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Ordinary to ExtraordinaryImproving Healthcare in Florida

Ferdinand Richards III, MDChief Medical Director

Peggy Loesch, BSN, MBA, RNCare Transitions Quality Specialist

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Overview

• FMQAI – Information for Healthcare Improvement Quality Improvement Organization (QIO) Program End Stage Renal Disease (ESRD) Network Program Key activities and opportunities to participate

• Improving Care Transitions through Collaboration, Commitment, and Action Care transitions and the reduction of avoidable readmissions Root causes of readmissions in Florida Coalition building across care settings to improve patient-

centered care

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FMQAIINFORMATION FOR HEALTHCARE IMPROVEMENT

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Who is FMQAI?

• Established in 1992 as Florida Medical Quality Assurance, Inc. Improve quality care and outcomes through data, education, and

technical assistance Collaborate with physicians, health plans, home health agencies,

nursing homes, dialysis facilities, rehabilitation facilities, and hospitals

• Nationally recognized healthcare contractor Florida Quality Improvement Organization (QIO) End Stage Renal Disease (ESRD) Networks – Arkansas, Florida,

Louisiana, Oklahoma, and Southern California Department of Health Private medical record review and chart abstraction

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The QIO Program

• Legislated under sections 1152-1154 of the Social Security Act• 53 QIOs tasked with review of medical care, investigation of

beneficiary complaints, and implementation of quality improvement activities for Medicare

• Evolution of the QIO program 1970s – Professional Standards Review Organization (PSRO) – performed

utilization reviews and special studies to improve quality of care 1982 – Utilization and Quality Control Peer Review Organization (PRO) – data

analysis to determine unnecessary, inappropriate, or poor quality 1992 – Health Care Quality Improvement Initiative (HCQII) – focus shifted from

case review to reporting patterns of care 2001 – QIO Program – renamed to be consistent with collaboration

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QIO 10th Statement of Work

• Bold goals – supports the aims of the DHHS National Quality Strategy

• Patient-centered care – includes the voice of the beneficiary in all their activities

• Boundarilessness – breaks down organizational, cultural, and geographic barriers

• Learning and Action Network (LAN) – accelerates change and spread of best practices where everyone teaches and learns

• Value-based purchasing – provides technical assistance, including sharing best practices and QI activities

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Medical Case Review

• Beneficiary complaints• Immediate advocacy• Appeals• Higher Weighted Diagnosis-Related Groups

(HWDRGs)• Emergency Medical Treatment and Active Labor Act

(EMTALA)

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Patient Safety

• Hospitals Central line-associated bloodstream infections (CLABSI) Catheter-associated urinary tract infections (CAUTI) Clostridium difficile (C. diff) Surgical site infections (SSI)

• Nursing homes Pressure ulcers Physical restraints Use of antipsychotic medications

• Clinical pharmacists, physicians, and facilities Adverse drug events (ADE) Potential ADEs

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Prevention

• Assist physician practices with use of electronic health record (EHR) system Coordinate prevention services Report quality measures

• Reduce patient risk factors for cardiac disease• Partner with local Health Information Technology

Regional Extension Centers (REC)

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Additional QIO Efforts

• Maintenance & Development of Medication Measures• Hospital Outpatient / Ambulatory Surgical Center Quality

Reporting Program Support Contractor• Beneficiary-centered Model for Weight Loss in African

American Communities – Senior Lifestyle Improvement Movement (SLIM)

• Patient and Family Engagement Campaign – Promoting e-Health Technology, Awareness & Knowledge (PEAK) Heart Health

• Beneficiary and Family-centered Care National Coordinating Center

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The ESRD Network Program

• The Social Security Amendments of 1972 created the national ESRD Program, which extended Medicare coverage to individuals with ESRD

• The Social Security Act was again amended in 1978 to create the ESRD Network Program Originally 32 regional ESRD Networks, now only 18 Networks Responsible for effective and efficient administration of

ESRD benefits Improve quality of care, collect data, provide technical

assistance, and review patient grievances

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Current ESRD Statement of Work

• Patient experience of care• Access to dialysis• Vascular access

management• Patient safety – healthcare

acquired infections (HAIs)• Immunization rates• ESRD quality incentive

program• Facility data submission

• Breakthrough collaboratives

• Patient engagement• Campaigns• Technical assistance• On-site visits• Learning and Action

Networks (LANs)

Strategic Aims Drivers of Change

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Key Activities & Opportunities

• HealthHub – community portal to promote sharing and collaboration of information resources, tools, and knowledge

• Learning and Action Networks – initiative that brings together healthcare professionals, patients, and other stakeholders

• No Place Like Home – stakeholders across care continuum to improve transitions of care and prevent hospital readmissions

• QIO Strategic Council (QSC) – leadership group to assist with coordinating efforts, minimizing duplication, maintaining momentum, enhancing commitment, and spreading the best practices

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www.healthhubfl.com

• Password protected• Secure repository for

documents, tools, and resources

• Forums• Polls• Calendar of events

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Learning and Action Network

April 11, 2014 Tampa, Florida

• Connect with organizations and individuals from across all provider types that have similar QI goals and challenges

• Learn from others in an "all teach, all learn" environment• Benefit from others' best practices • Receive and share free information and tools • Be recognized for meeting or exceeding improvement targets

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IMPROVING CARE TRANSITIONS THROUGH COLLABORATION, COMMITMENT, AND ACTION

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Objectives

• Know the significance of improving the quality of care transitions to reduce avoidable readmissions

• Understand the root causes of readmissions in Florida

• Recognize the importance of coalition building across care settings to improve patient-centered care

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National Strategy for Quality Improvement in Healthcare

• Established by the Affordable Care Act• Develops an infrastructure at the community level

that assumes responsibility for improvement efforts • Promotes patient-centered outcomes, efficiency, and

appropriate care while reducing or eliminating waste from the healthcare system

Source: http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm#fig3

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“Three-Part Aim”

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National Strategy for Quality Improvement in Healthcare

• Reduce Readmissions• Reduce inappropriate or

unnecessary care

Safer Care

• Enable patients and families to be able to navigate, coordinate care

• Improve the experience of care related to quality, safety, and access across settings

Engage

• Improve care transitions and communications

• Establish shared accountability and integration of communities and providers

CoordinateSource: www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm#fig3

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Timeline for National Quality Initiatives

2010 2011 2012 2013 2014 2015/2016

Hospital Medicare readmission penalties

NH Value-based purchasing demo (ended June 2012)

Hospital value-based purchasing program penalties

Community-based care transitions program Expansion of pilot programs to evaluate bundling payment for an episode of care

Reduce avoidable hospitalizations among nursing facility residents (ends August 2016)

QAPI demonstration project (ended August 2013)

Source: The Henry J. Kaiser Foundation. Health Reform Implementation Timeline : www.kff.org/healthreform/8060.cfm.

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Definition of Readmissions

“… in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital with in 30 days from the date of discharge.”

Source: http://www.cms.gov/Medicare/Medicare-fee-for-ServicePayment/AcuteInpatientPPS/Readmissions-Reduction-Program.html

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Readmissions Impact Multiple Areas

Quality

Patient Safety

Cost

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Magnitude of the Problem

• Analysis of 2007 Medicare data finds: 20% of beneficiaries are re-hospitalized within 30 days 35% are re-hospitalized within 90 days

• Among those re-hospitalized within 30 days: 50% had no claim for physician services between discharge

and re-hospitalization

Source: Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. The New England Journal of Medicine. 2009;360:1418-1428.

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Magnitude of the Problem (continued)

Beneficiaries with 10 or more chronic conditions are 6 times more likely to be readmitted to the hospital.

Source: Berkowitz SA, Anderson GF. Medicare beneficiaries most likely to be readmitted. J. Hosp. Med. Nov 2013;8(11):639-641.

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Magnitude of the Problem (continued)

A managed care organization with 18 hospitals:250 out of 537 (or 47%) readmissions were considered potentially avoidable.

Factors contributing to avoidable readmissions: Index stay

o Suboptimal management of the condition present The discharge process, care transitions, and care

coordinationo Unaddressed psychological and social needs

Follow-up careo Failure to adjust the plan of care to better meet patient needsSource: Feigenbaum P, Neuwirth E, Trowbridge L, et al. Factors contributing to all-cause 30-day readmissions: a structured case series across 18

hospitals. Med. Care. Jul 2012;50(7):599-605

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30-Day Readmission Rates

Source: ICPC Quarterly Scorecard for Florida, 1/1/2009-12/31/2012 issued 6/1/2013 from Colorado Foundation for Medical Care

18.60%19.36%

NationFlorida

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Risk of ReadmissionsHospitalDischarge

No post-acute f

ollow up

Readmission

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Issues Related to Care Transitions: Findings From Florida Communities

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Examples of Causes of Readmissions in Florida

Lack of Effective

Communication

Medication

Related

Issues

Lack of Resources

Discharge

Processes

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Industry Impact

Source: Medicare FFS Inpatient Claims, 2011.

$At $9,600 per readmission in 2011 readmission cost

Nation: $18,931,200,000

Florida: $47,833,440

$$

$$

$

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Patient Impact

• Re-hospitalization places patient and family under significant physical and emotional distress.

• The patient is at risk for potential medical errors, falls, and infections.

• Exposed to Post-Hospital Syndrome: “During hospitalization, patients are commonly deprived of sleep,

experience disruption of normal circadian rhythms, are nourished poorly, have pain and discomfort, confront a baffling array of mentally challenging situations, receive medications that can alter cognition and physical function, and become deconditioned by bed rest or inactivity…”

Source: Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N. Engl. J. Med. Jan 10 2013;368(2):100-102.

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State and National Quality Initiatives

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FMQAI – The Florida QIO

CommitmentCollaboration

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Role of FMQAI in Care Transitions

• Facilitate in coalition building• Assist with conducting root cause analyses• Provide education and support for the selection of

evidence-based interventions, implementation, and measurement

• Partner with local, regional, & statewide groups • Provide technical assistance including readmission

data for the coalitions

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The Role of the Community Organization

• Spearheads coalition building among providers, stakeholders, and service organizations Seen as trusted community presence Understands and transcends the politics of the community Motivates and engages in ongoing communications among

community stakeholders Promotes a shared vision for patient-centered change

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The Role of the Community Organization (continued)

• Provides expertise in the local community regarding needs and resources to maintain the health, independence, and choice of older adults and individuals with disabilities

• Represents the voice of the patient • Identifies the self-management support needed to

enhance patient and family engagement in their care

The Care Transitions Solution

Define the Problem Discharge

Process Mapping

Cause & Effect

Diagram (Fishbone)

Data Driven Root-Cause

Analysis

Evidenced-Based

SolutionsCost-Benefit

Analysis

Action Plan for

Improvement

Measure Intervention

Results

Sustain or Modify the

PlanHome Health

Hospitals

Skilled Nursing

Physicians

Patients

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CMS Partnership for Patients

• Hospital Engagement Networks (HENs)• Community-based Care Transitions Program (CCTP)• Patient and family engagement (through HEN, CCTP,

and QIO)

Source: http://partnershipforpatients.cms.gov/about-the-partnership/aboutthepartnershipforpatients.html

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26 Hospital Engagement Networks

8 of the 26 HENs are working with Florida Hospitals• The Health Research & Educational Trust, an affiliate of the

American Hospital Association (AHA)

• Ascension Health• Intermountain Healthcare

• Joint Commission Resources, Inc.• Lifepoint Hospitals, Inc. • Premier• UHC (formerly University Health System Consortium) • VHASource :http://partnershipforpatients.cms.gov/about-the-partnership/hospital-engagement-networks/thehospitalengagementnetworks.html

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The Goals of the Hospital Engagement Networks (HENs)

Source: http://partnershipforpatients.cms.gov/about-the-partnership/hospital-engagement-networks/thehospitalengagementnetworks.html

Learning Collaboratives

Patient Safety

Training Technical Assistance

Track & Monitor Progress

Coach Hospitals to Serve as

Leaders

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Community-based Care Transitions Program (CCTP)

The CCTP Partners – 5 in Florida

• Elder Options FL – Gainesville• Catholic Health Care Transitions

Services, Inc. − Lauderdale Lakes• Osceola-St. Cloud Community-based

Care Transitions Coalition • The Greater Miami Coalition to Prevent

Unnecessary Rehospitalizations FL• West Central Florida Area Agency on

Aging − Tampa

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The Goals of the Community-Based Care Transitions Program

Source: http://innovation.cms.gov/initiatives/CCTP

Improve Quality of

Care

Improve Care

Transitions

Reduce Readmissi

ons

Document Savings to Medicare

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No Place Like Home Campaign

• A campaign supported by a broad and growing base of stakeholders in the Florida healthcare community

• Focused on: Addressing the drivers of

through the implementation of evidenced-based practices

READMISSIONS

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No Place Like Home Campaign (continued)

• Shared Vision: A healthcare system where discharged patients:

o UNDERSTAND their conditionso KNOW who to contact with questions (and when)o ARE SUPPORTED by healthcare professionals who have

access to the right information, at the right time

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No Place Like Home Campaign (continued)

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No Place Like Home Campaign Basics

• Hospitals assign a multidisciplinary team Team lead, physician champion, and other team players

• Collect and analyze data• Invite post-discharge providers to participate

Skilled nursing facilities, home health, managed care organizations

• Develop and evaluate corrective actions using Plan, Do, Study, Act (PDSA)

• Implement successful corrective actions• Share lessons learned throughout the organization and

community

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30-day All-Cause Readmissions by Regions

Source: Medicare fee-for-service claims for Florida inpatient discharges January 1, 2013 – June 30, 2013.

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www.noplacelikehomefl.com (continued)

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www.noplacelikehomefl.com (continued)

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www.noplacelikehomefl.com (continued)

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Moving From Competition To Collaboration

• Taking risk (in this case, collaborating with your competition) can be the best opportunity for success and innovation.

• Create a strategic alliance with the goal of providing mutual benefit (e.g., improving the quality of patient centered care while reducing readmission rates).

• Recognize that improving care transitions and reducing readmissions takes time and commitment. Some challenges require “quick and easy” fixes while most

others will take long-term dedication.

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Moving From Competition To Collaboration (continued)

• Providers tend to have similar challenges but rarely have a chance to discuss these challenges across provider types.

• Identifying challenges within a community with all provider types represented at the table often starts with lots of finger pointing.

• Use other providers’ perspectives as learning opportunities. Challenges are likely interconnected between providers.

• Once everyone at the table decides to take ownership of the challenges as a community, actionable items arise.

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Organizing: People, Power, & Change

Source: Colorado Foundation for Medical Care.

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What is Power?

The ability to achieve purpose The ability to grow in capacity

Source: Adapted from ReThink Health.

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Building Relationships

Source: Colorado Foundation for Medical Care.

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One to One Meeting

Source: Colorado Foundation for Medical Care.

Collective Impact

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Source: Hanleybrown F, Kania J, Kramer M. Channeling change: Making collective impact work. Stanford Social Innovation Review;2012.

Shared agenda

Common, consistent

measurement

Mutually reinforced activities

Continuous, two-way

communication

Backbone support

Conditions needed to foster change through collective impact:

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What To Do By Next Tuesday?

Leave in Action:• Save the Date – April 11, 2014• Join HealthHub• What is a request or offer you would like to make?

“If you want to go quickly, go alone. If you want to go far, go together.”

-African proverb

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Questions

Ferdinand Richards III, MDfrichards@fmqai.com813-865-3584

Peggy Loesch, BSN, MBA, RNploesch@fmqai.com813-865-3438

This material was prepared by FMQAI, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services (HHS). The contents presented do not necessarily reflect CMS policy. FL-201X10SOW-XXXXXX-XX-XXXX