Lessons from the Care Transitions Theme

Jane Brock, MD, MSPHAlicia 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

• Methods used by QIOs for analyzing root causes of readmissions

• Drivers of readmission• How to plan for success

14 QIOs with 14 Target CommunitiesCommunity 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

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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.

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Measure CT Theme (National) CT Theme (National)

Absolute Change Relative Change

% readmitted -0.08% (+0.05%) -0.39% (+0.24%)

Readmissions/1000 -2.96/1000 (-1.93/1000) -4.75% (-3.34%)

Admissions/1000 -15.23/1000 (-11.8/1000) -4.59% (-3.77%)

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?

Provider-Patient interfaceunmanaged condition worsening, use of suboptimal

medication regimens, return to an emergency department

Unreliable system supportLack of standard and known processesUnreliable information transferUnsupported patient activation during transfers

Why do hospitals have unwanted readmissions?

Unreliable system supportLack of standard and known processesUnreliable information transferUnsupported patient activation during transfers

No Community infrastructure No Community infrastructure for achieving common goalsfor achieving common goals

Provider-Patient interfaceunmanaged condition worsening, use of suboptimal

medication regimens, return to an emergency department

Why do hospitals have unwanted readmissions?

Unreliable system supportLack of standard and known processesUnreliable information transferUnsupported patient activation during transfers

No Community infrastructure No Community infrastructure for achieving common goalsfor achieving common goals

Provider-Patient interfaceunmanaged condition worsening, use of suboptimal medication regimens, return to an emergency department

Handing Over Medical ResponsibilityReal time communication to PCPs SNF needs functional status

<20% at time of discharge High refusal rates33% unaware of discharge 3-day stay rule

Communication to HHAs Discharge Summaries No direct conversation 86% in 48 hoursNeed signature from PCP 33% prior to follow up visit

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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

1. Multi-representative steering committee2. Aggregate providers vertically in clusters,

then merge3. Aggregate providers by setting then

vertically integrate4. Individual improvement projects, with

information and data-broker

Make it visibly a community effort

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 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