Organization
Washington State Hospital
Association
Washington State Medical
Association
Primary Focus Activity
Smooth Transition Care Transitions:
Focus on reducing fragmentation and creating process for all patients to have the support they need to manage their care where they live.

Set of standard practices agreed upon by physicians and hospitals for health care personnel communications and handoffs between inpatient and community settings.


Standardized plan of care to aid in timely communications as patients move between settings.
Coordinated case management where the various organizations have a defined process where patient needs are addressed once and at the time needed.

Patient activated plan of care for patients where discharge planning begins prior to admission.
Target Audience:

Hospitals, primary care, home care, long term care, and patients.
Purpose:

Achieve the Partnership for Patients’ goal of reducing readmissions rates by 20% by the end of 2013 to an overall rate of <11%.
Interventions:

Implementing and testing a tool kit through pilot demonstration projects.

Disseminating lessons from pilots to Partnership for Patients hospitals.
Smooth Transition Partnership for Patients Hospital Engagement Network (subcontractor)

Best practices for patient activation and healthcare personnel communications and handoffs between inpatient and community settings.
Target Audience:

Independent primary care medical practices, and hospital-owned primary care medical clinics and practices.
Purpose:

Achieve the Partnership for Patients’ goal of reducing readmissions rates by 20% by the end of 2013 to an overall rate of <11%.
Prepared by Mara Zabari – MaraZ@wsha.org
- Washington State Hospital Association
1

Organization
Leading Age Washington
(formerly Aging Services of
Washington)
Qualis
Primary Focus Activity
Collaboration
Interventions:

Development and implementation of hospital-targeted readmissions reduction toolkit.

Joint collaboration with WSHA on testing pilots in two counties (Pierce and Spokane), and outreach to independent physician practices (where feasible through the county medical societies).
Partnership & Collaboration Committee:

Collaborative committee consisting of providers, administrators, nurses, executive directors, and other interested parties such as Qualis and Consonus focus on reducing readmission rates. Consonus is an
Oregon based company that provides pharmacy and rehabilitation services primarily to long term care nursing homes.
Target Audience:

Nursing homes, assisted living, and housing members.

Pilot programs in Whatcom County, Kitsap County, Pierce County, and Tacoma Lutheran,
Purpose:

Strengthen relationships with hospitals, and other post-acute organizations.

Develop a toolkit to help patients in transition of care.

Standardize use of INTERACT II tools, discharge summaries, physician communication and Standard Call sheet for non-clinical and clinical use.
Interventions:

Potentially using INTERACT II.
Smooth Transition Improving Care for Populations and Communities:

Statewide effort to reduce Medicare readmission rates by 2% overall. Also, focused on reducing
Medicare readmissions rate by 7% and admissions rate by 5% in three identified communities.
Target Audience:

Statewide effort across all settings with a focus on three specific communities in Kitsap County, South
King County, and Spokane/North Idaho.
Purpose:

Reduce readmissions and admissions by creating safer transition of care, and engaging communities.
Prepared by Mara Zabari – MaraZ@wsha.org
- Washington State Hospital Association
2

Organization
Washington Health Care
Authority
Primary Focus
Smooth Transition
Research
Collaboration
Activity
Interventions:

Depending on community, interventions include the Eric Coleman Care Transitions Intervention, and standard processes by setting (e.g., Project RED/BOOST in hospitals; INTERACT II in SNFs, Best Practices in Home Health, and PCMH in physician offices).
Transitional Health Care Services Performance Improvement Project:

Medicaid Managed Care Plans collaboration on a Transitional Health Care Services Improvement
Project.
Target Audience:

Potentially all hospitals in the state, with the intention of collaborating with existing projects.
Purpose:

Reduce readmissions and facilitate transitions of care with focus on those at high risk for readmissions.
Interventions:

Not determined.
Study

A sixteen state study of 30-day readmissions.
Target Audience:

Medicaid programs, hospitals, and payers.
Purpose:

Comparison of Washington State to others on readmissions.
Interventions:

Defining standards for data collection and performance comparisons.
Stakeholder Collaborations:

Washington State Hospital Association and the Bree Collaborative projects.
Target Audience:

Medicaid programs, hospitals, and payers.
Prepared by Mara Zabari – MaraZ@wsha.org
- Washington State Hospital Association
3

Organization
The Bree Collaborative
Home Care Association of
Washington
Primary Focus Activity
Stakeholder
Collaboration to
Reduce Potentially
Avoidable
Readmissions
(PARs) in WA State
Purpose:

Understand practices and define best practices.
Interventions:

Adopt best practices to reduce readmissions.
Three Primary Strategies:

Support for local readmissions activities: Identifying alignment opportunities where the collaborative can promote and augment current evidenced-based, quality improvement initiatives aimed at reducing
PARs.

Measurement, transparency and reporting: Supporting the use of process and outcome measures for reducing PARs and transparency of methodologies and readmission rates, by hospital and physician group, in semi-public manner.

New Payment Models: Research and recommend components and structures essential to creating a successful PAR accountable payment model that aligns incentives, including warranty pricing, bundled payments, and other innovative methodologies.
Target Audience:

Public and private healthcare purchasers, health carriers and providers.
Purpose:

To reduce potentially avoidable readmissions in Washington State
Interventions:

Endorsement of the WSHA Toolkit and smooth transition process

Payment change to bundled payment in hips and knees.
Smooth Transition Promoting In Home Services in Transitions in Care:

Promote the role of in-home services in transitions of care.
Target Audience:

In home services agencies, hospitals, SNF's, physicians, ACO's, medical homes, health homes, and third party payers.
Purpose:
Prepared by Mara Zabari – MaraZ@wsha.org
- Washington State Hospital Association
4

Organization
Providence Health &
Services
(St. Peter and Centralia
Hospital)
Olympic Area Agency on
Aging
Primary Focus
Collaboration
Activity

Facilitate a smooth discharge process to home by encouraging partners to initiate discharge planning at the time of hospital admission and not at discharge.

Increase effectiveness of in home services by encouraging the development of patient centered coaching by a home health clinical liaison - the coaching is initiated while the patient is in the hospital and facilitates the hand off to the home.

Educate and promote smooth care transitions between all settings, including home to physician office.

Improve effectiveness of physician follow up visit.
Interventions:

Encourage participation in the Paula Suter Innovation Advisor project or tenants of transition model.

Sponsor seminars and internal collaborative for association members on the Integrated Chronic Care
Management model.

Developed a standard for Home Health Transitions in care document.
Care Continuum Partnership:

Collaborative approach to reduce readmission rates.
Target Audience:

Hospital staff and care continuum partners including Providence infusion services, Group Health, Home
Care, and Senior and Community Services.
Purpose:

Early identification of patients most at risk for readmission and implement appropriate interventions.
Interventions:

Risk screening to identify specific interventions and accountability from the time of admission. Based on finding, develop care plan that reflects interventions that reduce readmission risks.
Smooth Transition Care Transitions (CTI- Dr. Coleman's model); Chronic Care Management (CCM- precursor to Health
Homes, along with CTI); Chronic Disease Self-Management (Stanford Evidence-based model):

Reduce avoidable readmissions using a Transitions Coach to help clients build skills for self-care.
Adopted by over 230 health care organizations nationwide, client-centered and evidenced-based model intervention is built on four pillars to reduce 30-day, 90-day and 180-day re-admissions:

Medication Self-Management Client-centered personal health record.
Prepared by Mara Zabari – MaraZ@wsha.org
- Washington State Hospital Association
5

Organization
Foundation for Health Care
Quality
Primary Focus
Education
Activity

Follow-up with PCP/Specialist.

Knowledge of “red flags” and how to respond.

One home visit & three follow up calls.
Target Audience:

CTI just starting up with two hospitals- OMC in Port Angeles, and Grays Harbor Community Hospital.

3-year pilot of CCM with existing high cost consumers such as in-home Medicaid long term care clients.
Purpose:

Provide discharged patients with knowledge about their condition(s), treatments, symptoms, and actionable steps to take when red flags occur; correct medication adherence; and provide pre- and post-Patient Activation measures (PAM 13).
Interventions:

Nursing case management in-home for Medicaid clients, for those recently discharges from hospitals.
Education:

Self-selected: anyone working on readmissions preventions in any setting including inpatient and outpatient settings.
Purpose:

Provide resources on best practices, and opportunities to exchange information.
Interventions:

Best practices shared on web conferences.
Prepared by Mara Zabari – MaraZ@wsha.org
- Washington State Hospital Association
6