Progress in the MA STAAR Collaborative and Working Across the Continuum

Pat Rutherford

Rebecca Steinfield(The presenters have nothing to disclose)

MA STAAR Collaborative Learning SessionOctober 11, 2011

Session Objectives

Participants will be able to:

• Describe the case for creating a more patient-centered transition from the hospital to post-acute care

• Describe IHI/CMWF strategies and identify key interventions promoted in the MA STAAR Collaborative to reduce avoidable rehospitalizations

• Share an overview of the MA STAAR Collaborative progress to-date

Systems of Care

“The quality of patients’ experience is the “north star” for systems of care.” –Don Berwick

Rebecca Bryson lives in Whatcom County, WA and she suffers

from diabetes, cardiomyopathy, congestive heart failure, and a

number of other significant complications; during the worst of her

health crises, she saw 14 doctors and took 42 medications. In

addition to the challenges of understanding her conditions and the

treatments they required, she was burdened by the job of

coordinating communication among all her providers, passing

information to each one after every admission, appointment, and

medication change.

Rebecca’s Story

http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral/ImprovementStories/PursuingPerfectionReportfromWhatcomCountyWashingtononPatientCenteredCare.htm

Rebecca said if she were to dream up a tool that would be

truly helpful, it would be something that would help her

keep her care team all on the same page. Bryson described

typical medical records as being “location or process

centered, not patient-centered.” She also describes how

difficult it can be for patients to navigate a large health care

system. Rebecca summarizes her experience in this way –

“Patients are in the worst kind of maze, one filled with

hazards, barriers, and burdens.”

Rebecca’s Story

http://www.ihi.org/IHI/Topics/PatientCenteredCare/PatientCenteredCareGeneral/ImprovementStories/PursuingPerfectionReportfromWhatcomCountyWashingtononPatientCenteredCare.htm

“North Star” in STAAR?

Whose experience of care is the “north star” for your system of care?

Strategic Questions for Executive Leaders

• Is reducing the hospital’s readmission rate a strategic priority for the executive leaders at your hospital? Why?

• Do you know your hospital’s 30-day readmission rate?

• What is your understanding of the problem?

• Have you assessed the financial implications of reducing readmissions? Of potential decreases in reimbursement?

• Have you declared your improvement goals?

• Do you have the capability to make improvements?

• How will you provide oversight for the collaborative, learn from the work and spread successes?

What can be done, and how?

There exist a growing number of approaches to reduce

30-day readmissions that have been successful locally

Which are high leverage?

Which are scalable?

Success requires engaging clinicians, providers across organizational and service delivery types, patients, payers, and policy makers

How to align incentives?

How to catalyze coordinated effort?

• Provide technical assistance to front-line teams of providers working to improve the transition out of the hospital and into the next care setting

• Actively engage hospitals and their community partners in co-designing processes to improve transitions

• Provide coaching by content experts and facilitate collaborative learning with the goals of creating exemplary cross continuum models in each state and identifying high-leverage changes in each care setting

• Develop quality improvement expertise and content experts to mentor others

• Create and support state-based, multi-stakeholder initiatives to concurrently examine and address the systemic barriers to improving care transitions, care coordination over time.

• State leadership, steering committees, key allies, aligning initiatives• Technical assistance to “staff” challenges in framing the issue, designing strategy,

scanning for developments in best practice/policy• Specific focus areas: understanding the financial impact of success, aligning payment

to support high leverage interventions, developing state rehospitalization data reports

STAAR Initiative: Two Concurrent Strategies

Evidence-Based Interventions

• Boutwell, A. Griffin, F. Hwu, S. Shannon, D. Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions. Cambridge, MA: Institute for Healthcare Improvement; 2009

• Kanaan SB. Homeward Bound: Nine Patient-Centered Programs Cut Readmissions. CHCF, Sept 2009.

• Osei-Anto A, Joshi M, Audet AM, Berman A, Jencks S, Health

Care Leader Action Guide to Reduce Avoidable Readmissions. Health Research & Educational Trust, Chicago, IL. January 2010

or

IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations

* Additional Costs for these Services

Improved Transitionsand Coordination of Care

Reduction in Avoidable Rehospitalizations

Patient and Family Engagement

Cross-Continuum Team Collaboration

Evidence-based Care in All Clinical Settings

Health Information Exchange and Shared Care Plans

or

IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations

* Additional Costs for these Services

Improved Transitionsand Coordination of Care

Reduction in Avoidable Rehospitalizations

Patient and Family Engagement

Cross-Continuum Team Collaboration

Evidence-based Care in All Clinical Settings

Health Information Exchange and Shared Care Plans

Co-designing Processes to Improve Transitions

4 Key Changes to Improve the Transition from Hospital to Home

1. Perform an Enhanced Assessment of Post-Hospital Needs

2. Provide Effective Teaching and Facilitate Enhanced Learning

3. Ensure Post-Hospital Care Follow-Up

4. Provide Real-Time Handover Communications

1. Enhanced Assessment

 1. Perform an Enhanced Assessment of Post-Hospital Needs 

A. Involve the patient, family caregiver(s) and community provider(s) as full partners in completing a needs assessment of the patient’s home-going needs.

 B. Reconcile medications upon admission.

C. Create a customized discharge plan based on the assessment

2. Effective Teaching and Facilitate Learning

 2. Provide Effective Teaching and Facilitate Enhanced Learning

 A. Involve all learners in patient education.

 B. Redesign the patient education process.

 C. Redesign patient teaching print materials.

 D. Use Teach Back regularly throughout the hospital stay to assess the patient’s and family caregivers’ understanding of discharge instructions and ability to perform self-care.

3. Follow-up Care

 3. Ensure Post-Hospital Care Follow-up

 A. Reassess the patient’s medical and social risk for readmission.

 B. Prior to discharge, schedule timely follow-up care and initiate clinical and social services based upon the risk assessment.

 

4. Handover Communications

 4. Provide Real-Time Handover Communications

 A. Give patient and family members a patient-friendly post-hospital care plan which includes a clear medication list.

 B. Provide customized, real-time critical information to next clinical care provider(s).

 C. For high-risk patients, a clinician calls the individual(s) listed as the patient’s next clinical care providers(s) to discuss the patient’s status and plan of care. 

or

IHI’s Roadmap for Improving Transitions and Reducing Avoidable Rehospitalizations

* Additional Costs for these Services

Improved Transitionsand Coordination of Care

Reduction in Avoidable Rehospitalizations

Patient and Family Engagement

Cross-Continuum Team Collaboration

Evidence-based Care in All Clinical Settings

Health Information Exchange and Shared Care Plans

New Frontiers in the STAAR Initiative

Engaging Payers:

• Payers are motivated to reduce avoidable rehospitalizations

• Individual payer efforts─ Mostly focus on pre-discharge preparation─ CMS 3026 to pay for additional community-based care─ Discrepancies between what providers get paid for and what is needed

for care ─ Supplemental services for high-risk patients are of paramount

importance─ What is the comparative effectiveness for various interventions for

high-risk patients?

• Myriad payer-based discharge planning and care coordination services create chaos at provider level. How can interests be aligned and coordinated?

Improving Transitions and Reducing Avoidable Rehospitalizations

RESULTS

Ideas

Will

Execution

Build confidence

Sequencing and tempo

Newpossibilities

What Changes Are You Working On?

What Changes Are You Working On?

Including Patients and Families

Including Comm

unity Caregivers

Med Reconciliation

initial risk of readmission

Customized post-hosp. care plan

Involving all Learners

Using Teachback

reassessing risk

Scheduling post-acute FU internventions

Provide written post-hosp care plan

Provide real-time critical info

Warm

handover

Baystate Medical CenterBerkshire Medical CenterBeth Israel Deaconess Medical CenterBrigham and Women's HospitalCambridge Health AllianceCooley Dickinson HospitalFairview HospitalFaulkner HospitalLahey Clinic Medical CenterMassachusetts General HospitalMetroWest Medical CenterNewton-Wellesley HospitalNorth Shore Medical CenterNortheast Hospital CorporationSaint Vincent HospitalSaints Medical CenterSouth Shore HospitalSt. Elizabeth's Medical CenterSturdy Memorial HospitalTufts Medical CenterUMass Memorial Medical CenterVA Boston Healthcare System

UnknownUK

No changes being testedtesting

implementingspreading

spread complete/already established

Key

Cohort 1

Including Patients and Families

Including Comm

unity Caregivers

Med Reconciliation

initial risk of readmission

Customized post-hosp. care plan

Involving all Learners

Using Teachback

reassessing risk

Scheduling post-acute FU internventions

Provide written post-hosp care plan

Provide real-time critical info

Warm

handover

Baystate Franklin Medical CenterBaystate Mary Lane HospitalBIDMC NeedhamCape Cod HospitalCarney HospitalEmerson HospitalFalmouth HospitalGood Samaritan Medical CenterHallmark Health SystemHarrington HospitalHeywood HospitalHoly Family Hospital & Medical CenterHolyoke Medical CenterJordan HospitalLawrence General HospitalLowell General HospitalMerrimack Valley HospitalMilford Regional Medical CenterMilton HospitalMorton Hospital & Medical CenterMt. Auburn HospitalNew England Baptist HospitalNorwood HospitalSisters of Providence Health SystemSt. Anne's HospitalWinchester HospitalWing Memorial Hospital and Medical Center

UnknownUK

No changes being testedtesting

implementingspreading

spread complete/already established

Key

Cohort 2

Analysis of Results-to-Date

• Reducing readmissions is dependent on highly functional cross continuum teams and a focus on the patient’s journey over time

• Improving transitions in care requires co-design of transitional care processes among “senders and receivers”

• Providing intensive care management services for targeted high risk patients is critical

• Reliable implementation of changes in pilot units or pilot populations require 18 to 24 months

The Next Year in the MA STAAR Initiative

• Two 1.5-day state-wide Learning Sessions plus monthly content coaching calls

• State Leaders and IAs facilitate monthly networking/peer coaching calls

• Improvement Science in Action Workshop (for day-to-day leaders in hospitals, SNFs, HC agencies and OPs) plus monthly coaching calls

• IHI and expert faculty will facilitate Learning Networks for clinicians and staff in OP, SNFs and HC Agencies

• MA STAAR State Leaders and State-wide Steering Committee Meetings align initiatives and address systemic barriers