Solution Title: Meeting the Challenge of Health Care Change

Organization: Western Maryland Health System Solution Title: Meeting the Challenge of Health Care Change Program/Project Description, including Goals: What was the problem to be solved? How was it identified? What baseline data existed? What were the goals how would you know if you were successful? Moving from a volume based to value based healthcare model, especially in Maryland where a CMS waiver exists, creates a set of circumstances that call for innovative thinking. As one of the pilot Total Patient Revenue (TPR) health systems, the pressure to be innovative while developing a safety net for our patient population was paramount for Western Maryland Health System (WMHS). With 48% of service area families living below 200% of the federal poverty level, our mission demands that we develop programs to creatively address their needs. Allegany County has a 14.8% diabetes rate, which is the highest of any jurisdiction in Maryland and higher than the US average of 8.3%. The area also reflects national data showing 1 in 4 Americans live with multiple chronic conditions with individuals over 65 or of low socioeconomic status impacted more (DHHS). As a result of changes in government funding allocations, state and local government sponsored and charitable organizations no longer have the resources to provide service to their constituents at previous levels. Recognizing the impact of these changes, WMHS has become the de facto safety net to its service area which includes people in seven surrounding county regions in the Upper Potomac Region of Maryland, eastern West Virginia, and southwestern Pennsylvania. WMHS began attempting to address these needs at individual department levels. Although this resulted in good programmatic changes, it did not strengthen the safety net due to lack of coordination. For example, those patients who were the most vulnerable could frequently have appointments in multiple locations. This resulted in high no show rates and noncompliance with treatment plans which resulted in frequent ED visits and readmissions. While these programmatic changes were moving in the right direction, they did not have the desired outcome of strengthening the coordinated care of our patients throughout the continuum. WMHS engaged the services of Berkley Research Group BRG) to help identify how patients were utilizing WMHS resources. That analysis revealed that there was an unbalanced utilization

of healthcare resources highly impacted by social, economic, and compliance issues (1,972 patients accounted for $140 million of annual WMHS cost - $70, 994 per patient on average). The BRG report became the baseline data for directing what additional services were needed in developing the safety net. The common diagnoses with the identified group of patients (Heart Failure, COPD, Diabetes, and Anticoagulation) became the cornerstone for developing the coordination of care between inpatient and outpatient. Our goals and measurement of success were to decrease ED visits, hospital admissions, and readmissions in order to improve the quality of life for our patients. Ultimately, in order to meet these goals, we needed to change the mindset of all affiliated with WMHS (employees, providers, board members) from volume to value based care (Attachments 1 & 2). Process: What methodology or process was used to develop the Solution? Although, WMHS had Diabetes, Heart Failure and Anticoagulation clinics in different areas of the city of Cumberland, we realized that we were not truly meeting these patient populations needs as demonstrated by the BRG data and anecdotal sense of large number of no-shows for appointments. It also appeared that there was redundancy in the various clinics, lack of coordination of care with the primary care physicians, and isolation of these clinics within the continuum of care which impeded inpatient Care Coordination staff ability to efficiently and effectively coordinate discharge planning resources. In talking with patients and their families, as well as community partners, it was identified that communication processes from inpatient hospitalization to the community were not at the level to consistently ensure safe patient transitions. As a result, we began to look for a solution to these issues in order for WMHS to enhance its service as a community safety net. Recognizing the need to coordinate the multiple departments efforts to address these issues, the WMHS CEO established the Triple Aim Coordinating Council (TACC). This Council provides oversight of the WMHS value-based care delivery process by vetting all new initiatives and ensuring current initiatives are effective in meeting the established goals. Membership on this Council includes the Executive Management team, Care Coordination, Quality, Wellness, and IT. The primary focus of this group is to meet the Triple Aim of Healthcare goals better care, improved community health, and cost effective healthcare in order to meet the Challenge of Healthcare Change. Some examples of areas reviewed include: reducing unnecessary readmissions, admissions and potentially preventable conditions (PPCs); inpatient discharge process; and partnering with community skilled nursing facility (SNF) providers. Solution: What Solution was developed? How was it implemented?

Once the Triple Aim Council came together, the gaps in our safety net became apparent. While there were multiple identified needs, working within this Council we were able to identify solutions to address the gaps between inpatient and outpatient care in a streamlined, nonredundant manner. Some of the identified initiatives included transitions of care, medication reconciliation, behavioral health case management, and coordination of post discharge resources for patients with chronic co-morbidities. Based on team members identified strengths, we began to work on different initiatives but always bringing ideas and progress back to the Council for input and direction. In order to be effective, these initiatives had to follow the patients as they moved through the continuum of care. For example, beginning in the ED, Care Coordination expanded coverage to 24/7 in order to provide support for discharge planning from the ED as well as providing guidance regarding appropriate level of care for patients unable to be discharged from the ED. For patients transitioning from inpatient to community settings, medication reconciliation, management, and affordability are very common issues contributing to readmissions and ED visits. To address this cross-continuum problem, solutions were developed that would impact inpatient care, transitional care, as well as the outpatient arena. Pharmacy technicians were assigned to the Emergency Department to obtain an accurate list of medications in order to facilitate improved medication reconciliation on admission. On the inpatient side, Pharmacists were de-centralized so that they became unit-based and could perform medication reconciliation for admission and discharge as well as patient medication education. Next, we implemented our MedStart Program which provides bedside delivery of a 30 day supply of new prescriptions upon discharge. If patients have a prescription insurance plan, that is billed; however, if patients cannot afford either their co-pay or medications, WMHS has a program in place to assist. A Medication Therapy Management Program was developed for outpatients to provide intensive medication assessment and education. Additionally, the Outpatient Anticoagulation Clinic (OPAC) that was already in place provided another avenue for medication-related needs. All of these medication related solutions strengthened the safety net for our patients in a very high risk component of patient care and transitions. By developing strong partnerships with community skilled nursing facilities (SNFs), better communication occurs which leads to safer patient transitions, thereby decreasing readmissions and ED visits as well as medication errors. It was important for us to determine methods for enhancing communication and information sharing between WMHS and our local SNFs. We addressed this in a multi-faceted approach including a SNF Transitionist, bimonthly meetings with the SNFs, and a pilot SNFist program. The SNF Transitionist is a member of the Care Coordination Department who facilities communication with the SNFs regarding hospitalized residents or new patients who will be

going to a SNF. There is telephonic and on-site interaction between the SNF Transitionist and the SNF staff to discuss residents conditions, both chronic and acute. SNF partners are invited to a bi-monthly luncheon at WMHS to discuss communication and process needs. This group is called, Partnership to Perfection to recognize that in order to provide perfect care for our shared population, it takes a very strong partnership between WMHS and our local SNFs. One outcome of this partnership has been providing the SNFs with access to our electronic medical record; and in return, our SNF Transitionist has access to the individual SNF records. Recognizing the need to take this partnership to an even higher level, the SNF-ist program is being piloted in conjunction with three of our community SNFs. This program includes a physician and nurse practitioners who round in the three facilities daily as well as being on-call 24/7 to address acute needs as well as follow up to chronic conditions of the residents. Behavioral Health crosses all locations on the continuum. At WMHS, we have a very strong inpatient behavioral health program and recognized that adding an outpatient Case Management Program would strengthen the safety net we provide to this patient population. As a result, an Outpatient Behavioral Health Case Management Program was implemented to bridge the gap between inpatient services, outpatient services and patients who present in the Emergency Department in crisis. Referrals for this service can be made from the inpatient Behavioral Health Unit, outpatient Behavioral Health Services or from the ED. All patients admitted to the inpatient Behavioral Health Unit are assessed for need of case management services, and if deemed appropriate, are followed upon discharge in the community where continued assessment of needs occur, coordination of services are facilitated by this case manager, and linkage and procurement of needed community benefits and services occur. The goal of the program is to meet the patients where they are at, in which the Outpatient Behavioral Health Case Manager may meet the patients at public locations, provide linkage with transportation resources, provide prompting for upcoming appointments and keep all elements of the community treatment team updated on the patients issues, concerns and needs One of our biggest initiatives was centered on coordinating the various existing outpatient clinics efforts. A multidisciplinary team composed of all the providers in the clinics, along with Finance, Care Coordination, and IT, worked together to determine the best method to provide these services. Several Lean Six Sigma tools including flow charts, brainstorming, and process mapping, were employed by this multidisciplinary team. Through this process, it was clear that the most effective and efficient solution would be to bring all these clinics into one location. The hope was that by centralizing all services there would be increased compliance with appointments and coordinated treatment plans, thereby decreasing ED visits, hospital admissions, and readmissions. Given the fact that these clinics would no longer be independent, the team had to actually develop the patient flow for one location. Additionally, this process resulted in innovative

thinking to reduce redundancies such as staffing, registration, provider orders, and electronic medical records. Due to some other non-related renovations, a large area in the WMHS Medical Arts Center became available for bringing the Diabetes, Heart Failure and Anticoagulation clinics together on campus. Implementation of this centralized location occurred on November 4, 2013 with the opening of the Center for Clinical Resources (CCR). Since that date, we have added COPD and Medication Therapy Management along with collaborating with the WMHS Wound Center and Outpatient Behavioral Health which are located adjacent to the CCR. The CCR has proven to be a bridge between inpatient and community providers. Again, WMHS, through the CCR has become the safety net for patients when they are unable to see their PCP post discharge within 7-10 days due to a limited number of PCPs in the community. Additionally, the CCR has provided the more intensive patient education (i.e. diabetes and heart failure) that PCPs would like to provide their patients but do not have the time. One other initiative that developed through the Triple Aim Coordinating Council was the Patient Assistance Program. This program provides assistance to patients with financial or support challenges that impact their ability for a safe, timely and successful transition back into the community. These services include, but are not limited to, medical equipment and supplies, home care visits, and emergency housing. The innovative aspect to this program is that employees in Care Coordination, CCR, Behavioral Health, and Home Care are empowered to purchase these services at pre-determined approval levels in order to expedite patients receiving the services necessary for a safe and smooth transition back to the community. Measurable Outcomes: What are the results of implementing the Solution? Provide qualitative and/or quantitative results to data. (Please include graphs, charts, or tools). One of the keys of having measureable outcomes was to ensure that we had an agreed upon method between IT, Finance and the Clinical areas to determine quality and financial outcomes for these programs. To do this, it took considerable coordination and leadership to develop the process and agree on the components comprising the outcomes. The financial outcomes are composed of both actual savings and cost avoidance. The clinical quality outcomes are based on those items required by national and state standards as well as those outcomes we believed were germane to our patient populations. The attachments demonstrate our successful results to date. As demonstrated by Attachment 3, the implementation of the Outpatient Behavioral Health Case Management program has had a significant impact on WMHS readmission rates. In addition, this program has enabled the implementation of complex discharge disposition plans for the most difficult patients with psychiatric of substance abuse needs. Our MedStart data to date indicates that those patients who participate in this program have a considerably reduced readmission rate (Attachment 4). One of the challenges we are faced with is

that many of our older patients see this program as disloyalty to their pharmacy; even though we emphasize that we are only providing a 30 day supply and will facilitate the prescriptions being transferred to their own pharmacy. Partnerships with our local SNFs become very significant due to the complexities of long term and acute care. The programs that we have put into place have positively impacted on reducing SNF specific readmissions (Attachment 5). In the Center for Clinical Resources, as indicated in attachments 6-10, the continual growth of patients with multiple co-morbidities participating in the CCR clinics demonstrates excellent support of our community primary care providers to our program. Diabetes, Heart Failure, and Anticoagulation, have all demonstrated excellent results in the areas of ED visits and admissions / readmissions. With COPD and Medication Therapy Management being our newest programs, outcome measurements are limited (Attachment 11). All of these outcomes impact our quality of care in particular, readmission rates and potentially preventable conditions (MHACs/ PPCs). As demonstrated on Attachments 12 and 13, our initiatives to improve the coordination of patient care have had a positive impact on the quality of care we provide to our patients. Sustainability: What measures are being taken to ensure that results can be sustained and spread? Outcome measurements were one of the clear requirements established by the Triple Aim Coordinating Council in order to obtain provisional funding to develop these programs. Close attention is being paid to the relationship between the work being done in the CCR and admissions/readmission and ED visits. It is the savings/cost avoidance from those reductions that are allowing the CCR to continue and expand to treat further types of chronic illnesses. This same premise is applied to all other program as they are vetted through the Council. Readmissions are reviewed 3-4 times a week to determine reasons for the occurrence. Post discharge plans are evaluated to determine if appropriate resources were put into place and if the patient was able to follow through on those plans. If not, we re-evaluate our approach and recommendations so that our patients can be as successful as possible in their next transition. Role of Collaboration and Leadership: What role did teamwork and collaboration play in the Solution? What partners and participants were involved? Was the organization s leadership engaged and did they share the vision for success? How was leadership support demonstrated? The Mission and Core Values of WMHS were the driving force for the initiatives that were developed. WMHS Executive Management Team focuses on supporting those initiatives which

advance the culture of patient safety. This commitment provided the support to develop successful collaborations, both internally and externally, which would be the foundation for our safety net. The C-Suite executives demonstrated their support by allowing these programs to be provided at basically no charge to our patients and allowing us to hire and move staff into these programs based on a vision of what these services could mean to population health, and meeting the challenges of our community. The atmosphere for teamwork began with our Executive group and their leadership of the Triple Aim Coordinating Council. We were able to come together from all areas to discuss and collaborate, keeping the patients in the center of our decision-making with the recognition that we would not be able to meet our patients needs if departmental silos existed. The outcomes of our programs are reflective of this multidisciplinary approach and collaboration. Innovation: What makes this Solution innovative? What are its unique attributes? There are many aspects that make the WMHS programs both innovative and unique. We have recognized that to treat and help individuals with multiple chronic illnesses, all socioeconomic issues must be addressed. To do this takes time and a network throughout the community to bring support to the patients so they in turn can better manage their own health. Another aspect that makes our programs unique is that we do not charge for any of the services provided, particularly in the CCR where high level, high cost interventions are delivered. This removes a huge barrier in patients willingness to accept the services of the CCR. This required innovative thinking in order to show that the CCR was profitable even though the patients and/or their insurance were not being billed for these services. These programs could be easily reproduced in various settings based upon population needs provided that the needed executive support and teamwork exist in the organization. At WMHS, this high level of working across the continuum of care from ED to inpatient to transition back into the community has been greatly enhanced as a result of innovative thinking supported by teamwork and leadership. Contact Person: Karen Howsare Title: Director of Care Coordination Email: khowsare@wmhs.com Phone: 240-964-7366

The Solutions selected to receive the Minogue Award for Patient Safety Innovation will reflect the following Award criteria: Be innovative Demonstrate measurable change Exhibit strong collaboration Exhibit strong leadership Advance the culture of patient safety Constitute a best practice with the ability to spread

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MedStart Program Readmission Impact Attachment 4

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Excellent Outcomes Diabetes 27% decrease in admissions and observation stays; 16% decrease in ED visits CHF patients had a 57% decrease in admissions 73.5% of anticoagulation patients had no hospital visits of any kind Total Cost Savings/Avoidance: $3.65 million Based on patient s experience one year prior to participation in the CCR and one year after being managed by CCR Attachment 11

Results So Far Inpatient Admissions Readmissions 24% over last 4 years 46% over last 2 years SNF Readmissions 38% Inpatient Behavioral Health Admissions 10% Readmissions 9% ED Use Rates 3% ED Admissions 6% Attachment 12

Clinical Initiatives/Results Maryland Hospital Acquired Conditions Maryland Goal 8% reduction WMHS 38% reduction in 1 year Ranked 8 th of 46 hospitals ARR Incentive Program (Admission-Readmission Revenue) Maryland Goal 6.76% reduction every year over the next 5 years = 30% All hospitals are expected to achieve the same reduction WMHS 9% reduction since January 2014 Attachment 13