partnership for patients

Partnership for Patients Initiative: Relationships and Collaborations National Organization of State Offices of Rural Health May 31, 2012 Jessica Burkard, Presenters Special Projects Coordinator NOSORH Traci Archibald, Office of

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  1. Partnership for Patients Initiative: Relationships and Collaborations National Organization of State Offices of Rural Health May 31, 2012

  2.  Jessica Burkard, Presenters Special Projects Coordinator NOSORH  Traci Archibald, Office of Clinical Standards and Quality, Centers for Medicare and Medicaid Services  Ed Shanshala, II, Chief Executive Officer Ammonoosuc Community Health Services, Inc.  Jeff Spade, Executive Director, NC Center for Rural Health Innovation and Performance, North Carolina Hospital Association

  3. Presentation Outline  NOSORH PfP Work  Current/Past Work  Upcoming Meetings  Quality Improvement Organization  Hospital Engagement Network  Rural Health Clinic  Questions and Comments

  4. NOSORH PfP Work What’s we’ve done What we’re planning PfP Toolkit Edition 2 SORH Calls assessing 1. 1. Learning Community interest 2. Calls 2. Webinar Introduction PfP Updates at 3. to PfP Regional Meetings PfP Toolkit Edition 1 3. Post Conference 4. Session-NOSORH 4. Learning Community Annual Mtg Calls (2 series) Participate in HEN 5. Member of Rural 5. meeting content Affinity Group development


  6. ICPCA Goals  Improve the quality of care for Medicare beneficiaries as they transition between providers  Reduce 30 day hospital re-admissions by 20% over 3 years for the nation 6

  7. Care Transitions A definition…  Movement of patients between health care locations, providers, or different levels of care within the same location, as their conditions and care needs change.  Specifically, they can occur:  Within settings  Between settings  Across health states  Between providers National Transitions of Care Coalition 7

  8. QIOs and Community Engagement 8  Identify potential communities- defined by the Medicare beneficiaries that live in contiguous set of zip codes  Recruit and convene community providers and stakeholders to collaborate to improve care transitions and reduce 30-day hospital readmissions for the beneficiaries they serve

  9. QIO Technical Assistance 9  Community Coalition Formation  Community-specific Root Cause Analysis  Intervention Selection, Implementation and Measurement Strategies  Assist with an Application for a Care Transitions Program

  10. Community Organizing Techniques  Tie participation to values  Include personal narratives  Intentionally develop other leaders  Intentionally develop relationships  Develop flexible tactics

  11. Strategic Plan  Include broad range of community leaders  Provider groups  Community based organizations (CBO’s)  AAAs and ADRC’s  Regional Health Initiatives  State and local government  Advocacy and Service Organizations  Other payers 11

  12. Why are people readmitted? Provider-Patient interface U nmanaged 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

  13. Community Specific Root Cause Analysis  Data Analysis  Proportion of Transitions Table  Coalition Readmission rates  Coalition Admission rates  Hospital Admission rates  Hospital Readmission rates  ED visit Rates  Observation Stay Rates  Mortality Rates  Post acute care setting Readmission rates  Disease specific readmission rates  Process Mapping  Chart Reviews 13  Patient/Stakeholder feedback

  14. ZIP Code Level Readmissions per 1000 Beneficiaries (January 1, 2010 – December 31, 2010

  15. Intervention Selection & Implementation Plan  Results from the community specific root cause analysis  Existing local programs and resources  Funding resources  Cost estimates associated with intervention implementation  Estimates for intervention penetration  Sustainability  Community preferences 15

  16. Intervention Models THE BRIDGE MODEL 16

  17. Intervention Measurement Strategies  Involves a series of Reach, Intervention Effectiveness and Utilization Measures  Providers and CBO’s will need to collect most of the Reach and Intervention Effectiveness Measure data  QIOs can help facilitate linking Medicare claims- based Utilization Measures to interventions  QIOs are working with communities to prepare run charts showing the impact of interventions over time

  18. Application for participation in a formal Care Transitions Program  Data analyses and trending reports  Interventions selection rationale  Cost estimates for interventions  Other application requirements 18

  19. Additional Assistance for Communities  Provide quarterly community readmission metrics  Host a State-wide Learning and Action Network  Participate in Care Transitions Learning Sessions  Use QIO developed tools and resources 19

  20. QIO Activity (August 1, 2011-March 31, 2012)  149 Communities Recruited  121 Community Coalition Charters Signed  Assisted with 68 Communities Submitting Applications to Care Transitions Funded Programs  Contributed to 22 Accepted Care Transitions Program Applications 20

  21. QIO-Recruited Communities March 30, 2012


  23. Objectives  Describe the Partnership for Patients (PFP) initiative  Understand the key elements of the Hospital Engagement Network  NoCVA as HEN example  Engagement ideas for SORHs

  24. Partnership for Patients

  25. National Alignment  Affordable Care Act – the law  National Quality Strategy – the vision o To set the priorities for increased access to high quality, affordable care o National aims and priorities  Partnership for Patients – the campaign  Hospital Engagement Network – resources and support

  26. Partnership Goals Reduce harm caused to patients in hospitals By the end of 2013, preventable hospital- acquired conditions would decrease by 40% compared to 2010 Approximately 1.8 million fewer injuries to patients, more than 60,000 lives saved over three years!

  27. Hospital-acquired Conditions  Central line associated blood stream infection  Catheter associated urinary tract infection  Surgical site infection  Pressure ulcers  Injuries from falls and immobility  Adverse drug events  Obstetrical adverse events  Venous thromboembolism  Ventilator-associated pneumonia

  28. Partnership Goals Improve care transitions By the end of 2013, preventable complications during a transition from one care setting to another would be decreased such that all hospital readmissions would be reduced by 20% compared to 2010 Approximately 1.6 million patients would recover from illness without suffering a preventable complication requiring re-admission within 30 days of discharge!

  29. Partnership Programs  The Hospital Engagement Network (HEN) o Essential network of resources to support hospitals in achieving PFP goals. o 26 HENs o Conduct training programs in all core events o Provide technical assistance o Measure and track improvements/outcomes o Funding for 2 years, optional third year o Hospitals pledge to join only one HEN

  30. Hospital Engagement Networks American Hospital Association Minnesota Hospital Association   Ascension Health National Public Health and Hospital   Institute Carolinas HealthCare System  New Jersey Hospital Association Catholic Healthcare West   Nevada Hospital Association Dallas-Fort Worth Hospital Council   Foundation North Carolina Hospital Association  Georgia Hospital Association Research Ohio Children’s Hospital Solutions for   and Education Foundation Patient Safety Healthcare Association of New York State Ohio Hospital Association   Hospital & Healthsystem Association of Premier Tennessee Hospital Association   Pennsylvania Texas Center for Quality & Patient Safety  Intermountain Healthcare  United Healthcare Veteran’s Health  Iowa Healthcare Collaborative Administration  Joint Commission Resources, Inc. Washington State Hospital Association   Lifepoint Hospitals, Inc.  Michigan Health & Hospital Association 

  31. PFP Internet Resources  CMS Innovation Center  Patients/index.html AHA & HRET  Institute for Healthcare Improvement (IHI)  efault.aspx Healthcare Communities (PFP) 

  32. North Carolina Virginia Hospital Engagement Network

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