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Finger Lakes Health Systems Agency CMS Community-Wide Care Transitions Intervention Ann Marie Cook, President and CEO, Lifespan Mary Rose McBride, Vice President, Lifespan April 16, 2012 July 16, 2015 1 CMS Community-Wide Care Transitions Program Goals • Improve transitions of Medicare FFS beneficiaries from the inpatient hospital setting to home or other care settings • Improve quality of care for chronically ill • Reduce readmissions for high risk beneficiaries • Document measurable savings to the Medicare program and expand program beyond the initial 5 years July 16, 2015 2 Our CMS Community - Wide Care Transitions Intervention • Lifespan – lead AOA / CBO Agency • Five hospitals and Two Home Care Agencies – Rochester General, Unity, Strong Memorial, Highland and Newark-Wayne Hospitals, Lifetime Healthcare and VNS Target Population: Medicare FFS beneficiaries with an active PQI diagnosis or having 2 or more characteristics at risk of re-hospitalization: – 3 co-morbid chronic illnesses – 5 prescription medications – 2 hospital admissions within the last 12 months – Failure to teach back – Special Circumstances subject to interdisciplinary judgment July 16, 2015 3 Patient Admitted to the hospital Hospital Risk Screens Patient Hospital Pharmaceutical Intervention Eligible patient information shared with Lifespan and Home Care Agency to begin Coaching Services Lifespan searches Peer Place, creates List Bill for CMS, Tracks Patients for 180 day readmissions, and Reimburses Hospitals and Home Care Agencies for Services July 16, 2015 4 Hospital Initiatives 1. Identify and Track Reasons for Readmissions 2. Risk Assessment Stratification shared with Lifespan and Home Care Agencies to begin Coaching Services 3. Medication Reconciliation; upon admission through to discharge 4. Provider Checklist for High Risk Patients 5. Teach backs 6. Community Standards for Discharge Planning 7. Timely PCP Follow up Appointments 8. Hospitalist to PCP and SNF Communications July 16, 2015 5 Coaching Services • Lifetime Healthcare at RGH and Newark Wayne Hospitals • Visiting Nurse Service at Highland and Strong Memorial Hospitals • Lifespan at Unity Hospital July 16, 2015 6 First CMS Learning Collaborative Baltimore, MD - March 19-21, 2012 Lifespan, Lifetime Healthcare, Visiting Nurse Service and FLHSA; one of 30 teams in 14 states Information Sharing and Assessment : 1. Community wide infrastructure 2. Process for seamless integrated care 3. Activate Patients /Caregivers SelfManagement 4. Measure Performance and Accountability July 16, 2015 7 Pathway to 20% Reduction by 2013 Partnership Aim: Prevent 841,068 Readmissions Annually Program # Readmission s Prevented Annually Best Current Estimate of “Footprint”, in Place Now (March 2012) CCTP 11,294 30 Communities, 126+ Hospitals, 20 States 223,000 high-risk beneficiaries QIO ICPC Aim 23,609 129 Communities, 50 states+3 territories HEN TBD 26 HENs, 3,800+ hospitals AoA ADRC Grantees TBD 100 current sites, 169 Active Hospitals, 3,708 individuals served TBD TBD – announced on 3/15/2012 CMMI/MMCO Initiative to Reduce Avoidable Hospitalizations among Nursing CMS Request Coordinate and Collaborate with Hospital Engagement Networks - HENS – RGH (Premier) – Unity (NYS PFP) – Strong UHC) – Highland (NYSPFP) Collaborate and Expand the number of payors and hospitals included in the community effort July 16, 2015 9 Monthly Reporting and Measurement to CMS • # of patients in target population discharged from hospital • # of patients who initiated/accepted intervention • # of patients who completed intervention • # of patients who completed intervention who were readmitted within 30 days • Any additional run charts or data that demonstrates the impact on improving care transitions and reducing readmissions July 16, 2015 10 CMS Community-Wide Care Transitions Intervention • Target Launch Date – June 2012 • Second CMS Learning Collaborative July 23-25, 2012 • Participate in monthly learning webinars • IPRO presentation April 18, 2012 July 16, 2015 11 Finger Lakes Health Systems Agency The triangle represents our agency’s role as a fulcrum—the point on which a lever pivots—boosting the community’s health by leveraging the strengths of all stakeholders. The fulcrum is also a point of equilibrium, reflecting our ability to balance the needs of consumers, providers and payers on complex health matters. The inner triangle also evokes the Greek letter delta—used in medical and mathematical contexts to represent change—with a forward lean as we work with our community to achieve positive changes in health care. Give me a lever long enough and a fulcrum on which to place it, and I shall move the world. —Archimedes 1150 University Avenue • Rochester, New York • 14607-1647 585.461.3520 • www.FLHSA.org July 16, 2015 12