularly scheduled, advance notice Geographically neutral meeting location Continental breakfast Timely agenda/attachments Ongoing and frequent communication Topics of varied and cross sectional interest 9

10. Objectives Education dissemination Networking Shared Stories/shared commitment Relationship/partnership building Readmission prevention collaboration

11. Keys to Success • Persistence and reinforcement/high visibility • Senior leader support • Multidisciplinary cooperation & collaboration • Accurate, timely and relevant data • Communicate – flexibility • Right people • Willing to try changes and take a risk • Develop reliable systems • Incorporate into workflow • Make changes easy => transparent => meaningful Make The Right Thing The Easy Thing

12. Baystate All-Cause 30-Day Readmissions

13. Next Steps/Priority Focus • Standardization of patient education tools (HF, AMI, PN, Stroke, COPD zones) among cross continuum regional partners • Increase frequency of meetings with cross continuum regional partners. Shift from primary knowledge sharing to work groups and integrated projects. • 3026 grant partner • Interact survey (post acute facility survey on readmisson patterns) • Pilot med rec/teaching/on original pilot unit with pharmacists (August, 2011) • Submitted letter of intent for Partnership for Patients • Spreading the methods of Ask me 3/teach back throughout organization. Web based training for all nurses fy 2012

14. MHA - STAAR Fall Learning Session October 11 & 12, 2011 Ruth Odgren, RN, MS President Baystate VNA & Hospice Senior Executive for PAC Relationships, Baystate Health Ruth.Odgren@baystatehealth.org

15. Baystate VNA & Hospice (BVNAH)STAAR INVOLVEMENT • 2008 • Focus – Patient Centered Care of those with Heart Failure (HF) as 1o or 2o diagnosis • 2009 • Hired part time Heart failure Clinical Nurse Specialist • Developed protocols • Incorporated use of telemonitoring

16. BVNAH STAAR INVOLVEMENT (Cont.) • 2010 • Implemented use of HF Zones, ASKME3 and Teach Back • Coordinated patient care with BMC HF Unit Staff • Began subsidy program for uninsured and underinsured HF patients

17. BVNAH STAAR INVOLVEMENT (Cont.) • 2011 • Began journey to educate and certify all home care clinicians in Integrated Chronic Care Management (ICCM) • By end of year, 90% of staff to complete the ICCM Program (currently at 60%)

18. BVNAH STAAR INVOLVEMENT (Cont.) • Results – All cause HF readmissions • CMS Home Care Compare Data – All cause readmissions rate for all diagnoses is 23% • This is lower than regional, state & national results

19. Interact Survey ResultsTransfers back to Acute Hospital %

20. Authorization for Transfer

21. Pre-Transfer Management

22. Day of Week

23. Questions Thank you