Ordinary to
Extraordinary
Improving Healthcare in Florida
Ferdinand Richards III, MD
Chief Medical Director
Peggy Loesch, BSN, MBA, RN
Care Transitions Quality Specialist
1
Overview
• FMQAI – Information for Healthcare Improvement
 Quality Improvement Organization (QIO) Program
 End Stage Renal Disease (ESRD) Network Program
 Key activities and opportunities to participate
• Improving Care Transitions through Collaboration,
Commitment, and Action
 Care transitions and the reduction of avoidable
readmissions
 Root causes of readmissions in Florida
 Coalition building across care settings to improve patientcentered care
2
FMQAI
INFORMATION FOR HEALTHCARE IMPROVEMENT
3
Who is FMQAI?
• Established in 1992 as Florida Medical Quality Assurance, Inc.
 Improve quality care and outcomes through data, education, and
technical assistance
 Collaborate with physicians, health plans, home health agencies,
nursing homes, dialysis facilities, rehabilitation facilities, and hospitals
• Nationally recognized healthcare contractor
 Florida Quality Improvement Organization (QIO)
 End Stage Renal Disease (ESRD) Networks – Arkansas, Florida,
Louisiana, Oklahoma, and Southern California
 Department of Health
 Private medical record review and chart abstraction
4
The QIO Program
• Legislated under sections 1152-1154 of the Social Security Act
• 53 QIOs tasked with review of medical care, investigation of
beneficiary complaints, and implementation of quality
improvement activities for Medicare
• Evolution of the QIO program
 1970s – Professional Standards Review Organization (PSRO) – performed
utilization reviews and special studies to improve quality of care
 1982 – Utilization and Quality Control Peer Review Organization (PRO) – data
analysis to determine unnecessary, inappropriate, or poor quality
 1992 – Health Care Quality Improvement Initiative (HCQII) – focus shifted from
case review to reporting patterns of care
 2001 – QIO Program – renamed to be consistent with collaboration
5
QIO 10th Statement of Work
• Bold goals – supports the aims of the DHHS National Quality
Strategy
• Patient-centered care – includes the voice of the beneficiary
in all their activities
• Boundarilessness – breaks down organizational, cultural, and
geographic barriers
• Learning and Action Network (LAN) – accelerates change and
spread of best practices where everyone teaches and learns
• Value-based purchasing – provides technical assistance,
including sharing best practices and QI activities
6
Medical Case Review
•
•
•
•
Beneficiary complaints
Immediate advocacy
Appeals
Higher Weighted Diagnosis-Related Groups
(HWDRGs)
• Emergency Medical Treatment and Active Labor Act
(EMTALA)
7
Patient Safety
• Hospitals




Central line-associated bloodstream infections (CLABSI)
Catheter-associated urinary tract infections (CAUTI)
Clostridium difficile (C. diff)
Surgical site infections (SSI)
• Nursing homes
 Pressure ulcers
 Physical restraints
 Use of antipsychotic medications
• Clinical pharmacists, physicians, and facilities
 Adverse drug events (ADE)
 Potential ADEs
8
Prevention
• Assist physician practices with use of electronic
health record (EHR) system
 Coordinate prevention services
 Report quality measures
• Reduce patient risk factors for cardiac disease
• Partner with local Health Information Technology
Regional Extension Centers (REC)
9
Additional QIO Efforts
• Maintenance & Development of Medication Measures
• Hospital Outpatient / Ambulatory Surgical Center Quality
Reporting Program Support Contractor
• Beneficiary-centered Model for Weight Loss in African
American Communities – Senior Lifestyle Improvement
Movement (SLIM)
• Patient and Family Engagement Campaign – Promoting eHealth Technology, Awareness & Knowledge (PEAK) Heart
Health
• Beneficiary and Family-centered Care National Coordinating
Center
10
The ESRD Network Program
• The Social Security Amendments of 1972 created the
national ESRD Program, which extended Medicare
coverage to individuals with ESRD
• The Social Security Act was again amended in 1978
to create the ESRD Network Program
 Originally 32 regional ESRD Networks, now only 18
Networks
 Responsible for effective and efficient administration of
ESRD benefits
 Improve quality of care, collect data, provide technical
assistance, and review patient grievances
11
Current ESRD Statement of Work
Strategic Aims
Drivers of Change
• Patient experience of care
• Access to dialysis
• Vascular access
management
• Patient safety –
healthcare acquired
infections (HAIs)
• Immunization rates
• ESRD quality incentive
program
• Facility data submission
• Breakthrough
collaboratives
• Patient engagement
• Campaigns
• Technical assistance
• On-site visits
• Learning and Action
Networks (LANs)
12
Key Activities & Opportunities
• HealthHub – community portal to promote sharing and
collaboration of information resources, tools, and knowledge
• Learning and Action Networks – initiative that brings together
healthcare professionals, patients, and other stakeholders
• No Place Like Home – stakeholders across care continuum to
improve transitions of care and prevent hospital readmissions
• QIO Strategic Council (QSC) – leadership group to assist with
coordinating efforts, minimizing duplication, maintaining
momentum, enhancing commitment, and spreading the best
practices
13
www.healthhubfl.com
• Password protected
• Secure repository for
documents, tools,
and resources
• Forums
• Polls
• Calendar of events
14
Learning and Action Network
April 11, 2014
Tampa, Florida
• Connect with organizations and individuals from across all
provider types that have similar QI goals and challenges
• Learn from others in an "all teach, all learn" environment
• Benefit from others' best practices
• Receive and share free information and tools
• Be recognized for meeting or exceeding improvement targets
15
IMPROVING CARE TRANSITIONS
THROUGH COLLABORATION,
COMMITMENT, AND ACTION
16
Objectives
• Know the significance of improving the quality of
care transitions to reduce avoidable readmissions
• Understand the root causes of readmissions in
Florida
• Recognize the importance of coalition building across
care settings to improve patient-centered care
17
National Strategy for Quality
Improvement in Healthcare
• Established by the Affordable Care Act
• Develops an infrastructure at the community level
that assumes responsibility for improvement efforts
• Promotes patient-centered outcomes, efficiency,
and appropriate care while reducing or eliminating
waste from the healthcare system
Source: http://www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm#fig3
18
“Three-Part Aim”
Better Health
for the
Population
Better Care
for
Individuals
National
Quality
Strategy
Lower Cost
Through
Improvement
19
National Strategy for Quality
Improvement in Healthcare
• Reduce
Readmissions
• Reduce
inappropriate or
unnecessary care
• Enable patients
and families to be
able to navigate,
coordinate care
• Improve the
experience of care
related to quality,
safety, and access
across settings
• Improve care
transitions and
communications
• Establish shared
accountability and
integration of
communities and
providers
Safer Care
Engage
Coordinate
Source: www.ahrq.gov/workingforquality/nqs/nqs2013annlrpt.htm#fig3
20
Timeline for National Quality Initiatives
Hospital Medicare readmission penalties
NH Value-based
purchasing demo
(ended June 2012)
2010
2011
Hospital value-based purchasing
program penalties
Reduce avoidable hospitalizations among nursing
facility residents (ends August 2016)
2012
Community-based care transitions program
2013
2014
2015/2016
Expansion of pilot programs to evaluate bundling
payment for an episode of care
QAPI demonstration project (ended August 2013)
Source: The Henry J. Kaiser Foundation. Health Reform Implementation Timeline : www.kff.org/healthreform/8060.cfm.
21
Definition of Readmissions
“… in the case of an individual who is discharged from an
applicable hospital, the admission of the individual to the
same or another applicable hospital with in 30 days from the
date of discharge.”
Source: http://www.cms.gov/Medicare/Medicare-fee-for-ServicePayment/AcuteInpatientPPS/Readmissions-Reduction-Program.html
22
Readmissions Impact Multiple Areas
Cost
Quality
Patient
Safety
23
Magnitude of the Problem
• Analysis of 2007 Medicare data finds:
 20% of beneficiaries are re-hospitalized within 30 days
 35% are re-hospitalized within 90 days
• Among those re-hospitalized within 30 days:
 50% had no claim for physician services between discharge
and re-hospitalization
Source: Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. The New England Journal of Medicine.
2009;360:1418-1428.
24
Magnitude of the Problem (continued)
Beneficiaries with
10 or more chronic
conditions are 6
times more likely
to be readmitted
to the hospital.
Source: Berkowitz SA, Anderson GF. Medicare beneficiaries most likely to be readmitted. J. Hosp. Med. Nov 2013;8(11):639-641.
25
Magnitude of the Problem (continued)
A managed care organization with 18 hospitals:
250 out of 537 (or 47%) readmissions were considered
potentially avoidable.
Factors contributing to avoidable readmissions:
 Index stay
o
Suboptimal management of the condition present
 The discharge process, care transitions, and care
coordination
o
Unaddressed psychological and social needs
 Follow-up care
o
Failure to adjust the plan of care to better meet patient needs
Source: Feigenbaum P, Neuwirth E, Trowbridge L, et al. Factors contributing to all-cause 30-day readmissions: a structured case series across 18
hospitals. Med. Care. Jul 2012;50(7):599-605
26
30-Day Readmission Rates
Nation
Florida
Source: ICPC Quarterly Scorecard for Florida, 1/1/2009-12/31/2012 issued 6/1/2013 from Colorado Foundation for Medical Care
27
Risk of Readmissions
Hospital
Discharge
Readmission
No postacute
follow up
28
Issues Related to Care Transitions: Findings From Florida Communities
29
Examples of Causes of Readmissions in
Florida
Lack of Effective
Communication
Medication
Related
Issues
Discharge
Processes
Lack of Resources
30
Industry Impact
At $9,600 per
readmission in 2011
readmission cost
Nation:
$18,931,200,000
Florida: $47,833,440
$
Source: Medicare FFS Inpatient Claims, 2011.
31
Patient Impact
• Re-hospitalization places patient and family under significant
physical and emotional distress.
• The patient is at risk for potential medical errors, falls, and
infections.
• Exposed to Post-Hospital Syndrome:
 “During hospitalization, patients are commonly deprived of sleep,
experience disruption of normal circadian rhythms, are nourished
poorly, have pain and discomfort, confront a baffling array of mentally
challenging situations, receive medications that can alter cognition
and physical function, and become deconditioned by bed rest or
inactivity…”
Source: Krumholz HM. Post-hospital syndrome--an acquired, transient condition of generalized risk. N. Engl. J. Med. Jan 10 2013;368(2):100-102.
32
State and National Quality Initiatives
33
FMQAI – The Florida QIO
Collaboration
Commitment
34
Role of FMQAI in Care Transitions
• Facilitate in coalition building
• Assist with conducting root cause analyses
• Provide education and support for the selection of
evidence-based interventions, implementation, and
measurement
• Partner with local, regional, & statewide groups
• Provide technical assistance including readmission
data for the coalitions
35
The Role of the Community Organization
• Spearheads coalition building among providers,
stakeholders, and service organizations
 Seen as trusted community presence
 Understands and transcends the politics of the community
 Motivates and engages in ongoing communications among
community stakeholders
 Promotes a shared vision for patient-centered change
36
The Role of the Community Organization
(continued)
• Provides expertise in the local community regarding
needs and resources to maintain the health,
independence, and choice of older adults and
individuals with disabilities
• Represents the voice of the patient
• Identifies the self-management support needed to
enhance patient and family engagement in their care
37
The Care Transitions Solution
38
CMS Partnership for Patients
• Hospital Engagement Networks (HENs)
• Community-based Care Transitions Program (CCTP)
• Patient and family engagement (through HEN, CCTP,
and QIO)
Source: http://partnershipforpatients.cms.gov/about-the-partnership/aboutthepartnershipforpatients.html
39
26 Hospital Engagement Networks
8 of the 26 HENs are working with Florida Hospitals
• The Health Research & Educational Trust, an affiliate of the
American Hospital Association (AHA)
• Ascension Health
• Intermountain Healthcare
• Joint Commission Resources, Inc.
• Lifepoint Hospitals, Inc.
• Premier
• UHC (formerly University Health System Consortium)
• VHA
Source :http://partnershipforpatients.cms.gov/about-the-partnership/hospital-engagement-networks/thehospitalengagementnetworks.html
40
The Goals of the Hospital Engagement
Networks (HENs)
Learning
Collaboratives
Patient Safety
Training
Technical
Assistance
Track & Monitor
Progress
Coach Hospitals
to Serve as
Leaders
Source: http://partnershipforpatients.cms.gov/about-the-partnership/hospital-engagement-networks/thehospitalengagementnetworks.html
41
Community-based Care Transitions
Program (CCTP)
The CCTP Partners – 5 in Florida
• Elder Options FL – Gainesville
• Catholic Health Care Transitions
Services, Inc. − Lauderdale Lakes
• Osceola-St. Cloud Community-based
Care Transitions Coalition
• The Greater Miami Coalition to Prevent
Unnecessary Rehospitalizations FL
• West Central Florida Area Agency on
Aging − Tampa
42
The Goals of the Community-Based Care
Transitions Program
Improve Care
Transitions
Document
Savings to
Medicare
Improve
Quality
of Care
Reduce
Readmissions
Source: http://innovation.cms.gov/initiatives/CCTP
43
No Place Like Home Campaign
• A campaign supported by a broad and growing base
of stakeholders in the Florida healthcare community
• Focused on:
 Addressing the drivers of
through the implementation of evidenced-based
practices
44
No Place Like Home Campaign
(continued)
• Shared Vision:
 A healthcare system where discharged patients:
o UNDERSTAND their conditions
o KNOW who to contact with questions (and when)
o ARE SUPPORTED by healthcare professionals who have
access to the right information, at the right time
45
No Place Like Home Campaign
(continued)
46
No Place Like Home Campaign Basics
• Hospitals assign a multidisciplinary team
 Team lead, physician champion, and other team players
• Collect and analyze data
• Invite post-discharge providers to participate
 Skilled nursing facilities, home health, managed care
organizations
• Develop and evaluate corrective actions using Plan, Do,
Study, Act (PDSA)
• Implement successful corrective actions
• Share lessons learned throughout the organization and
community
47
30-day All-Cause Readmissions by Regions
Source: Medicare fee-for-service claims for Florida inpatient discharges January 1, 2013 – June 30, 2013.
48
www.noplacelikehomefl.com
(continued)
49
www.noplacelikehomefl.com
(continued)
50
www.noplacelikehomefl.com
(continued)
51
Moving From Competition To Collaboration
• Taking risk (in this case, collaborating with your
competition) can be the best opportunity for success
and innovation.
• Create a strategic alliance with the goal of providing
mutual benefit (e.g., improving the quality of patient
centered care while reducing readmission rates).
• Recognize that improving care transitions and reducing
readmissions takes time and commitment.
 Some challenges require “quick and easy” fixes while most
others will take long-term dedication.
52
Moving From Competition To Collaboration
(continued)
• Providers tend to have similar challenges but rarely have
a chance to discuss these challenges across provider
types.
• Identifying challenges within a community with all
provider types represented at the table often starts with
lots of finger pointing.
• Use other providers’ perspectives as learning
opportunities.
 Challenges are likely interconnected between providers.
• Once everyone at the table decides to take ownership of
the challenges as a community, actionable items arise.
53
Organizing: People, Power, & Change
Source: Colorado Foundation for Medical Care.
54
What is Power?
The ability to achieve purpose
The ability to grow in capacity
Source: Adapted from ReThink Health.
55
Building Relationships
Source: Colorado Foundation for Medical Care.
56
One to One Meeting
Source: Colorado Foundation for Medical Care.
57
Collective Impact
Conditions needed to foster change through
collective impact:
Shared
agenda
Common,
consistent
measurement
Mutually
reinforced
activities
Continuous,
two-way
communication
Backbone
support
Source: Hanleybrown F, Kania J, Kramer M. Channeling change: Making collective impact work. Stanford Social Innovation Review;2012.
58
What To Do By Next Tuesday?
Leave in Action:
• Save the Date – April 11, 2014
• Join HealthHub
• What is a request or offer you would like to make?
“If you want to go quickly, go alone.
If you want to go far, go together.”
-African proverb
59
Questions
Ferdinand Richards III, MD
frichards@fmqai.com
813-865-3584
Peggy Loesch, BSN, MBA, RN
ploesch@fmqai.com
813-865-3438
This material was prepared by FMQAI, the Medicare Quality Improvement Organization for
Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of
the Department of Health and Human Services (HHS). The contents presented do not necessarily
reflect CMS policy. FL-201X10SOW-XXXXXX-XX-XXXX
60