It Takes a Village
Community-Based Care Transitions
Improvement
Jane Brock, MD, MSPH
Colorado 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
Management
Lessons from the Care Transitions Theme
Drivers of Readmission, or why reducing hospital
readmissions is a community engagement project
Developing 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 Management
CPR Management
Clearly defined borders
Geographic isolation
Local adaptation of access ‘rules’
Local payer serving community needs
Participation of ‘appropriators’ in decisionmaking 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
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
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






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
30-day hospital readmissions per 1,000 eligible beneficiaries, semi-annual
(O-4)
Best-fit lines for observed rates
Lower is better. Statistically significant trends, per Cochrane-Armitage test, are indicated by bolded p-values.
50.00
45.00
11
1
40.00
35.00
30.00
11 (p<0.0001)
3
13
3 (p=0.8862)
1 (p<0.0001)
7
12
9
86
10
5
13 (p<0.0001)
9 (p=0.6007)
12 (p=0.0010)
7 (p<0.0001)
10 (p<0.0001)
8 (p<0.0001)
6 (p<0.0001)
5 (p=0.0003)
25.00
4
4 (p=0.0526)
20.00
15.00
2
2 (p<0.0001)
14
14 (p=0.1434)
10.00
Oct07-Mar08* Jan08-Jun08
Apr08-Sep08
Jul08-Dec08
Oct08-Mar09 Jan09-Jun09
Apr09-Sep09
Jul09-Dec09 Oct09-Mar10† Jan10-Jun10
Evaluation Period
Baseline measurement is indicated by an asterisk (*).
Follow-up evaluation is indicated by a dagger (†).
Apr10-Sep10
Jul10-Dec10
It’s not a hospital project
It’s a Community Problem
HHA
SNF
HHA
SNF
The ‘Zip Code Overlap’ Community
Definition
FFS Medicare beneficiaries
living in zip codes of interest
Target Population
FFS beneficiaries discharged
from hospitals of interest
Community identity supports both social and economic sustainability
Social Network Analytic techniques for
displaying the provider network
19
DEVELOPING A COMMUNITY PROJECT
TO REDUCE HOSPITAL READMISSIONS
1. RCA
Drivers
Data
Medical record review
Process assessment
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
1. RCA
Drivers
1. Data
2. Medical record review
3. Process assessment
2. Drivers + Settings = Interventions
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
CMS’ Table of Interventions
Available at: www.cfmc.org/caretransitions
Intervention Packages
Intervention
Reference
Main tools
Driver addressed
SKP
PAct
Inf
#
Care 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/ResourecRoom
Redesign
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_resour
ces/interventionpackages/default.aspx
Comprehensive manual for HHA process
improvement includes CTI teaching
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/StrategicInitiative
s/TransformingCareAt TheBedside.htm
(Re)Admission assessment, teach-back, pt
and family communication, scheduled f/u
XXX
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
XX
XX
Building Community Infrastructure
1. RCA
Drivers
1. Data
2. Medical record review
3. Process assessment
2. Drivers + Settings = Interventions
3. Backbone ‘agency’
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
I think it’s an
elephant!
• Backbone ‘agency’
•
•
•
Common agenda
Common measures
Structured collaboration
3 IMPORTANT THINGS WE
LEARNED:
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
PATIENT ACTIVATION
The CMS Discharge Planning
Checklist
http://www.medicare.gov/Publications/Pubs/pdf/11376.pdf
The Patient Activation Measure
www.insigniahealth.com
Sample
Questions:
#1: “When all is
said and done, I
am the person
who is
responsible for
taking care of my
health.”
The PAM is scored on a 100 point continuum. Most
patients score between 35 and 80
#12: “I am
confident I can
figure out
solutions when
new problems
arise with my
health”
Knowledge, skills and confidence
PATIENT ACTIVATION
37
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”
Community Organizing Techniques
Tie participation to values
Include personal
narratives
Intentionally develop
other leaders
Intentionally develop
relationships
Develop flexible tactics
EXAMPLES
Provider Pair:
HHAs and hospital pharmacy (NY)
25
20
15
HHA 1
10
HHA 2
5
0
Q1
(2009)
Q2
Q3
Q4
Q1
(2010)
Q2
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)
30-day hospital readmissions per 1,000 eligible beneficiaries
Hospital A, monthly
2
1.8
1.6
1.4
1.2
Median: 1.16
1
0.8
0.6
Readmission rate
Median
PATIENT ACTIVATION
J
M
A
M
F
D
Jan10
N
O
S
A
J
J
A
M
M
F
Jan09
D
N
S
O
J
A
J
A
M
F
M
D
Jan08
N
S
O
J
A
J
M
A
M
Jan07
0.2
F
Monthly readmissions per 1,000 eligible Medicare FFS beneficiaries in the target community depict a reduction in readmissions, first
observed in July 2009, due to special cause.
0.4
“IT’S CLEAR THAT SOMEBODY HAS TO
DO SOMETHING AND IT’S INCREDIBLY
PATHETIC THAT IT HAS TO BE US”
Jerry Garcia