Rebekah Gardner, MD Senior Medical Scientist, Healthcentric Advisors Assistant Professor of Medicine, Brown University

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1 Improving the Safety of Care Transitions through Best Practices and Community Collaboration The Rhode Island Experience Rebekah Gardner, MD Senior Medical Scientist, Healthcentric Advisors Assistant Professor of Medicine, Brown University This material was prepared by Healthcentric Advisors(10SOW-RI C ), the Medicare Quality Improvement Organization for Rhode Island, 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.

2 Care Transitions Problem Complex and cross setting communication required RI: 25% of Medicare patients readmitted in 30 days Most within 5 days Readmission diagnoses: AMI, CHF, PNE, C. Difficile Poor transitions negatively impact patient safety, outcomes, satisfaction and cost Researchers report 30% reduction in readmissions by improving care transitions

3 Care Transitions in 9th SOW Medicare funded pilot 3 year pilot (September 2008 August 2011) Competitively awarded 14 contracts nationwide Each independent, interventions evidence based Cross setting project Hospitals, home health, nursing homes and PCPs

4 Pilot Goals Improve coordination across settings Evidence based practice Communication among providers Increase patient self management Ultimately: Reduce 30 day readmission rates Improve discharge related outcomes (satisfaction) In Rhode Island, our long term goal is to sustain proven interventions via community collaboration

5 Vision Statement As a community, we defined our vision A healthcare system where discharged patients and their caregivers: understand their conditions and medications, know who to contact with questions (and when), and are supported by healthcare professionals who have access to the right information, at the right time

6 Readmission Drivers Incomplete, inaccurate or delayed transfer of information Lack of patient activation Inconsistent implementation of standard and known processes

7 Interventions Addressing Drivers National Programs Care Transitions Intervention Project RED INTERACT Home Health Best Practice Intervention Packages Statewide Efforts State mandated interagency form Follow up physician appointments Patient call back programs

8 30 Day Readmission Rates, CTI Intervention January 2009 June 2010* 9th SOW Results: CTI * This includes only those persons who had FFS claims available in the time period

9 Best Practices Identified best practices for all care settings from medical literature and local preferences Revised by convening setting specific groups Refined with multi stakeholder advisory board Reviewed with input from health plan auditors Incorporated into provider contracting To date, for hospitals and PCMH practices

10 RI: 9th SOW Results

11 RI: 9th SOW Results

12 Prelim National 9th SOW Results

13 Sustainability and Spread Attain buy in Storming and norming process Shared ownership over problem and solutions Guided by data, evidence base and facilitation Move local success to system success Stakeholder consensus (including payors) to align incentives with best practices Change in expectations about how and when information is communicated

14 The Work Continues Expanding statewide and applying lessons learned to our 10th SOW approach

15 A Four-Pronged Approach 1. Align related efforts to minimize burden on providers and maximize benefit for patients 2. Provide education and onsite technical support Evidence based best practices 3. Form Community Coalitions Assist communities applying for other formal care transition programs (e.g., community based care transitions programs, bundled payments) 4. Facilitate statewide Learning & Action Network

16 Technical Support Technical support with plan dostudy act (PDSA) cycles to achieve the Best Practices Root cause analysis Intervention selection Tracking (process), measuring impact (proximal outcomes), and analysis (utilization outcomes) On site education, participation in internal meetings, highlighting successes

17 Community Coalitions Community Approach: Providers who share patients in small networks (includes non traditional participants) Focus on improving transitions between their settings Formal Agreement: Signed charter Goals, roles, and membership Activities: Review readmissions Collaborate to identify opportunities Select evidence based interventions Implement, track, and evaluate

18 Learning & Action Network All learn all teach environment Quarterly sessions Performing root cause analysis Exploring end of life care options Delivering effective patient education Addressing medication barriers Collaboration Tools Safe Transitions LAN Listserv Safe Transitions SharePoint Site

19 Approach HATCh Safe Transitions Model Insurers C Suites, Opinion Leaders Home Health Agencies Nursing Homes PCP Hospitals Hospice Non traditional providers Patient/caregiver

20 Approach HATCh Safe Transitions Model Statewide LAN facilitates sharing, sustainability & spread Insurers C Suites, Opinion Leaders Coalitions drive community based collaboration & improvement Home Health Agencies Nursing Homes PCP Hospitals Hospice Patient/caregiver Non traditional providers Individual facilities implement Best Practices with evidence based Interventions

21 Early 10th SOW Results

22 Early 10th SOW Results

23 Core philosophy: Translating a pilot into systems change Advice to Others Coaching affects individual patients, but components can be adopted as best practices Allows for broader impact Acknowledge elephant in the room Reducing readmissions may be threatening to hospitals facing pressure to increase census Health plans can help offset lost revenue and be valuable partners in elevating local care practices

24 Advice to Others It s all about relationships Convene your partners early It can take a year to build solid foundation for behavior change Facilitate discussion Allow for period of storming and norming Let participants voices prioritize next steps Use data to drive decision making

25 Contact Information Rebekah Gardner, MD Senior Medical Scientist, Healthcentric Advisors Assistant Professor of Medicine, Brown University Lynne Chase Senior Program Administrator, Healthcentric Advisors

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