Massachusetts Strategic Plan for Care Transitions


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  • Enhanced processes: Med Rec, Discharge MGT, F/U, Pt Education Enhanced Structures: HIT, HIE, Decision Support, PHRs, CCR
  • Massachusetts Strategic Plan for Care Transitions

    1. 1. Massachusetts Strategic Plan for Care Transitions Health Care Quality and Cost Council January 20 th , 2010 Alice Bonner, PhD, RN, Mass Department of Public Health Craig D. Schneider, PhD, Mass Health Data Consortium Joel S. Weissman, PhD, EOHHS For the Massachusetts State Quality Improvement Institute (SQII) of the Executive Office of Health and Human Services Commonwealth of Massachusetts Executive Office of Health and Human Services With support from The Practice Change Fellowship supported by an award from the John A. Hartford Foundation and Atlantic Philanthropies
    2. 2. Today’s Presentation <ul><li>Background: </li></ul><ul><ul><li>The Massachusetts State Quality Improvement Institute (SQII) </li></ul></ul><ul><ul><li>Barriers to Effective Transitions </li></ul></ul><ul><li>Transitions in Care Strategic Plan </li></ul><ul><ul><li>Effective Care Transitions: What is Known? </li></ul></ul><ul><ul><li>The Policy Landscape </li></ul></ul><ul><ul><li>Vision for Care Transitions in Massachusetts </li></ul></ul><ul><ul><li>Principles, Recommendations and Action Steps </li></ul></ul><ul><ul><li>Measuring Success </li></ul></ul>
    3. 3. State Quality Improvement Institute (SQII) <ul><li>Co-Team Leaders: Secretary Bigby and Joel Weissman </li></ul><ul><li>Nine states: CO; KS; MA; MN; NM; OH; OR; VT; WA. </li></ul><ul><li>Two Year Project: Spring 2008 to Spring 2010. </li></ul><ul><li>Goals: </li></ul><ul><ul><li>To provide customized support to states for quality improvement efforts with emphasis on creation of State Action Plans </li></ul></ul><ul><ul><li>In MA, we further seek to leverage the SQII efforts by working through public/private partnerships </li></ul></ul><ul><li>MA SQII State Action Plan 2009 =3148&navItemNumber=2502 </li></ul>
    4. 4. Barriers to Effective Care Transitions <ul><li>Lack of integrated care systems </li></ul><ul><li>Lack of longitudinal responsibility </li></ul><ul><li>Lack of standardized forms and processes </li></ul><ul><li>Incompatible information systems </li></ul><ul><li>Lack of care coordination and team-based training </li></ul><ul><li>Lack of established community links </li></ul><ul><li>Underuse of measures to indicate optimal transitions </li></ul><ul><li>Compensation and performance incentives not aligned with care coordination and transitions </li></ul><ul><li>Payment is for volume of services rather than outcomes </li></ul><ul><li>Ineffective communication </li></ul><ul><li>Failure to recognize cultural, educational or language differences </li></ul><ul><li>Processes are not patient-centered nor longitudinal </li></ul>Performance Measurement and Alignment Procedural Structural
    5. 5. Figure 1: Care Transitions Infrastructure Patient and Family Home Health Agencies Emergency Department Acute Hospital Hospice ADRC ASAP Outpatient Rehab SNF LTAC or Rehab Hospital COA Senior Center Faith-based Org Retail Pharmacy LTC Medical Home: NH, AL MH, DDS EMS Primary Care Medical Home
    6. 6. Massachusetts Strategic Plan for Care Transitions: Purpose <ul><li>To create a “living document” that: </li></ul><ul><ul><li>Creates a vision for optimal transitions in care for Massachusetts residents </li></ul></ul><ul><ul><li>Sets broad goals and actionable steps that will lead toward implementation </li></ul></ul><ul><li>To ensure that this work is aligned with related state and federal health care and payment reform efforts </li></ul>
    7. 7. The Vision <ul><li>Interdisciplinary teams delivering safe, effective, and timely care that is culturally and linguistically appropriate within and across settings </li></ul><ul><li>Aligning </li></ul><ul><ul><li>Clinical care (individuals) </li></ul></ul><ul><ul><li>Public health (populations) </li></ul></ul><ul><ul><li>Health policy (payment and organization of services) </li></ul></ul>
    8. 8. What is Known? National Examples of Best Practices <ul><li>The Care Transitions Model (Coleman) </li></ul><ul><li>The Transitional Care Model (Naylor) </li></ul><ul><li>The Guided Care Model </li></ul><ul><li>Project RED </li></ul><ul><li>The Continuity Assessment Record and Evaluation (CARE) Tool </li></ul>
    9. 9. Some Elements of Care Common to Most of the Transitions Models <ul><li>Medication Management </li></ul><ul><li>Assessing Patient's Understanding/Ability to Follow Care Plan </li></ul><ul><li>Discharge Support </li></ul><ul><li>Coaching for Primary Care Physician Visit </li></ul><ul><li>Use of Home Visits (with the exception of Project Red) </li></ul><ul><li>Screening for cognitive ability </li></ul><ul><li>Use of Centralized Health Record </li></ul><ul><li>Involving Family and Informal Caregivers </li></ul><ul><li>Arranging Community-Based Support Services </li></ul>From: The Lewin Group, December 16, 2009 Care Transitions Workgroup
    10. 10. What is Known about Costs and Savings? <ul><li>The Care Transitions Model (Coleman) </li></ul><ul><ul><li>Annual Cost= $74,310 for 379 patients ($196 per patient). </li></ul></ul><ul><ul><li>Estimated Annual Cost Savings: $844 per patient </li></ul></ul><ul><li>The Transitional Care Model (Naylor) </li></ul><ul><ul><li>The total intervention cost was $115,856 ($982 per patient). </li></ul></ul><ul><ul><li>One study demonstrated mean cost savings of $5000/patient </li></ul></ul><ul><li>The Guided Care Model </li></ul><ul><ul><li>Randomized studies indicate cost savings of $1364 per patient ($75,000 per nurse) </li></ul></ul><ul><li>Project RED </li></ul><ul><ul><li>Randomized Studies showed cost savings of $380/patient </li></ul></ul>From: The Lewin Group, December 16, 2009 Care Transitions Workgroup
    11. 11. The Policy Landscape <ul><li>Legislative </li></ul><ul><ul><li>For example, AHCAA * H.R.3962 – Sec. 1151 “Reducing Potentially Preventable Hospital Readmissions” </li></ul></ul><ul><li>Guidelines and consensus statements </li></ul><ul><ul><li>For example, the Transitions of Care Consensus Conference (TOCCC) </li></ul></ul><ul><li>Massachusetts policy initiatives </li></ul><ul><ul><li>HCQCC Roadmap to Cost Containment </li></ul></ul><ul><ul><li>Healthy MA Compact </li></ul></ul><ul><ul><li>EOL Expert Panel </li></ul></ul><ul><ul><li>Care Transitions Forum </li></ul></ul><ul><ul><li>EOHHS Patient-Centered Medical Home Initiative </li></ul></ul><ul><li>State and Federal Payment Reform </li></ul>* ‘‘Affordable Health Care for America Act’’
    12. 12. Policy Landscape, cont’d: HIT, HIE and Data Needs <ul><li>HIT and HIE are integral components of healthcare workflow </li></ul><ul><li>“ Improve Care Coordination” is one of the five Health Outcomes Policy Priorities of the Stage 1 Criteria in the federal draft meaningful use guidelines </li></ul><ul><ul><li> </li></ul></ul><ul><li>MeHI is readying state plan </li></ul>
    13. 13. Landscape, cont’d: Existing Care Transitions Models in Massachusetts <ul><li>INTERACT II </li></ul><ul><li>STAAR </li></ul><ul><li>MOLST </li></ul><ul><li>BOOST </li></ul><ul><li>RED </li></ul><ul><li>Partners Healthcare System Clinical Transitions Project </li></ul><ul><li>Somerville Hospital Study </li></ul><ul><li>Massachusetts Pressure Ulcer Collaborative </li></ul><ul><li>Aligning Forces for Quality Project (RWJ) </li></ul><ul><li>Patient-Centered Medical Home </li></ul><ul><li>Medicare High Cost Beneficiaries Demo (MGH) </li></ul><ul><li>ADRCs/ASAPs </li></ul>
    14. 14. Strategic Plan: Principles and Key Recommendations Principles Key Recommendations <ul><li>Incentive alignment </li></ul><ul><li>Data transparency </li></ul>7. Payment reform <ul><li>Collaboration with Expert Panel on Performance Measurement </li></ul>6. Standardized process and outcome measures, based on nationally endorsed measures <ul><li>Education/Best Practices </li></ul><ul><li>Mentors </li></ul>5. Provider and Practice Engagement <ul><li>Handoff responsibility </li></ul><ul><li>Identifiable provider </li></ul>4. Accountability for care remains with the sending set of providers <ul><li>Patient and/or advocacy group representation </li></ul>3. Patient and Family Engagement <ul><li>Contact information provided </li></ul><ul><li>Living database </li></ul><ul><li>Medication tracking </li></ul>2. Communication Infrastructure <ul><li>Standardized, minimum dataset </li></ul><ul><li>Cross-continuum teams </li></ul><ul><li>Enhanced early post-acute care follow up </li></ul>1. Timely feedback and feed forward of information
    15. 15. Measuring Success <ul><li>Establish collaboration between HCQCC Quality and Safety Committee and Expert Panel on Performance Measurement </li></ul><ul><li>Select measures endorsed by national bodies when available </li></ul><ul><li>Measure across the quality spectrum, including structure, processes, outcomes </li></ul>
    16. 16. A Model for Better Outcomes Across the Continuum of Care Implement the Strategic Plan to Improve Transitions Collaboratives Payment Reform Government Action Achieve the IHI Triple Aim of optimizing: 1) Patient Experience, 2) Health of Defined Populations, and 3) Per Capita Cost Improved Health Status & Patient Experience Complications Function Adverse Events Patient Satisfaction Patient Understanding Appropriate Utilization ER Visits Readmissions Preventable Admissions Unnecessary Tests Procedures
    17. 17. Examples of Measures of Care Transitions Successes and Failures <ul><li>NQF endorsed: </li></ul><ul><ul><li>3 item CTM measure ( ) </li></ul></ul><ul><ul><ul><li>“… staff took my preferences …into account…” </li></ul></ul></ul><ul><ul><ul><li>“… I [understood] the things I was responsible for …” </li></ul></ul></ul><ul><ul><ul><li>“… I …understood the purpose for taking each of my medications …” </li></ul></ul></ul><ul><li>ABIM Workgroup ( ) </li></ul><ul><ul><li>reconciled medication list </li></ul></ul><ul><ul><li>transition record with specified elements </li></ul></ul><ul><ul><li>the timeliness of post-discharge care for heart failure patients </li></ul></ul><ul><li>CMS QIO tool from 9 th scope of work </li></ul><ul><ul><li>H-CAHPS performance standard for medication management; </li></ul></ul><ul><ul><li>% of patients readmitted within 30 days seen by a physician; </li></ul></ul><ul><ul><li>% of transitions for which interventions show an improvement </li></ul></ul><ul><ul><li>% of transitions using the CARE tool </li></ul></ul><ul><li>ONC-HIT Meaningful Use ( ) </li></ul><ul><ul><li>% of transitions for which summary care record is shared. </li></ul></ul><ul><ul><li>Medication reconciliation for > 80% of relevant transitions. </li></ul></ul>
    18. 18. Next Steps <ul><li>Meet with Secretary Bigby to discuss implementation </li></ul><ul><li>Determine which groups will be involved </li></ul><ul><li>Continue to monitor progress of multiple, ongoing state initiatives </li></ul>
    19. 19. Questions & Answers [email_address] [email_address] [email_address]