QIO Care Transitions Activity: the good news so far… Alicia Goroski
Transcription
QIO Care Transitions Activity: the good news so far… Alicia Goroski
QIO Care Transitions Activity: the Good News so far… Kim Irby, MPH; [email protected] 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 • • • • 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 • • • • • • • • • • • • • • 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 • • • • 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 24 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 •••••• • INTERACT II HHQI Best Practices •• Project BOOST Bridge model GRACE Model •• Information Transfer • ••• ••••• •• •• •• •• •••••• ••• ••• Project RED STAAR Initiative Standard Process ••• •••••• ••• ••• ••• •• •• 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 41 Recurring Themes in Successful Communities • • • • • • 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 44 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) 45 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 – [email protected] – 303-784-5710 67