Massachusetts Strategic Plan for Care Transitions

Health Care Quality and Cost Council

January 20th, 2010

Alice Bonner, PhD, RN, Mass Department of Public HealthCraig D. Schneider, PhD, Mass Health Data Consortium

Joel S. Weissman, PhD, EOHHS

For the Massachusetts State Quality Improvement Institute (SQII) of the Executive Office of Health and Human Services

Commonwealth of MassachusettsExecutive Office of Health and Human Services

With support from The Practice Change Fellowship supported by an award from the John A. Hartford Foundation and Atlantic Philanthropies

Today’s Presentation

• Background: – The Massachusetts State Quality Improvement

Institute (SQII)– Barriers to Effective Transitions

• Transitions in Care Strategic Plan– Effective Care Transitions: What is Known?– The Policy Landscape– Vision for Care Transitions in Massachusetts– Principles, Recommendations and Action Steps– Measuring Success

State Quality Improvement Institute (SQII)

• Co-Team Leaders: Secretary Bigby and Joel Weissman• Nine states: CO; KS; MA; MN; NM; OH; OR; VT; WA. • Two Year Project: Spring 2008 to Spring 2010. • Goals:

– To provide customized support to states for quality improvement efforts with emphasis on creation of State Action Plans

– In MA, we further seek to leverage the SQII efforts by working through public/private partnerships

• MA SQII State Action Plan 2009 http://www.academyhealth.org/Programs/ProgramsDetail.cfm?ItemNumber=3148&navItemNumber=2502

Barriers to Effective Care Transitions

• Lack of integrated care systems

• Lack of longitudinal responsibility

• Lack of standardized forms and processes

• Incompatible information systems

• Lack of care coordination and team-based training

• Lack of established community links

• Underuse of measures to indicate optimal transitions

• Compensation and performance incentives not aligned with care coordination and transitions

• Payment is for volume of services rather than outcomes

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• Ineffective communication

• Failure to recognize cultural, educational or language differences

• Processes are not patient-centered nor longitudinal

Performance Measurement and Alignment

ProceduralStructural

Figure 1: Care Transitions Infrastructure

Patient andFamily

Home HealthAgencies Emergency

Department

Acute Hospital

Hospice

ADRCASAP

OutpatientRehab

SNF

LTAC orRehab Hospital

COASenior Center

Faith-based Org

RetailPharmacy

LTC MedicalHome: NH, AL

MH, DDS

EMS

Massachusetts Strategic Plan for Care Transitions: Purpose

• To create a “living document” that: – Creates a vision for optimal transitions in

care for Massachusetts residents– Sets broad goals and actionable steps that

will lead toward implementation• To ensure that this work is aligned with

related state and federal health care and payment reform efforts

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The Vision

• Interdisciplinary teams delivering safe, effective, and timely care that is culturally and linguistically appropriate within and across settings

• Aligning – Clinical care (individuals)– Public health (populations)– Health policy (payment and organization of

services)

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What is Known? National Examples of Best Practices

• The Care Transitions Model (Coleman)

• The Transitional Care Model (Naylor)

• The Guided Care Model

• Project RED

• The Continuity Assessment Record and Evaluation (CARE) Tool

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Some Elements of Care Common to Most of the Transitions Models

• Medication Management• Assessing Patient's Understanding/Ability to Follow

Care Plan• Discharge Support• Coaching for Primary Care Physician Visit• Use of Home Visits (with the exception of Project

Red)• Screening for cognitive ability• Use of Centralized Health Record• Involving Family and Informal Caregivers• Arranging Community-Based Support Services

From: The Lewin Group, December 16, 2009 Care Transitions Workgroup

What is Known about Costs and Savings?

• The Care Transitions Model (Coleman)– Annual Cost= $74,310 for 379 patients ($196 per patient).– Estimated Annual Cost Savings: $844 per patient

• The Transitional Care Model (Naylor)– The total intervention cost was $115,856 ($982 per patient).– One study demonstrated mean cost savings of $5000/patient

• The Guided Care Model– Randomized studies indicate cost savings of $1364 per

patient ($75,000 per nurse)• Project RED

– Randomized Studies showed cost savings of $380/patient

10From: The Lewin Group, December 16, 2009 Care Transitions Workgroup

The Policy Landscape

• Legislative– For example, AHCAA* H.R.3962 – Sec. 1151 “Reducing

Potentially Preventable Hospital Readmissions”• Guidelines and consensus statements

– For example, the Transitions of Care Consensus Conference (TOCCC)

• Massachusetts policy initiatives– HCQCC Roadmap to Cost Containment– Healthy MA Compact– EOL Expert Panel– Care Transitions Forum– EOHHS Patient-Centered Medical Home Initiative

• State and Federal Payment Reform11

* ‘‘Affordable Health Care for America Act’’

Policy Landscape, cont’d:HIT, HIE and Data Needs

• HIT and HIE are integral components of healthcare workflow

• “Improve Care Coordination” is one of the five Health Outcomes Policy Priorities of the Stage 1 Criteria in the federal draft meaningful use guidelines

– http://www.federalregister.gov/inspection.aspx#special

• MeHI is readying state plan

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Landscape, cont’d: Existing Care Transitions Models in Massachusetts

• INTERACT II• STAAR• MOLST• BOOST• RED• Partners Healthcare

System Clinical Transitions Project

• Somerville Hospital Study

• Massachusetts Pressure Ulcer Collaborative

• Aligning Forces for Quality Project (RWJ)

• Patient-Centered Medical Home

• Medicare High Cost Beneficiaries Demo (MGH)

• ADRCs/ASAPs

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Strategic Plan: Principles and Key Recommendations

1. Timely feedback and feed forward of information

Standardized, minimum datasetCross-continuum teamsEnhanced early post-acute care follow up

2. Communication Infrastructure Contact information providedLiving databaseMedication tracking

3. Patient and Family Engagement Patient and/or advocacy group representation

4. Accountability for care remains with the sending set of providers

Handoff responsibilityIdentifiable provider

5. Provider and Practice Engagement Education/Best PracticesMentors

6. Standardized process and outcome measures, based on nationally endorsed measures

Collaboration with Expert Panel on Performance Measurement

7. Payment reform Incentive alignmentData transparency

Principles Key Recommendations

Measuring Success

• Establish collaboration between HCQCC Quality and Safety Committee and Expert Panel on Performance Measurement

• Select measures endorsed by national bodies when available

• Measure across the quality spectrum, including structure, processes, outcomes

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A Model for Better Outcomes Across the Continuum of Care

Implement the Strategic Plan to Improve Transitions

Collaboratives Payment Reform Government Action

Improved Health Status & Patient Experience

Complications FunctionAdverse Events

Patient Satisfaction

Patient Understanding

Appropriate UtilizationER Visits Readmissions Preventable

AdmissionsUnnecessary Tests

Procedures

Achieve the IHI Triple Aim of optimizing: 1) Patient Experience, 2) Health of Defined Populations, and 3) Per Capita Cost

Examples of Measures of Care Transitions Successes and Failures

• NQF endorsed:– 3 item CTM measure (www.caretransitions.org )

• “…staff took my preferences …into account…”• “…I [understood] the things I was responsible for …”• “…I …understood the purpose for taking each of my medications …”

• ABIM Workgroup (http://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pdf )– reconciled medication list– transition record with specified elements – the timeliness of post-discharge care for heart failure patients

• CMS QIO tool from 9th scope of work http://www.cms.hhs.gov/QualityImprovementOrgs/downloads/9thSOWBaseContract_C_08-01-2008_2_.pdf – H-CAHPS performance standard for medication management; – % of patients readmitted within 30 days seen by a physician; – % of transitions for which interventions show an improvement– % of transitions using the CARE tool

• ONC-HIT Meaningful Use (http://www.federalregister.gov/inspection.aspx#special )

– % of transitions for which summary care record is shared.– Medication reconciliation for >80% of relevant transitions.

Next Steps

• Meet with Secretary Bigby to discuss implementation

• Determine which groups will be involved • Continue to monitor progress of multiple,

ongoing state initiatives

Questions & Answers

Alice.Bonner@state.ma.usJoel.Weissman@state.ma.us

Cschneider@mahealthdata.org