Collaboration: The Road to Healthcare Quality Improvement

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1 Collaboration: The Road to Healthcare Quality Improvement Andrew Miller, MD, MPH Medical Director H e a l t h c a r e Q u a l i t y S t r a t e g i e s, I n c. 557 Cranbury Road Suite 21 East Brunswick, NJ Phone: Fax: This material was prepared by Healthcare Quality Strategies, Inc., (HQSI), the Medicare Quality Improvement Organization for New Jersey, 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. 10SOW-NJ-C /2013

2 HQSI New Jersey s QIO HQSI s mission is to accelerate healthcare quality improvement through a collaborative and interactive process with the healthcare community. Designated by the Centers for Medicare & Medicaid Services (CMS) as the Medicare quality improvement organization (QIO) for New Jersey QIO role: Improve quality of care Protect beneficiaries Protect Medicare Trust Fund 2

3 HQSI s Current QIO Projects Promoting beneficiary and family-centered care Case Review Patient and family engagement activities Improving individual patient care Reducing: Healthcare-associated infections Healthcare-acquired conditions Adverse drug events Participation in National Nursing Home Quality Care Collaborative Quality reporting and improvement 3

4 HQSI s Current QIO Projects continued Improving health for populations and communities Promotion of immunizations and screenings Cardiovascular health campaign/million Hearts Integrating care for populations and communities Improving care transitions to a reduce readmissions 4

5 Where are we going? 5

6 New Jersey Rankings out of 53 Jurisdictions* 30-Day Readmission 2010 Rank (Rate) 2011 Rank (Rate) All Readmissions 50 (21.48%) 50 (21.20%) Readmissions of Patients Discharged to Home without Home Health Care Readmissions of Patients Discharged to SNFs Readmissions of Patients Discharged with Home Health Care 48 (17.88%) 49 (18.05%) 53 (26.87%) 52 (26.05%) 40 (23.43%) 42 (23.41%) Readmissions of Hospice Patients 20 (2.96%) 24 (2.80%) *Source: Post Acute Care Readmission Rankings as prepared by CFMC, the Medicare Quality Improvement Organization for Colorado, 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. 6

7 Readmissions per 1,000 Readmissions per 1,000 Medicare FFS Beneficiaries National and New Jersey National NJ Annual data ending in the time frame specified SOURCE: HQSI s analysis of ICPC Scorecard for New Jersey prepared by the Integrating Care for Populations & Communities National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. (Jan-2009 to Apr-2012) 7

8 VI DC VT UT MI ND WV WI HI VA NH IA AL IN AR OH FL RI SC CA KY CT NM NY NC MO TX MN LA KS WY PA GA OK OR IL ME WA CO MS ID DE NE TN MD MA PR SD AK AZ NJ NV MT Readmission data slides (RIRs) 20.00% Relative Reduction in Hospital Inpatient Readmissions per 1,000 Medicare Beneficiaries: 10/1/2010-3/31/2011 vs. 10/1/2011-3/31/ % 10.00% 5.00% 0.00% -5.00% % % % SOURCE: HQSI s analysis of ICPC Scorecard for New Jersey prepared by the Integrating Care for Populations & Communities National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. (Jan-2009 to Apr- 2012) 8

9 Q County Readmission Rates Source: These statistics are HQSI internal analysis of Medicare FFS claims for eligible beneficiaries discharged from NJ hospitals. 9

10 Six Month County Readmission Data 10

11 Reduce Readmissions Prevent Breakdowns on the Road 11

12 Drivers of Hospital Readmissions Lack of standard and known processes as patients move between healthcare settings Example Ineffective or unreliable sharing of relevant clinical information Example Lack of medication reconciliation Lack of verbal communication Lack of engagement of patients and their families in managing their chronic health conditions Example Patients not aware of what they need to do to keep themselves healthy, such as warning signs 12

13 Readmissions are not just a hospital problem Improving transitions of care and reducing hospital readmissions requires community collaboration. 13

14 What Organizations in the Community Need to be Involved? Social Service Providers Hospitals Nursing Facilities (SNFs and long-term care) Behavioral Health Providers Physician Practices Collaboration Across Settings Rehabilitation Facilities Home Health Agencies Pharmacies Dialysis Facilities Hospices 14

15 Sussex County Department of Human Services Transitional Care Partners NJ Department of Health NJ Department of Human Services Mary Naylor, PhD, RN, University of Pennsylvania HQSI s NJ-CIAC Sussex County Regional ACO Premier Health Associates Newton Medical Center Bridgeway 15

16 Sussex County Transitional Care Program Purpose of this program is for the Transitional Care Coordinator to identify hospitalized patients at high risk of readmission and link them with community services, such as: Transportation Case management Meals on Wheels Currently the county has a Transitional Care social worker at the Newton Medical Center Monday through Friday 16

17 How are we getting there? 17

18 HQSI s Care Integration Activities Analysis and dissemination of care transitionsrelated data Development of community coalitions Encouraging and assisting communities to apply for Community-based Care Transitions Program (CCTP) funding 18

19 Care Integration Communities 19

20 Central New Jersey Care Transitions Program (CNJCTP) CMS Demonstration Project Kathleen McConnell, RN, MPH Vice President Care Coordination

21 Participating Agencies VNAHG Lead Agency Acute Care Hospital Partners: CentraState Medical Center Raritan Bay Medical Center Robert Wood Johnson University Hospital Robert Wood Johnson University Hospital at Rahway Saint Peter s University Hospital Trinitas Regional Medical Center 21

22 Participating Agencies Home Health Agency Partners: Holy Redeemer Home Care Community VNA Robert Wood Johnson Visiting Nurses Visiting Nurse Association Health Group 22

23 Participating Agencies Community Partners/Offices On Aging: Monmouth County Division on Aging Disabilities and Veterans Services Middlesex County Office on Aging and Disabled Services Union County Division on Aging Jewish Family Services of Central Jersey 23

24 Current CMS Status & VNAHG Awaiting Program Agreement from CMS VNAHG Responsible for: Coordination of advisory committee Implementation Billing Patient registry Outcomes measurement Data submission to CMS 24

25 Project Details Expect to serve 4,000 patients over the age of 65 Diagnosis: Acute MI, Heart Failure, Cerebrovascular Disease, Heart & Vascular Surgery, Pneumonia or Chronic Obstructive Pulmonary Disease Patients that are complicated by past readmissions, multiple chronic conditions, activity limitations, dementia, caregiver or social risks 25

26 Geographic Area Within 3-County Area in NJ Monmouth Middlesex Union 26

27 Visit URL: LAN/Do-the-Wave-NJ.html URL: URL: -Office/Physician-Office-LAN/Cardiac- LAN.html 27

28 Together we will get there! 28

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