Partnership for Patients Initiative: Relationships and

Collaborations

National Organization of State Offices of Rural Health May 31, 2012

Presenters Jessica Burkard,

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

Presentation Outline

NOSORH PfP Work

Current/Past Work

Upcoming Meetings

Quality Improvement Organization

Hospital Engagement Network

Rural Health Clinic

Questions and Comments

What’s we’ve done What we’re planning

1. SORH Calls assessing interest

2. Webinar Introduction to PfP

3. PfP Toolkit Edition 1

4. Learning Community Calls (2 series)

5. Member of Rural Affinity Group

1. PfP Toolkit Edition 2 2. Learning Community

Calls 3. PfP Updates at

Regional Meetings 4. Post Conference

Session-NOSORH Annual Mtg

5. Participate in HEN meeting content development

NOSORH PfP Work

Integrating Care for Populations and

Communities Aim

T R A C I A R C H I B A L D , O T R / L , M B A

Q U A L I T Y I M P R O V E M E N T G R O U P

O F F I C E O F C L I N I C A L S T A N D A R D S A N D Q U A L I T Y

C E N T E R S F O R M E D I C A R E A N D M E D I C A I D S E R V I C E S

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

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

http://www.ntocc.org/Portals/0/TransitionsOfCare_Measures.pdf

7

QIOs and Community Engagement

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

8

QIO Technical Assistance

Community Coalition Formation

Community-specific Root Cause Analysis

Intervention Selection, Implementation and Measurement Strategies

Assist with an Application for a Care Transitions Program

9

Community Organizing Techniques

Tie participation to values

Include personal narratives

Intentionally develop other leaders

Intentionally develop relationships

Develop flexible tactics

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

Why are people readmitted?

No Community infrastructure for achieving common goals

Unreliable system support Lack of standard and known processes Unreliable information transfer Unsupported patient activation during transfers

Provider-Patient interface Unmanaged condition worsening

Use of suboptimal medication regimens

Return to an emergency department

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

Patient/Stakeholder feedback

13

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

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

Intervention Models

16

THE BRIDGE MODEL

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

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

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

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

QIO-Recruited Communities March 30, 2012

J E F F S P A D E , E X E C U T I V E D I R E C T O R ,

N C C E N T E R F O R R U R A L H E A L T H I N N O V A T I O N A N D P E R F O R M A N C E

Hospital Engagement Network

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

Partnership for Patients

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

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!

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

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

Approximately1.6 million patients would recover from

illness without suffering a preventable complication

requiring re-admission within 30 days of discharge!

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

American Hospital Association Ascension Health Carolinas HealthCare System Catholic Healthcare West Dallas-Fort Worth Hospital Council

Foundation Georgia Hospital Association Research

and Education Foundation Healthcare Association of New York State Hospital & Healthsystem Association of

Pennsylvania Intermountain Healthcare Iowa Healthcare Collaborative Joint Commission Resources, Inc. Lifepoint Hospitals, Inc. Michigan Health & Hospital Association

Minnesota Hospital Association National Public Health and Hospital

Institute New Jersey Hospital Association Nevada Hospital Association North Carolina Hospital Association Ohio Children’s Hospital Solutions for

Patient Safety Ohio Hospital Association Premier Tennessee Hospital Association Texas Center for Quality & Patient Safety United Healthcare Veteran’s Health

Administration Washington State Hospital Association

Hospital Engagement Networks

PFP Internet Resources

CMS.gov http://www.healthcare.gov/compare/partnership-for-patients/

CMS Innovation Center http://innovations.cms.gov/initiatives/Partnership-for-

Patients/index.html

AHA & HRET http://www.hret-hen.org/

Institute for Healthcare Improvement (IHI) http://www.ihi.org/explore/CMSPartnershipForPatients/Pages/d

efault.aspx

Healthcare Communities (PFP) http://www.healthcarecommunities.org/default.aspx

North Carolina Virginia

Hospital Engagement Network

North Carolina Virginia HEN

NCHA as the prime contractor

o NC Quality Center is leading the initiative

VHHA is a subcontractor and partner

Other subcontractors

o Carolinas Center for Medical Excellence (CCME)

o Healthcare Team Training (HTT)

o Virginia Health Quality Center (VHQC)

Many partners

120 NC and VA hospitals

Who Has Pledged?

170 VA organizations

260 NC organizations

http://partnershippledge.healthcare.gov/

Component Collaborative

Learning Network

Campaign Educational Program

Data collection X X X X

In-person learning sessions X X X X

Comprehensive toolkit X X X X

Teleconferences/web conferences

monthly quarterly X X

Cultural components X X X X

Website X (collab only)

X (LN only)

X

List serv X X

Prework X

Project timeline with milestones

X

AHRQ Hospital Survey on Patient Safety Culture (HSOPSC) or Surgical Safety Survey (SSS)

X

Quarterly, individual telephone consult calls with collaborative coach

X

Small, Rural Hospitals Enrolled

in NoCVA

17 Critical Access Hospitals

22 rural hospitals less than 30 average daily census

8 hospitals 30 to 50 average daily census

3 hospitals 50 to 60 average daily census

Small, Rural Focus Areas

Targeting six PfP activities that are the most relevant harm categories and improvement opportunities for small, rural hospitals:

o Eliminating CAUTI

o Falls prevention

o Improved pressure ulcer care

o Surgical site infection prevention

o Reducing adverse drug events

o Improving care transitions to prevent hospital

readmissions

Major Activities for Rural Hospitals

Complete the organizational assessment.

The Center will help small, rural hospitals enroll in the collaboratives organized by NoCVA.

Organizing face-to-face improvement workshops, two workshops in eastern NC and two workshops in western NC annually.

Develop and post to the internet two webinars annually focused on the six PfP activities.

Webinars and workshops are devoted to focused improvement concepts, evidence-based practices, rural hospital examples and shared learning.

Engagement and Partnership Ideas

Sign the PFP Pledge as a state-level partner

Actively seek a partnership role: How can I (we) help achieve success?

Promotion

Enrollment

Engagement

Encourage CAHs and small, rural hospitals to join the HEN

Align MBQIP and FLEX with PFP

Help organize improvement collaboratives

Engage rural health partners

E D W A R D D S H A N S H A L A I I , M S H S A , M S E D , C E O

ACHS Ammonoosuc Community

Health Services

Who are we? We are ACHS.

Scope ACHS is an NCQA Level 3 PCMH including medical, behavioral,

dental, pharmacological and enabling services.

Priorities/Mission To provide a network of comprehensive Primary Health Care and

Support Services to individuals and families throughout the 26 communities we serve. In support of this mission, ACHS provides evidence-based, outcome-specific, systematic care that is: patient-centered, prevention-focused, accessible and affordable for all.

Community ACHS Serves 26 towns in the White Mountain Region of Northern

New Hampshire Collaborating Partners cover the continuum of care

Statistics ACHS is the Patient Centered Medical Home of Choice for 1 in 3 of

the 31,000 residents in our service area.

Quality & Patient Safety an Integrated Approach

Rather than Quality & Patient Safety contrasted an integrated paradigm may proved most effective and efficient; a question to consider.

Place the patient at the center and work one’s way outward to resolve differences.

Not a zero sum endeavor rather a multi-win scenario

Current Partnership for Patients Initiatives

Examples of Projects for SORH Collaboration

• Health Resource Service Administration (HRSA)

• Chronic Disease Collaborations

• Patient Safety Pharmacy Collaborative (PSPC)

• Federally Qualified Health Center (FQHC), Critical Access Hospital (CAH), and Certified Home Health & Hospice Agency (CHHA) Collaborations

• Health Information Exchange (HIE)

• Accountable Care Organization (ACO)

• Patient Safety Pharmacy Collaborative (PSPC)

• Regional Healthcare Consortium Collaborations

• Oral Health

• Accountable Care Organization (ACO)

• Statewide Healthcare Consortium Collaborations

• New Hampshire (NH) Citizens Health Initiative (CHI) Patient Centered Medical Home (PCMH) Pilot Project

• New Hampshire Citizens Health Initiative Accountable Care Organization Pilot Project

BACKGROUND

• 1998 Depression, Diabetes, Asthma, Coronary Artery Disease.

GOALS

• Disease specif ic i .e . , PHQ9 (Depression), HgA1c (Diabetes), etc. ,

Health Resource Service Administration (HRSA) Chronic Disease Collaborations

BACKGROUND

• 2009 ACHS joins PSPC with an init ial population of focus of 62 diabetics who had 12 or more prescription medications on their active medication l ist .

GOALS

• (1) Diabetes in control , (2) decrease potential & adverse drug events (ADE), (3) decrease emergency department and acute care uti l ization for ADE’s

HRSA Patient Safety Pharmacy Collaborative (PSPC)

BACKGROUND

• 2006 ACHS ini t iates labs being performed by Lit t leton Regional Hospi ta l and Cottage Hospi ta l whereby the resul ts are del ivered through an HL7 inter face into the ACHS General E lectr ic Centr ic i ty Electronic Heal th Record/Pract ice Management Solut ion.

GOALS

• (1)Increase accuracy , t imel iness , e f fect iveness , and ef f ic iency of lab resul ts . (2) F inancia l s tabi l i zat ion of a l l organizat ions through co l laborat ion

FQHC and CAH Collaborations Health Information Exchange (HIE)

BACKGROUND

• ACHS was the lead agency leveraging NCQA PCMH Level 3 recogni t ion and exis t ing co l laborat ion with Lit t leton Regional Hospi ta l , Cottage Hospi ta l , and North Country Home Health and Hospice to become a p i lot for the NH CHI ACO Pi lot Project

GOALS

• (1) enhance pat ient f low through the cont inuum of care (2) improve qual i ty o f c l in ica l outcomes (3) e l iminate non -value added work and associated expense.

FQHC, CAH, CHAA Collaborations Accountable Care Organization (ACO)

BACKGROUND

• ACHS is the 340B Contract for Li t t le ton Regional Hospita l , i s in conversat ions wi th Cottage Hospi ta l for 340B and both of which are engaged in the PSC

GOALS

• (1) Implement and integrate c l in ica l pharmacy services across the cont inuum of care , (2) decrease potent ia l/adverse drug events , (3) decrease polypharmacy, (4) decrease pharmacy re lated emergency department and acute care use .

FQHC and CAH Collaborations Patient Safety Pharmacy Collaborative (PSPC)

B A C K G R O U N D

• T h e N o r t h C o u n t r y H e a l t h C o n s o r t i u m ( N C H C ) i s a r u r a l h e a l t h n e t w o r k , c r e a t e d i n 1 9 9 7 , a s a v e h i c l e f o r a d d r e s s i n g c o m m o n i s s u e s t h r o u g h c o l l a b o r a t i o n a m o n g h e a l t h a n d h u m a n s e r v i c e p r o v i d e r s s e r v i n g N o r t h e r n N e w H a m p s h i r e . T h e M o l a r E x p r e s s i s a n e x a m p l e o f a c o l l a b o r a t i v e e f f o r t t o m e e t t h e u n m e t o r a l h e a l t h n e e d s o f a r u r a l p o p u l a t i o n

G O A L S

• ( 1 ) F o c u s o n S c h o o l - B a s e d H y g i e n e P r o g r a m , O r a l H e a l t h E d u c a t i o n , N u r s i n g H o m e s a n d e f f i c i e n t u s e o f l i m i t e d o r a l h e a l t h r e s o u r c e s . ( 2 ) E x p a n d t o a “ H u b & S p o k e ” m o d e l w i t h F Q H C a n d C A H C o l l a b o r a t i o n . ( 3 ) E x p a n d t o t e a c h f a c i l i t y w i t h N H D H H S , B i - S t a t e , P C A , H R S A , a n d U n i v e r s i t y o f N e w E n g l a n d

Regional Healthcare Consortium Collaborations Oral Health: Molar Express

B A C K G R O U N D

• L e a d b y M i d S t a t e H e a l t h C e n t e r , t h e N o r t h C o u n t r y H e a l t h C o n s o r t i u m a s t h e p a r e n t o r g a n i z a t i o n c r e a t e d t h e N o r t h C o u n t r y A c c o u n t a b l e C a r e O r g a n i z a t i o n a s a n o n - p r o f i t s u b s i d i a r y o f N C H C c o m p r i s e d o f M i d S t a t e H e a l t h C e n t e r , A m m o n o o s u c C o m m u n i t y H e a l t h S e r v i c e s , C o ö s F a m i l y H e a l t h S e r v i c e s , a n d I n d i a n S t r e a m H e a l t h C e n t e r . N C A C O i s n o w a C M S S h a r e d S a v i n g s A d v a n c e d P a y m e n t M o d e l A C O P i l o t P r o j e c t .

G O A L S

• ( 1 ) e n h a n c e p a t i e n t f l o w t h r o u g h t h e c o n t i n u u m o f c a r e ( 2 ) i m p r o v e q u a l i t y o f c l i n i c a l o u t c o m e s ( 3 ) e l i m i n a t e n o n - v a l u e a d d e d w o r k a n d a s s o c i a t e d e x p e n s e .

Regional Healthcare Consortium Collaborations Accountable Care Organization (ACO)

B A C K G R O U N D

• A C H S p a r t i c i p a t e d w i t h 8 o t h e r o r g a n i z a t i o n s a n d c o m m e r c i a l i n s u r a n c e o r g a n i z a t i o n s i n a p a t i e n t c e n t e r e d m e d i c a l h o m e t h r e e y e a r d e m o n s t r a t i o n p r o j e c t . T h e u n p u b l i s h e d r e s u l t s o f w h i c h d e m o n s t r a t e s u c c e s s b o t h c l i n i c a l l y a n d f i n a n c i a l l y a n d e n a b l e A C H S t o e x p a n d i n t o t w o A C O p i l o t p r o j e c t s

G O A L S

• ( 1 ) C l i n i c a l o u t c o m e s c o n s i s t e n t w i t h H e a l t h P e o p l e s t a n d a r d s . ( 2 ) e n h a n c e d p a t i e n t e n g a g e m e n t a s a c t i v e p a r t i c i p a n t s i n t h e i r o w n h e a l t h c a r e . ( 3 ) f i n a n c i a l l y s u s t a i n a b l e m o d e l o f c a r e

Statewide Healthcare Consortium Collaborations NH CHI PCMH Pilot Project

B A C K G R O U N D

• A C H S w a s t h e l e a d a g e n c y l e v e r a g i n g N C Q A P C M H L e v e l 3 r e c o g n i t i o n a n d e x i s t i n g c o l l a b o r a t i o n w i t h L i t t l e t o n R e g i o n a l H o s p i t a l , C o t t a g e H o s p i t a l , a n d N o r t h C o u n t r y H o m e H e a l t h a n d H o s p i c e t o b e c o m e a p i l o t f o r t h e N H C H I A C O P i l o t P r o j e c t

G O A L S

• ( 1 ) e n h a n c e p a t i e n t f l o w t h r o u g h t h e c o n t i n u u m o f c a r e ( 2 ) i m p r o v e q u a l i t y o f c l i n i c a l o u t c o m e s ( 3 ) e l i m i n a t e n o n - v a l u e a d d e d w o r k a n d a s s o c i a t e d e x p e n s e .

Statewide Healthcare Consortium Collaborations NH CHI ACO Pilot Project

NEEDS-HIGHLIGHT SORH ROLE

• Facilitator of process.

• Connector to policy makers

• Provider of data and / or data analysis

• Access to funders

Needs-highlight SORH role in Collaboration

What works What doesn’t work

• C o n v e n e p o t e n t i a l c o l l a b o r a t o r s

• F a c i l i t a t e c o l l a b o r a t i v e p r o c e s s

• C r e a t e c o n n e c t i o n t o t o p o l i c y m a k e r s

• P r o v i d e d a t a a n d / o r d a t a a n a l y s i s

• P r o v i d e a c c e s s t o f u n d e r s

• A u t h o r t h e “ s t o r y ” .

• F a c i l i t a t e r e p l i c a t i o n

• L e a d b y

• B e i n g

• K n o w i n g

• D o i n g

• T a k i n g s i d e s

• H a v i n g a l l t h e a n s w e r s

• B e i n g P a r t i s a n

• N o t m a i n t a i n i n g a f o c u s o n t h e p a t i e n t

• B e i n g p r e s c r i p t i v e r a t h e r t h a n d e s c r i p t i v e

• U s i n g w o r d s s u c h a s w h y , c a n ’ t g o o d , b a d , b e t t e r , w o r s e , r i g h t , w r o n g , a n d b u t .

• N o t h a v i n g i n t e g r i t y

• M a n a g i n g r a t h e r t h a n l e a d i n g

Collaboration with SORHs

Questions and Comments?