QIO Care Transitions Activity: the good news so far… Alicia Goroski

QIO Care Transitions Activity:
the Good News so far…
Kim Irby, MPH; kirby@cfmc.org
Senior Project Director
Colorado Foundation for Medical Care
www.cfmc.org/integratingcare
This material was prepared by CFMC (PM-4010-046 CO 2012), 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
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Why we know it worked – JAMA publication
Describe the need for better transitions
Discuss leading interventions in this work
Outline current and future work and
implications
– National and Alabama data
2
It Worked!!
http://jama.jamanetw
ork.com/article.aspx?
articleid=1558278
August 2008-July 2011: 14 QIOs
working in 14 Communities
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4
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
Totals among Communities
•
•
•
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70 Hospitals
277 Skilled Nursing Facilities
316 Home Health Agencies
89 Other types of Providers (Dialysis, Hospice, etc.)
• 666 ZIP Codes
• 1,125,649 Fee-for-Service Medicare Beneficiaries
5
The Strategy
• Define a community
• Identify service patterns associated with
readmission
• Recruit and convene providers/partners
• To reduce unplanned 30d hospital readmissions
for the community
• Using evidence based interventions and tools
6
Interim Quarterly Results
Baseline Quarter Readmissions = 12,926
First quarter after intervention readmissions = 12,151
20.00%
19.80%
19.68%
19.60%
19.48%
19.40%
p=0.0024
19.20%
19.00%
18.80%
Jan07Mar07
N = 66590
Apr07- Jul07-Sep07 Oct07Jun07
N = 62060
Dec07
N = 64621
N = 62822
Jan08Mar08
N = 65689
A
Apr08- Jul08-Sep08 Oct08Jun08
N = 59098
Dec08
N = 61781
B
N = 59962
Jan09Mar09
N = 61517
C
Apr09- Jul09-Sep09 Oct09Jun09
N = 56395
Dec09
N = 58825
N = 57766
Jan10Mar10
N = 60616
D
Apr10- Jul10-Sep10 Oct10Jun10
N = 57984
Dec10
N = 59422
N = 59630
Numerator and Denominator Quarterly
Denominator (admissions)
63,000
58,000
20,000
25,000
30,000
68,000
Numerator (readmissions)
15,000
53,000
10,000
48,000
5,000
43,000
Jan07-Mar07 Apr07-Jun07 Jul07-Sep07 Oct07-Dec07 Jan08-Mar08 Apr08-Jun08 Jul08-Sep08 Oct08-Dec08 Jan09-Mar09 Apr09-Jun09 Jul09-Sep09 Oct09-Dec09 Jan10-Mar10 Apr10-Jun10 Jul10-Sep10 Oct10-Dec10
N = 66590
N = 64621
N = 62060
N = 62822
N = 65689
N = 61781
N = 59098
N = 59962
N = 61517
N = 58825
N = 56395
N = 57766
N = 60616
N = 59422
N = 57984
N = 59630
A
B
C
D
Quarter
The unit N represents target community eligible beneficiaries.
MIlestones: A) baseline quarter; B) Care Transitions theme initiation (Aug 2008);
C) intervention implementation (Jan 2009); and D) 28-month follow up quarter.
Rehospitalization Trends, Intervention and Comparison Communities
-5.7% (p<.001)
-2.1% (p=.08)
P=.03 (difference)
Hospitalization Trends, Intervention and Comparison Communities
-5.7% (p<.001)
-3.1% (p<.001)
P=.01 (difference)
Statistical process control
• Assesses variation in an outcome presumed to be
related to system functioning
• A change worth investigating:
– Reduced variation (increased control)
– Significant change in the value of the outcome
Process control limits = 3sd from the mean variation during ‘baseline’
‘Significant’: 8 points in a row above/below the mean with at least one
point in the ‘during intervention’ time period
OR
A single point above/below the process control limit in the ‘during
intervention’ time period
Community Results
Rehospitalizations
Intervention
Comparison
Special cause decrease
10/14 (71%)
22/50 (44%)
Special cause increase
2/14 (14%)
13/50 (26%)
Hospitalizations
Intervention
Comparison
Special cause decrease
13/14 (93%)
31/50 (63%)
Special cause increase
0/14 (0%)
8/50 (16%)
Control Charts – an innovative way to
measure progress in healthcare
Target Community - AL_0
3s Limits
For n=2:
22
UCL=22.01
20
X=20.08
The
Improvement
continues….
LCL=18.14
18
Test1
Test1
Test1
Test1
16
Test1
Test1
Test1Test1
14
0
2
4
6
8
10
12
14
16
18
20
22
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Target Community - TX_0
3s Limits
For n=2:
22
Readmissions per 1000 Benes
Readmissions per 1000 Benes
24
UCL=20.66
20
X=18.54
18
16
Test1
LCL=16.42
Test2
Test2 Test1
Test1 Test1
Test1
Test1
Test1
Test1
14
0
2
4
6
8
10
12
14
16
18
20
22
24
What’s important about this
publication?
• Intervention communities avoided twice as many
rehospitalizations (1 hospitalization for every 1000 Medicare
beneficiaries) and hospitalizations (5 for every 1000
beneficiaries) as comparison communities
• Improvement for whole communities is a promising strategy
– Providers engaged based on relevance
– QIOs in the role of convener/supporter
– Included community and social services
• Unadjusted geographic population data allows easy data
display/sharing
What Else was Important?
• Allowing flexibility leverages local
resources/context
• Shewhart control charts published in a major
peer-reviewed journal
• Rehospitalizations/1000 and
hospitalizations/1000 metrics proved useful for
improvement work
Why are people readmitted?
Provider-Patient interface
Unmanaged condition worsening;
Use of suboptimal medication regimens;
Return to an emergency department
Why are people readmitted?
Provider-Patient interface
Unmanaged condition worsening;
Use of suboptimal medication regimens;
Return to an emergency department
Unreliable system support
Lack of standard and known processes;
Unreliable information transfer;
Unsupported patient activation during transfers
Why are people readmitted?
Provider-Patient interface
Unmanaged condition worsening;
Use of suboptimal medication regimens;
Return to an emergency department
Unreliable system support
Lack of standard and known processes;
Unreliable information transfer;
Unsupported patient activation during transfers
No Community infrastructure
for achieving common goals
Why are people readmitted?
Provider-Patient interface
Unmanaged condition worsening;
Use of suboptimal medication regimens;
Return to an emergency department
Unreliable system support
Lack of standard and known processes;
Unreliable information transfer;
Unsupported patient activation during transfers
No Community infrastructure
for achieving common goals
Why Engage a Community?
• Every readmission begins with hospital discharge
• Every transition has 2 sides
• Isolated information is not safe medical management
• Inevitably need to share
• The problem of home
• Patients are people too
• Visibility to drive improvement and mission
• Providers are people too
It’s not a hospital project
It’s a Community Problem
HHA
SNF
Ways to Convene a Community
System-Level Drivers of Readmissions
Provider-Patient interface
Unmanaged condition worsening;
Use of suboptimal medication regimens;
Return to an emergency department
Unreliable system support
Lack of standard and known processes;
Unreliable information transfer;
Unsupported patient activation during transfers
No Community infrastructure
for achieving common goals
Interventions and Drivers
Intervention
Care Transitions Intervention℠
Transitional Care Model
Patient
Activation
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INTERACT II
HHQI Best Practices
••
Project BOOST
Bridge model
GRACE Model
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Information
Transfer
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••••••
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Project RED
STAAR Initiative
Standard
Process
•••
••••••
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•••
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CMS’ Table of Interventions
Available at:
www.cfmc.org/integratingcare
Hospital discharge
standardization protocols
• RED – 11 item checklist
• BOOST – QI support for hospitalists and
discharge planners
• Evidence: weak for readmissions; insufficient but probably
necessary
• Driver: standard known process, information transfer
• Setting: Hospital
The CMS Discharge Planning
Checklist
• Description: CMS
developed checklist for
patients and families to
prepare for care capability
after transition
• Resource:
http://www.medicare.gov/Public
ations/Pubs/pdf/11376.pdf
Care Transitions InterventionSM (CTI)
• Description: Transitions coaches support selfmanagement capacity
– Personal Health Record
– Medication discrepancy tool
– 5 contacts
• Evidence: RCTs and the Care Transitions Theme (30-50%
30d; 50% 180d)
• Driver: patient activation, information transfer
• Setting: hospital to home
Transitional Care Nursing Model
• Description: Transitional Care Nurses follow patients from
the hospital into the home; work with a multidisciplinary
team to develop and deliver comprehensive care plan; risk
assessment tool(s)
• Evidence: RCTs (45% 90d)
• Driver: information transfer, creates a new standard process
that individualizes services
• Setting: hospital to home health
Interventions to Reduce Acute
Care Transfers (INTERACT)
• Description: Toolkit for SNF personnel to reduce avoidable
hospital admission. Three types of tools:
– 1) communication;
– 2) clinical care paths;
– 3) advance care planning.
• Evidence: Ouslander (2008): Higher hospitalization rates
associated with larger facilities, more Medicaid and
Medicare skilled care residents, lower percentage of
Caucasian residents and higher percentage of residents
with impaired decision making; 68% of hospitalizations
were avoidable, per expert panel record review.
In Reality
• Adapted models/components of models
• 2 tracks: activation plus provider process
What’s he saying? I sure
hope my wife is getting
this..
No I’m good to
go. Whatever
you say is what
we’ll do Doctor
Blah blah blah,
blah blah.
Any questions?
1. Patient
activation
trumps all
The PAM is very helpful to guide
interventions
2. Local adaptation is inevitable
• Adapt gold standard models
• Do not adapt others’ adaptations
3. Ask the community to help
• “Brought to you by
your Community
Partners”
Organize a Community
• Tie participation to values
• Include personal
narratives
• Develop flexible tactics
• Community champion
• Align with other federal
and local initiatives
• Develop a leadership
team/advisory group
4. Measuring is important
p=0.0024
Insist on a population based measure of progress
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Recurring Themes
in Successful Communities
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•
•
•
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Community cohesiveness
Provider activation/will
Strategic Partners
Cross-setting Work
Coaching as an intervention
Strong community leadership (e.g., physician
champions)
QIO Care Transitions:
Good News continues…
Integrate Care for Populations & Communities
–August 2011-present
August 2011
Integrating Care for Populations & Communities
Aims:
• Improve the quality of care for Medicare
beneficiaries as they transition between
providers
• Reduce 30 day hospital readmissions
(nationally) by 20% within 3 years
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QIO assistance
• Toolkit
– Root cause analysis
– Learning and Action Networks
– Learning Sessions
• Community Convening
• Social Network Analysis Diagrams
• Hot-spotting maps
• Data, data, data (e.g., readmission/admission
metrics; reach/intervention effectiveness measures)
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QIO Accomplishments as of March 31, 2013
# of Engaged Communities
# of Beneficiaries Living there
375
12,455,368
# Formally Recruited Communities
227
# Communities with Signed Coalition Charter
221
# Applications Submitted
125
# Communities Receiving Formal Funding
81
# Recruited Hospitals
859
# Recruited Nursing Homes
1,533
# Recruited Home Health Agencies
901
# Recruited Hospice Facilities
342
# Recruited Dialysis Facilities
91
# Recruited Outpatient Physicians
> 1900
National Coalition of QIO-recruited Communities Early Progress
6.8%
National Coalition of QIO-recruited Communities Early Progress
9.1%
50
Alabama Data
• Tied for 3rd highest number of recruited
communities over LOE; 5th highest number of
engaged communities over LOE
• Among 17 states having ALL interventions showing
improvement
• 38th in readmissions reduction
• 41st in admissions reduction
Interim Reductions!!!
10/1/10-3/31/11 compared to 10/1/11-3/31/12
53
Community
Readmissions
Admissions
Statewide
2.9%
2.8%
Community Care Coalition
of East Alabama
14.9%
9.4%
Top of Alabama Care
Transitions Innovation
Coalition
13.1%
5.2%
Healthy Gulf Coast Care
Transitions
7.2%
6.5%
Alabama
Top of Alabama Care Transitions Innovation Coalition
CCTP Partner as of March 2013
Intervention
# Beneficiaries
Touched
PCP follow-up appointments arranged
600
CHF program readmission rates
1500
INTERACT II
42
Patients Contacted Who Had Hospital Arranged Follow-up
Appointments
100%
Percent of those contacted
90%
80%
70%
R² = 0.7375
60%
50%
Median 41%
40%
30%
<-Intervention
20%
10%
0%
Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12
Month
Jul-12
Aug-12 Sep-12 Oct-12
Monthly CHF Readmission Rates
35.00%
Readmission Rate
30.00%
25.00%
CHF Program Median
18.67%
20.00%
15.00%
R² = 0.1116
10.00%
5.00%
0.00%
Month
Rate of Unplanned ER Visit + Hospitalization
0.45%
0.40%
0.35%
0.30%
Rate
Median 0.25%
0.25%
0.20%
0.15%
0.10%
R² = 0.1113
0.05%
0.00%
Jan-12
Feb-12 Mar-12 Apr-12 May-12 Jun-12
Month
Jul-12
Aug-12 Sep-12
Oct-12 Nov-12 Dec-12
October 1, 2010-March 31, 2011
compared to
October 1, 2011-March 31, 2012
5.2% Relative
Improvement in
Admissions/1000
Medicare FFS
Beneficiaries
13.1% Relative
Improvement in
Readmissions/1000
Medicare FFS
Beneficiaries
Community Care Coalition of East Alabama
Intervention
PCP follow-up appointment scheduled by patient
# Beneficiaries
Touched
256
Percent of Patients Who Made Their PCP Appointment
100%
R² = 0.7991
90%
Mean 92%
80%
Compliance
70%
60%
<-Intervention
50%
40%
30%
20%
10%
0%
March 26-31, 2012
Apr-12
May-12
Month
Jun-12
Jul-12
October 1, 2010-March 31, 2011
compared to
October 1, 2011-March 31, 2012
9.4% Relative
Improvement in
Admissions/1000
Medicare FFS
Beneficiaries
14.9% Relative
Improvement in
Readmissions/1000
Medicare FFS
Beneficiaries
Seeing Ourselves in the System
First image of the
entire Earth - 1968
Each of us is a system citizen
in that we are (potential) change agents
in the systems of which we are a part.
How to Get Started
• Contact your QIO
http://www.cfmc.org/integratingcare/files/ICPC_contacts.pdf
• Join (and listen to archived) Care Transitions
Learning Sessions
http://www.cfmc.org/integratingcare/learning_sessions.htm
• Browse our Toolkit
http://www.cfmc.org/integratingcare/toolkit.htm
65
Additional Resources
• Medicaring – an independent website for
improving care transitions www.medicaring.org
• Partnership for Patients
www.healthcare.gov/compare/partnership-for-patients/
• Community-based Care Transitions Program
http://go.cms.gov/caretransitions
• The AoA Toolkit
www.aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_caretransitions/Toolkit/index.aspx
66
Thank You & Questions
• NCC website
– www.cfmc.org/integratingcare
• Kim Irby
– kirby@cfmc.org
– 303-784-5710
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