The document discusses innovations in quality improvement at rural hospitals in Illinois. It summarizes initiatives at three rural hospitals - Graham Hospital, Herrin Hospital, and Anderson Hospital - to reduce readmissions. Graham Hospital implemented a WRAP program to reduce COPD readmissions which has proven effective and cost-saving. Herrin Hospital partnered with Centerstone to provide crisis services that have prevented emergency department visits and hospitalizations for behavioral health patients. Anderson Hospital integrated its electronic medical record system with the Illinois Prescription Monitoring Program to enhance medication reconciliation efforts.

1. Innovations In Quality:
Rural Success Stories
Adam Kohlrus, MS, CPHQ, CPPS
Director of Performance Improvement
Institute for Innovations in Care and Quality
June 17, 2015

2. Aims
• Illinois Hospital Success in 2014
• The Landscape
• Innovative Rural Programs
-Readmissions (Graham Hospital)
-Behavioral Health (Herrin Hospital)
-Medication Reconciliation (Anderson Hospital)
• The Institute Road Ahead-HEN 2.0
2

3. Statewide Success 2014
3

4. As part of HEN 1.0, 100 IL IHA HEN hospitals prevented
15,887 instances of patient harm for a cost savings of
$161.8 million between January 2012 and March 2014
 14,294 readmissions prevented;
 285 early-elective deliveries prevented;
 234 post-operative pulmonary embolisms
or incidents of deep vein thrombosis
prevented;
 192 central line-associated bloodstream
infections prevented;
 188 catheter-associated urinary tract
infections prevented;
 152 incidents of ventilator-associated
pneumonia prevented;
 131 surgical site infections prevented;
 126 birth trauma or injuries to neonates
prevented;
 123 pressure ulcers prevented;
 116 falls with injury prevented; and
 46 manifestations of poor glycemic control
prevented.
http://www.ihatoday.org/IHA-Institute/Raising-the-Bar.aspx 4

5. 5
AHA/HRET: Achievement of Targets – November 2014
AREA
At least 60%
Reporting
At least 70%
Reporting
At least 80%
Reporting
17.6% Change
from Baseline
(15% Readm)
AND At Least
60% Reporting
40% Change from
Baseline (20% Readm)
AND At Least 80%
Reporting
Met High
Perf.
Benchmk
Achievement
of Target
ADE 
CAUTI  

100% reporting

33% reduction
CLABSI  

100% reporting

61% reduction

Falls  

60%-53% reporting

9% reduction/
25% reduction
OB-EED  

90% reporting

79% reduction

OB-Other  

98% reporting

41% reduction

PrU  

100% reporting

28% reduction

SSI  

100% reporting
Readm  

100% reporting
VAP/VAE  

100% reporting

23% reduction
VTE  

100% reporting

42% reduction

IL IHA HEN 1.0 Results

6. The Landscape
6

7. CMS has adopted a framework that
categorizes payments to providers
Description
Medicare
Fee-for-
Service
examples
 Payments are
based on
volume of
services and
not linked to
quality or
efficiency
Category 1:
Fee for Service –
No Link to Value
Category 2:
Fee for Service –
Link to Quality
Category 3:
Alternative Payment Models Built
on Fee-for-Service Architecture
Category 4:
Population-Based Payment
 At least a portion
of payments vary
based on the
quality or
efficiency of
health care
delivery
 Some payment is linked to the
effective management of a
population or an episode of
care
 Payments still triggered by
delivery of services, but
opportunities for shared
savings or 2-sided risk
 Payment is not directly
triggered by service
delivery so volume is not
linked to payment
 Clinicians and
organizations are paid and
responsible for the care of
a beneficiary for a long
period (e.g., ≥1 year)
 Limited in
Medicare fee-
for-service
 Majority of
Medicare
payments now
are linked to
quality
 Hospital value-
based purchasing
 Physician Value
Modifier
 Readmissions /
Hospital Acquired
Condition
Reduction
Program
 Accountable Care Organizations
 Medical homes
 Bundled payments
 Comprehensive Primary Care
initiative
 Comprehensive ESRD
 Medicare-Medicaid Financial
Alignment Initiative Fee-For-
Service Model
 Eligible Pioneer
Accountable Care
Organizations in years 3-5
 Maryland hospitals
Source: Rajkumar R, Conway PH, Tavenner M. CMS ─ engaging multiple payers in payment reform. JAMA 2014; 311: 1967-8.

8. During January 2015, HHS announced goals for value-
based payments within the Medicare FFS system

9. 2016
30%
85%
2018
50%
90%
Target percentage of payments in ‘FFS linked to quality’
and ‘alternative payment models’ by 2016 and 2018
2014
~20%
>80%
2011
0%
~70%
GoalsHistorical Performance
All Medicare FFS (Categories 1-4)
FFS linked to quality (Categories 2-4)
Alternative payment models (Categories 3-4)

10. Medicare
Penalties
Medicaid
Penalties
2011 25.3 Million N/A
2012 20.9 Million N/A
2013 18.8 Million 40 Million
2014 14.8 Million 12 Million
2015 30.5 Million 12 Million
10
IL Medicare/Medicaid
Readmissions Penalties
• $174.3 Million in
Medicare/Medicaid
penalties which
Illinois Hospitals
have incurred since
2011...

11. Our Solution…Systems Innovation
System
Innovation
Consumer
Experience
Service
Model
Product
Offering
Channel
Partners
Process
Operations
Revenue
Model
Source: Adapted from Change and Innovation in Healthcare: Avia (Roy Smythe and Leslie Wainwright)
• The Ipod
• Integrated offerings
which create a unique
and holistic customer
experience are needed
in order to adapt to
the system and
consumer

12. 12
The IHI Triple Aim

13. Innovative Rural Programs
13
How you respond to the challenge in the second half will
determine what you become after the game, whether
you are a winner or a loser.
-Louis Camuti

14. An Innovative Solution to
Reducing Readmissions:
Graham Hospital and The
W.R.A.P Program
14

15. W.R.A.P-Graham Hospital
• With the rising emphasis on reducing hospital readmissions, it is
important to identify and utilize evidence based programs that
can help ensure patient safety at discharge, as well as shore up
hospital confidence that it is providing effective and successful
individualized discharged plans for each patient.
• Wellness Recovery Action Plan (W.R.A.P.) offers many of the
necessary components for a successful disease management
program
• Offered in both in-patient and out-patient settings, to maximize
efforts to successfully reduce preventable hospital readmissions,
specifically for the C.O.P.D. population
15

16. Why Use W.R.A.P
While countless curriculums' can be found on disease management techniques, W.R.A.P. has some
unique components that set it apart from the others:
A) It is an Evidence Based Practice- Extensive research has proven its techniques are effective in the
management of chronic health conditions.
B) Low cost to implement- there are no costly materials to buy or fees associated with the use of the
curriculum.
C) It is empowering and offers immediate buy-in for the participants- There is no one telling them
what they must do. They can choose the wellness tools that they know will work best for them and
then put it all together in a succinct plan they can reference daily and revise as see their needs
changing.
D) It looks at the WHOLE person and helps participants to see the spectrum of wellness to illness and
action steps they can use to intervene before they end up back in a crisis and must go back to the
hospital again.
16

17. W.R.A.P COPD Program
• Week 1- Introduction to W.R.A.P.
• Week 2- Explanation of COPD
• Week 3- Representative from Dietary address how diet affects their COPD
management, as well as tools they can use each day to help improve their quality
of life.
• Week 4- Representative from Pharmacy address how their meds work to help
improve lung function and other overall organ systems connected with COPD.
• Week 5- Coverage of the W.R.A.P. curriculum that helps group members develop
Wellness Tools that they can use each day to help stay healthy, despite having
COPD.
17

18. W.R.A.P COPD Program
• Week 6- Explanation of the W.R.A.P. curriculum, which allows group members
to identify COPD triggers, early warning signs, when things are breaking down,
crisis plan management of COPD.
• Week 7- Coverage of the W.R.A.P. curriculum for a Post Crisis W.R.A.P. plan.
• Week 8- Question and answer time, assistance with group members in writing
certain parts of their W.R.A.P. plan, finish up any W.R.A.P. curriculum that had
not been covered in previous weeks, etc.
*Department representatives are there for question and answer only. They do not
need to bring any prepared curriculum with them, but are welcome to bring
ideas, handouts or demonstrate techniques they think might be beneficial to
participants.
18

19. Required Resources
A) Train the Trainer cost: 7 weeks of one day per week training=
$1,386.00
B) Cost per class for the facilitator's salary: Weekly 2 hours= $49.50 or
$396.00 for 8 weeks
C) Yearly cost for the four required W.R.A.P. C.E.U. sessions: 8 hours
each-$198.00 or $792.00 total
A+B+C= If W.R.A.P. was offered four times a year, the total cost to the
organization including the train the trainer, group facilitator hourly
salary and yearly C.E.U. requirements would= $3,762.00
19

20. W.R.A.P-ROI
• An internal audit was done in 2012 by Graham's
financial services department to get an estimated
cost of what one readmission costs the
organization.
• At that time, they found the average gross charge
per inpatient to be $22,622.
• As of January, with the adjustment percentage of
58.5% being applied to each person, the average
net loss with each readmission is $9,388.
20

21. W.R.A.P-ROI
Cost of 4 W.R.A.P. Training
Sessions (Each Training
Session is 8 Weeks)
Net loss for each COPD
readmission
21
$ 3,762
$ 9,388

22. 22
W.R.A.P
Achieving the Triple Aim
Low cost to implement: High ROI
Patient-Centered Care
Largest readmitted
diagnostic population
(COPD)
Focuses on the WHOLE
person from wellness to
illness

23. An Innovative Solution to
Reducing Behavioral Health
Readmissions:
Herrin Hospital
and Centerstone
Collaborative Pilot Project Aligning Community Partners
23

24. Behavioral Health Readmissions
24
HF Bipolar Septicemia
COPD
Major Depressive
Disorders & Other
Unspecified
Psychoses
• A “super-utilizer” groundswell is emerging. Programs designed
to serve high-need, high-cost populations are growing in number
– the Center for Health Care Strategies (CHCS) recently
catalogued such programs in 26 states, and expects this number
to steadily increase.
Top 5 APR-DRGs in Illinois
These top 5 APR DRGs for Illinois are from October 1, 2013-September 30, 2014 RAP Statewide Report
In other states and at the
federal level,
policymakers are
increasingly
making it a priority to
launch and scale these
programs.

25. Centerstone Crisis Center in
Partnership with Herrin Hospital
• Hospital and Emergency Department costs related to mental
health crises are one of the biggest drivers of Medicaid costs in
southern Illinois. Seeing a need to reduce unnecessary ED and
hospital utilization for persons with mental illness in crisis,
Centerstone has developed two service lines: Community Crisis
Assessment and Crisis Stabilization.
25

26. • In 2014, Centerstone’s ED and hospital
diversion care service lines saved Illinois $4.1
million in prevented Medicaid costs.
• In January 2014 at the start of the Southern
Illinois Healthcare Centerstone collaboration,
the average number of hours a person with a
behavioral health crisis could expect to be in
the Herrin Hospital ED was 7.3 hours.
• Due to the partnership with Centerstone, the
2015 average hours are now 6.1 hours.
• This is a 20% reduction, freeing up valuable
staff time in the ED to address other urgent
needs.
26
Centerstone Crisis Center in
Partnership with Herrin Hospital

27. • Centerstone’s Community Crisis Assessment Team provided 2,730 crisis
services in 2014.
• Mental health related ED visits can cost as much as 50% more than that of
other ED visits, for an average cost of $3,100.
• With Centerstone’s Crisis Assessment Services costing $402 per assessment
on average, this is a savings of $2,698 per encounter if the community
crisis assessment prevented an ED visit.
• For the individuals who received a preventative crisis assessment be for e
an ED visit occurred, estimated 2014 savings for ED visits alone is
$3 million.
27
Community Crisis Assessment

28. • Centerstone’s Crisis Stabilization Unit (CSU) is a cost-effective
hospitalization alternative for individuals with mental illness needing a
safe, short term, 24/7 staffed unit with nursing coverage.
• The CSU prevented 537 hospitalization nights while providing a safe,
short-term 24/7-staffed unit with nursing coverage.
• This amounted to a mean per diem savings of $2,021, a total savings of
nearly $1.1 million in 2014.
28
Crisis Stabilization Unit (CSU)

29. 29
Crisis Center
Achieving the Triple Aim
Meeting the patient at
the right place, at the
right time and with the
right level of care
Designed to serve high-need,
high cost population

30. An Innovative Solution to
Enhanced Medication
Reconciliation:
Anderson Hospital
Collaborative Pilot Project: Connecting Hospital EMRs with the
IL PMP
30

31. 31
The Illinois Prescription Monitoring Program
(PMP) Collaborative
A collaborative effort to leverage existing
technology in order to enhance medication
reconciliation by facilitating accurate and more
timely communication of medications across the
continuum

32. • A centralized repository of controlled medication prescription
information collected from 2800+ pharmacies in Illinois
• Information is electronically uploaded on a weekly basis to the IL
Dept of Human Services (DHS) PMP website
o 1 million prescriptions/month
• Clinicians currently access the PMP
by navigating to and logging in at
the website to view patients current
& historical use of controlled medications
32
What is the Prescription Monitoring
Program (PMP)?

33. 33
Objectives of the Pilot Collaborative
Phase I: Introduce seamless direct integration between
PMP & Acute Care Hospital Electronic Medical
Record (EMR) - allowing clinicians direct access to
current PMP medication information from their
EMR
Phase II: Integrate a data transfer link between PMP & LTC
medication information to Hospital’s EMR to
provide enhanced accuracy of patient medication
reconciliation resulting in decreased readmissions
and improved safety

34.  Automated timely access = improved efficiencies
 Saves 100 hours / week of clinician time
 Eliminates need to remember additional username and
password currently needed to log into the PMP
 Allows for expanded monitoring of PMP information
 Is the requisite 1st step prior to Phase II connection of
PMP+ (LTC)
 IT consulting service is being offered FREE through this pilot
Advantages to
Integrating Now:
34

35. EMR-PMP pathway:
Anderson Hospital Prior to 2012
(and majority of hospitals today)
EMR
Clinician
logs in
twice – to
PMP & EMR
for a clear
picture of
medication
use
DHS PMP
BEFORE
INTEGRATION
EMR
35

36. Anderson Hospital Today
EMR
DHS PMP
AFTER PHASE 1
INTEGRATION
EMR
LISTENER
Clinician
logs into
EMR and
navigates
to a tab to
see the
PMP info
36

37. Direct Integration into Anderson
Hospital’s EMR
Phase 1 has already proven successful!
In 2012, DHS initiated an automated
request/response system
for PMP access at Anderson Hospital
in Maryville, Illinois
“It’s made a positive
difference, for sure!”
- Anderson
ED Physician
37

38. • Huge value add due to the EMR button
-no need to log into the PMP manually
• Expands numbers of staff “eyes” to monitor medication
sources
• Used PMP data to justify denial of medications to potential
drug seeking patients
• Augments medication reconciliation for admission &
discharge
38
Anderson Clinician Feedback
“It’s been awesome!”

39. 39
PMP
Achieving the Triple Aim
More accurate real-
time medication
reconciliation
Since Anderson Hospital submits
approximately 1,200 automated
requests weekly, the
approximate value to the
hospital equals $8,000 weekly or
slightly more than two FTE
physicians annually.
Enhanced continuity of
care on transfers
between LTC &
hospitals
Increased accuracy of
medication reconciliation
resulting in decreased
readmissions and improved
patient outcomes

40. The Institute
and the Road Ahead
40

41. Content Across the Continuum…
41

42. 42
• Encourage your Quality
Departments, CEOs,
CMOs, CNOs and fellow
Board Members to
engage in HEN 2.0 and
the Institute’s Quality
Initiatives moving
forward
The Institute for Innovations in
Care and Quality

43. 43
Adam Kohlrus, MS, CPHQ, CPPS
Director, Performance Improvement
akohlrus@ihastaff.org
217-541-1181