It Takes a VillageCommunity-Based Care Transitions

Improvement

Jane Brock, MD, MSPHColorado Foundation for Medical Care

December 8, 2011

This material was prepared by CFMC (PM-4010-031 CO 2011), 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

Introduction: Common Pool Resource ManagementLessons from the Care Transitions Theme

Drivers of Readmission, or why reducing hospital readmissions is a community engagement projectDeveloping a community project in care transitions‘Collective Impact’ as a framework for managing the project

A collection of insights

The Tragedy of the Commons

“The… problem has no technical solution; it requires a fundamental extension of morality.” Garret Hardin

Science, New Series, Vol. 162 (3859): 1243-8, 1968.

Principles of Enduring CPR Arrangements

1. Clearly defined boundaries

2. Congruence between rules governing the taking (appropriation) and providing of resources and local conditions

3. Collective-choice arrangements allowing for the participation of most of the appropriators in the decision making process

4. Effective monitoring by monitors who are part of or accountable to the appropriators

5. Graduated sanctions for appropriators who do not respect community rules

6. Conflict-resolution mechanisms which are cheap and easily available

“Polycentric Local Management”

What does this have to do with healthcare?

What does this have to do with healthcare?

Year Spending ($) Rank

1992 3209 304

2006 5873 301

What does this have to do with healthcare?

Year Spending ($) Rank

1992 3209 304

2006 5873 301

A history of collective action to serve a visible group of people… Common mission/vision Local control Place Identity

http://content.healthaffairs.org/content/29/9/1678.full.html

Common-Pool Resource ManagementCPR Management

Clearly defined borders Geographic isolation

Local adaptation of access ‘rules’ Local payer serving community needs

Participation of ‘appropriators’ in decision-making process

Longstanding culture of collective action

Effective monitoring by appropriators Physician utilization comparison ranking

Graduated sanctions for those not respecting community rules

Payment incentives, pride in ranking

Conflict resolution mechanisms that are cheap and accessible

IPA culture, payment incentives, social networks – ‘the grocery store factor’

http://en.wikipedia.org/wiki/Common-pool_resource

CAN IT BE REPLICATED?LESSONS FROM THE CARE

TRANSITIONS THEME

The real world as opposed to ‘clearly defined borders’

14 QIOs with 14 Target Communities AL: Tuscaloosa CO: Northwest Denver FL: Miami GA: Metro Atlanta East IN: Evansville LA: Baton Rouge MI: Greater Lansing area NE: Omaha NJ: Southwestern NJ NY: Upper capital PA: Western PA RI: Providence TX: Harlingen HRR WA: Whatcom county

Results

Oct07-Mar08*

Jan08-Jun08 Apr08-Sep08 Jul08-Dec08 Oct08-Mar09 Jan09-Jun09 Apr09-Sep09 Jul09-Dec09 Oct09-Mar10†

Jan10-Jun10 Apr10-Sep10 Jul10-Dec1010.00

15.00

20.00

25.00

30.00

35.00

40.00

45.00

50.00

1

2

3 3 (p=0.8862)

4

5

5 (p=0.0003)

6

6 (p<0.0001)

7

7 (p<0.0001)

8

8 (p<0.0001)

9 9 (p=0.6007)

1010 (p<0.0001)

11

12

12 (p=0.0010)

13

14

30-day hospital readmissions per 1,000 eligible beneficiaries, semi-annual (O-4)

Best-fit lines for observed ratesLower is better. Statistically significant trends, per Cochrane-Armitage test, are

indicated by bolded p-values.

Evaluation PeriodBaseline measurement is indicated by an asterisk (*).

Follow-up evaluation is indicated by a dagger (†).

It’s not a hospital project

HHA

SNF

It’s a Community Problem

HHA

SNF

The ‘Zip Code Overlap’ Community Definition

FFS Medicare beneficiaries living in zip codes of interest

Target Population

Community identity supports both social and economic sustainability

FFS beneficiaries discharged from hospitals of interest

Social Network Analytic techniques for displaying the provider network

19

DEVELOPING A COMMUNITY PROJECT TO REDUCE HOSPITAL READMISSIONS

1. RCA DriversDataMedical record reviewProcess assessment

Why are people readmitted?

Provider-Patient interfaceUnmanaged condition worseningUse of suboptimal medication regimensReturn to an emergency department

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

1. RCA Drivers1. Data2. Medical record review3. Process assessment

2. Drivers + Settings = Interventions

Why are people readmitted?

Provider-Patient interfaceUnmanaged condition worseningUse of suboptimal medication regimensReturn to an emergency department

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

CMS’ Table of Interventions

Available at: www.cfmc.org/caretransitions

Intervention Packages

Intervention Reference Main tools Driver addressed #

SKP PAct InfCare Transitions Intervention

www.caretransitions.org Coaches, personal health record, medication discrepancy tool ? XXX X 13

Transitional Care Nursing www.transitionalcare.info/index.html Risk assessment , nursing training materials XX X XX 2

CMS Discharge Checklist www.medicare.gov Patient and family checklist of important items to address before discharge ? XXX X 9

BOOST www.hospitalmedicine.org/ResourecRoomRedesign

Screening/assessment , provider discharge checklist, transition record, teach-back instructions, data collection and tracking

XXX XX 2

Best Practices Intervention Package (BPIP)

www.homehealthquaqlity.org/hh/ed_resources/interventionpackages/default.aspx

Comprehensive manual for HHA process improvement includes CTI teaching XX XX XX 11

InterAct Interact.geriu.org Communication tools, clinical care paths, advanced care planning XX XX 10

Transforming Care at the Bedside (TCAB)

www.ihi.org/IHI/Programs/StrategicInitiatives/TransformingCareAt TheBedside.htm

(Re)Admission assessment, teach-back, pt and family communication, scheduled f/u XXX XX X 4

Re-Engineered Discharge (RED)

www.bu.edu/fammed/projectred/index.gtml Nurse discharge advocate, pharmacy f/u medication teaching, PCP f/u booklet XXX XX 4

Building Community Infrastructure

1. RCA Drivers1. Data2. Medical record review3. Process assessment

2. Drivers + Settings = Interventions3. Backbone ‘agency’

Why are people readmitted?

No Community infrastructure for achieving common goals

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

Provider-Patient interfaceUnmanaged condition worseningUse of suboptimal medication regimensReturn to an emergency department

I think it’s an elephant!

• Backbone ‘agency’• Common agenda• Common measures• Structured collaboration

3 IMPORTANT THINGS WE LEARNED:

Blah blah blah, blah blah. Any questions?

No I’m good to go. Whatever you say is what we’ll do Doctor

What’s he saying? I sure hope my wife is getting this..

1. Patient activation trumps all

PATIENT ACTIVATION

The CMS Discharge Planning Checklist

http://www.medicare.gov/Publications/Pubs/pdf/11376.pdf

Knowledge, skills and confidence

37

Sample Questions:#1: “When all is said and done, I am the person who is responsible for taking care of my health.”

#12: “I am confident I can figure out solutions when new problems arise with my health”

The PAM is scored on a 100 point continuum. Most patients score between 35 and 80

The Patient Activation Measurewww.insigniahealth.com

PATIENT ACTIVATION

The PAM is very helpful to guide interventions

2. Local adaptation is inevitable

Adapt gold standard modelsDo not adapt others’ adaptations

3. Ask the community to help

• “Brought to you by your Community Partners”

Community Organizing Techniques

Tie participation to valuesInclude personal narrativesIntentionally develop other leadersIntentionally develop relationshipsDevelop flexible tactics

EXAMPLES

Q 1 (2009)

Q 2 Q 3 Q 4 Q 1 (2010)

Q 2 0

5

10

15

20

25

HHA 1HHA 2

Provider Pair:HHAs and hospital pharmacy (NY)

Butterfield, Stegel, Tartaglia. Improving outcomes through re-engineering care transitions: The New York Experience. Remington Report May/June 2010.

MULTI-PROVIDER INTERVENTIONS

Lateral Cluster:30day hospital readmission rate from SNFs in Harlingen

http://www.cfmc.org/caretransitions/files/Feb24_2011%20Learning%20Session_FINAL.pdf

Partnering for coached discharges:Improved activation (Co)

Jan07 F M A M J J A S O N D Jan08 F M A M J J A S O N D Jan09 F M A M J J A S O N D Jan10 F M A M J0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Median: 1.16

30-day hospital readmissions per 1,000 eligible beneficiariesHospital A, monthly

Readmission rate Median

Monthly readmissions per 1,000 eligible Medicare FFS beneficiaries in the target community depict a reduction in readmissions, first ob-served in July 2009, due to special cause.

PATIENT ACTIVATION

“IT’S CLEAR THAT SOMEBODY HAS TO DO SOMETHING AND IT’S INCREDIBLY PATHETIC THAT IT HAS TO BE US”

Jerry Garcia