Mecklenburg Care Transitions
Committee Report
North Carolina Conference on Aging
October 11, 2011
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
Care Transitions....
…why is it important?
GOAL: Increase the number of people with
successful transitions from hospital to
home and reduce the number of people
GOAL: Increase the number of people with
successful transitions from hospital to
home and reduce the number of people
GOAL: Increase the number of people with
successful transitions from hospital to
home and reduce the number of people
GOAL: Increase the number of people with
successful transitions from hospital to
home and reduce the number of people
GOAL: Increase the number of people with
successful transitions from hospital to
home and reduce the number of people
GOAL: Increase the number of people with
successful transitions from hospital to
home and reduce the number of people
GOAL: Increase the number of people with
successful transitions from hospital to
home and reduce the number of people
GOAL: Increase the number of people with
successful transitions from hospital to
home and reduce the number of people
GOAL: Increase the number of people with
successful transitions from hospital to
home and reduce the number of people
GOAL: Increase the number of people with
successful transitions from hospital to
home and reduce the number of people
MECKLENBURG’S
APPROACH TO
CARE TRANSITIONS
GOAL: Increase the number of people with successful transitions from hospital to
home and reduce the number of people with readmissions within 30 days.
MARCH 23, 2011
COVENANT PRESBYTERIAN CHURCH
GOAL: Increase the number of people with successful transitions from hospital to home and
reduce the number of people with readmissions within 30 days.
Purpose of the Event
To bring together
partners/stakeholders involved
with successful transitioning
care for older adults and
adults with disabilities from
home to various settings.
To reduce the number of
people with readmissions
within 30 days
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
What We Want to AccomplishOutcomes in Care Transitions Effort
• Increase percentage of individuals who
return home following discharge from
hospital when it is their preference to
do so
• Decrease re-admissions to the hospital
for the same diagnosis
• Increase availability of adequate
community services and supports
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
What Does the Data Say?
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
Mecklenburg County Population
Based on NC State Data Center Projections
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
Mecklenburg Disability Population
It is very difficult to determine the
population of individuals with
disabilities in Mecklenburg County
because:
– Unlike age, disability is primarily
based on self-disclosure
– Many disabilities are hidden
– People confuse “having a disability”
with “getting Disability (SSDI)”
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of
people with readmissions within 30 days.
Mecklenburg Disability Population
Based on population percentages accepted by funding sources and
professionals, Mecklenburg County’s statistics are:
People each year
who acquire a
spinal cord injury
.004% = 37
People with
diabetes 74.9% =
668,957
People each year
who have a stroke
2.6% = 23,910
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
Mecklenburg Disability Population
– People with hearing loss
17% = 156,336
– People who have difficulty seeing (even with aids)
2.5% = 22,990
– People with mental illness
20% = 183,925
– People with intellectual disabilities
1% = 9,196
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
Hospital Studies
Nearly 20% of Medicare
hospitalizations are
followed by readmission
within 30 days.
19% of Medicare
discharges are followed
by an adverse event within
30 days—2/3 drug events,
the kind most often
judged “preventable.”
Unknown if lack of
physician visit causes
readmissions—but poor
continuity of care,esp. for
many chronically ill
patients.
90% of rehospitalizations
within 30 days appear to
be unplanned, the result
of clinical
deterioration.
Only half of the patients
rehospitalized within 30
days had a physician
visit before readmission.
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
Geographic Variation in Hospital Readmissions
2007 Medicare SAF data
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
30-Day Outcomes
Source: NC Hospital Quality Performance Results (2009)
Heart Attack 19.9
National Rate
Heart Failure
24.7 National
Rate
Pneumonia
18.3 National
Rate
Carolinas Medical Center
17.7 (998 pt)
20.1 (934 pt)
18.6 ( 464 pt)
CMC University
19.7(27 pt)
24.7 (134 pt)
16.8 (105 pt)
CMC Mercy
18.1(248 pt)
23.9 (639 pt)
17.5 (389 pt)
Lake Norman Regional
21.1(118 pt)
26.5 (388 pt)
18.1 (250 pt)
Presbyterian Hospital
18.2 (641 pt)
26.2 (145 pt)
22.3 (178 pt)
Presbyterian Matthews
19.6 (61 pt)
22.8 (362 pt)
18.2 ( 389 pt)
Presbyterian Huntersville
Not measures
( <25 pt)
25.5 (145 pt)
18.5 (178 pt)
Rate = % of Medicare patients readmitted out of the total # of Medicare patients ( number in parenthesis) admitted for
these diagnosis between 7/1/2006 and 6/30/2009. Source: www.hospitalcompare.hhs.gov/
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
Annual Cost of Care
For Age, Blind and Disabled Medicaid
Patients Enrolled in Carolina Access
ANNUAL COST OF CARE
FOR AGE, BLIND AND DISABLED MEDICAID
PATIENTS ENROLLED IN CAROLINA ACCESS
* Source: Community Care Partners of Greater Mecklenburg - Data represents Anson, Union and Mecklenburg Counties
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
Total Number of Acute Care Visits Per Year
For Medicaid Aged, Blind & Disabled Patients
Source: Community Care Partners of Greater Mecklenburg –
Data represents Anson, Union and Mecklenburg Counties
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
Top 8 Leading Causes of Death in
Mecklenburg County (2008)
•CANCER
•HEART DISEASE
•STROKE
•ALZHEIMER’S DISEASE
•CHRONIC OBSTRUCTIVE
•PULMONARY DISEASE (COPD)
•UNINTENTIONAL INJURY
•DIABETES
* source: 2009 State of the County Health Report – Mecklenburg County Health Department
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
1. Communication/Education @
collaboration with providers &
consumers
2. web based search tool
3. CRC Hospital Disch Partnership
4. 6 mo case managers
sharing/Networking
5. Transition Coach/Transitional
care
6. Active case mgt partnering w
churches
7. Community Patient Resource
8. Improving Continuity of Care
9. 6 steps of transportation
SMART SOLUTIONS
from March 23 Event
21%
15%
12%
12%
10%
9%
8%
7%
6%
1
2
3
4
5
6
GOAL: Increase the number of people with successful transitions from hospital to home and
reduce the number of people with readmissions within 30 days.
7
8
9
TOP THREE SOLUTIONS:
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
LEARNINGS SINCE OUR EVENT
Community Care Partners of Greater Mecklenburg
(CCPGM) is established by the State of NC and
uniquely positioned to do Care Transition Work
While it was unclear from the original instructions,
it is not the role of the CRC to be the lead on Care
Transitions.
Our unique partnership with the hospitals needs
to be broader and stronger.
The Community Partners have to understand the
language in the medical environment to be able to
communicate more effectively.
It takes time to identify and recruit the essential
partners that need to be a part of the Care
Transition process.
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
WHAT DO HOSPITALS NEED
FROM THE CRC?
• Challenge of hospitals - Keeping up
with program funding - what
programs have money?
• Find creative ways to meet gaps
(possibly grants) - transportation &
medication
• Consider ways to meet needs of newly
discharged patients - provide
community services in a package deal
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people
with readmissions within 30 days.
WHAT CHARLOTTE-MECKLENBURG
HAS IN PLACE FOR CARE
TRANSITIONS
• COMMUNITY CARE PROGRAM OF
GREATER MECKLENBURG
• CRC AND REFERRAL TOOL
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the
number of people with readmissions within 30 days.
FOCUS GOING FORWARD
DEMONSTRATION PROJECT
CURRENTLY DETERMINING WHAT
POPULATION WILL BE OUR FOCUS
TRACK TARGET GROUP FOR IMPACT
TRY TO ESTABLISH “BUNDLED SERVICES”
• Self Management
• In Home
Meals
Transportation
GOAL: Increase the number of people with successful transitions from hospital to home and reduce
the number of people with readmissions within 30 days.
Where Do We Go From Here?
Study national
toolkit
Redefine need
Increase/refine
membership and
involvement in
the taskforces
Educate
ourselves on the
national care
transitions effort
Conduct a root
cause analysis of
the causes of
readmissions or
adverse events
surrounding
hospital
discharge
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
Where Do We Go From Here?
(Continued)
Review national
evidence-based
interventions to
see if one
would work
best for
Mecklenburg
Determine the
best approach
for
Mecklenburg
Develop
implementation
plan for
intervention
Complete
intervention
Measure results
Create a
sustainable
approach
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.
PANEL CONTACT INFO
• Gayla Woody
gwoody@centralina.org
Centralina Area Agency on Aging
• Julia Sain
juliasain@disability-rights.org
Disability Rights & Resources
• Laura Wasson
lauras.wasson@mecklenburgcountync.gov
Mecklenburg County Department of Social Services
• Jane Dawson
jane.dawson@carolinashealthcare.org
Carolinas HealthCare System
• Stacy Wright
stacywright@novanthealth.org
Presbyterian Hospital
• Denise Bordeman dbordeman@mecklenburgcrc.org
Mecklenburg CRC Coordinator
"What I do you cannot do; but what you do, I
cannot do. The needs are great, and none of us,
including me, ever do great things. But we can
all do small things, with great love, and together
we can do something wonderful."
Teresa Calcutta
GOAL: Increase the number of people with successful transitions from hospital to home and reduce the number of people with
readmissions within 30 days.