Care Transitions in Georgia: Partnering with your community to move readmissions

Jennifer Hodge RN MSBAAim Lead, Integrating Care for Populations Communities Alliant Georgia Medical Care Foundation

Objectives

► Participants will be able to articulate 2 changes in the QIO program

► Participants will be able to discuss 2 advantages to partnership with other community stakeholders to improve care delivery

► Participants will be able to name the community health care connections meeting nearest to their home

Georgia’s Strategy

► Change focus of established regional meetings

► Engage wide variety of providers

► Grow local leaders ► Spread interventions that

work► Identify links in other

CMS quality work ► Partner with others

Georgia Performance by ZIP Code

GA Score Card. LEFT: Report Date: 12/31/11 RIGHT: Report Date: 10/31/13

What’s The impact of all our work in Georgia?

► In the yellow communities, readmissions have been reduced by 21.60%

► Statewide readmissions have fallen 20.79%

► In Georgia 7292 fewer readmissions occurred in 2013 than in 2010

16.45%

18.65%

11.54%

19.65%

15.50%

20.65%

Traveling to Georgia for Care

Readmissions Penalties

QIN Statement of Work: 4 Key Roles for QIO

1. Results-Oriented: A Multi-State and Local Change-Agent Champion ► Data driven► Active engagement of patients and other

partners► Proactive, intentional innovation spread

that improves and “sticks”

2. Learning and Action Networks: A Facilitator of Learning and Action ► Implement an “all teach, all learn”

approach to share clinical QI expertise

QIN Statement of Work: 4 Key Roles for QIO (cont’d)

3. Technical Assistance: A Teacher and Advisor► Consultation and education in QI science

and process improvement► Knowledge management so learning is

never lost

4. Communication: A Highly Effective Communicator and Trusted Partner► Optimal learning, patient activation and

sustained behavior change► The “Go To” for health care transformation

Clinical Focus of 11th SOW ActivitiesImprove Cardiac Health and Reduce

DisparitiesImprove Coordination of Care

Reduce Disparities in Diabetes Care Reduce Adverse Drug Events

Collaborate with Regional Extension Centers and Promote Meaningful Use of HIT

Support Quality Reporting with an Emphasis on Improvement

Reduce Healthcare-Associated Infections in Hospitals

Perform Quality Improvement Initiatives as Requested

Reduce Healthcare-Acquired Conditions in Nursing Homes

Opportunity to Propose Projects That Meet Regional Needs

How They Want the Work Done (cont’d)

► Beneficiary engagement

– Included as component of every aim

– Work directly with beneficiaries and include beneficiaries in meetings

– Target racial and ethnic minority beneficiaries, dual-eligible beneficiaries, rural beneficiaries and the community providers who serve them

How They Want the Work Done (cont’d)► More focus on physician and physician

practices─ Technical assistance for quality reporting─ Promote use of EHRs and electronic data

reporting

► Leverage “virtual” activities such as learning and action networks─ Work with communities that cover 60% of

beneficiaries─ Work with 75% of nursing homes─ Integrate efforts across aims

► Plan for sustainability from the start

Note to Self: Supporting individuals in

their communities as they age will

take more effort than any single entity can provide.

Different Communities,Different Discharge Plans

Com 4 Savannah0

10

20

30

40

50

60

70

44.9

59.06

22.45

13.93

24.49

15.7

5.44 3.556.6

11.44

HomeSNFHHHospiceRead. Rate/ 1000 Beneficiaries

Promising Interventions Right here in Georgia

This material was prepared by Alliant GMCF, the Medicare Quality Improvement Organization for Georgia, 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. Publication No.