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CMS Community-Wide Care Transitions Intervention. Overview. 1. How we got here 2. What we are doing 3. What is im portant to support success. FLHSA: Vision, Mission & Strategy.

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  • 1. How we got here

  • 2. What we are doing

  • 3. What is important to support success

Cms community wide care transitions intervention

FLHSA: Vision, Mission & Strategy

  • Vision:A local health-care system that makes people healthier and saves money, by delivering the right care, in the right place, and at the right time for everyone in the community.

  • Mission:We are an independent organization working to improve health care in Rochester and the Finger Lakes region, by analyzing the needs of the community, bringing together stakeholders and organizations to solve health problems, and measuring results.

Cms community wide care transitions intervention

FLHSA Community Health 2020 Commission

  • Shifted focus from individual CON applications to a determination of the aggregate community need

  • Recognized the unsustainable trend in growth driven by failure of optimal care in the community

  • Bed approvals scaled back and a commitment to “community investment” to alter the trend by improving care in the community

Cms community wide care transitions intervention

FLHSA 2020 Commission

The 2020 Commission recommended FLHSA convene the 2020 Performance Commission “to engage all stakeholders in a process that will result in community initiatives and requisite investments to improve access to care, avoid unnecessary hospital use, and eliminate disparities in health status across the region.”

Cms community wide care transitions intervention

Interactive Components



Resources and policies

Organization of Health Care

Clinical information systems

Delivery system design

Decision support

Self-management support

HS/Plan’s Job

Informed, activatedpatient

Provider’s Job

Prepared, proactive practice team


Quality and value outcomes; ROI; engaged, satisfied participants

HS = health system; ROI = return on investment.

Wagner EH. Effective Clinical Practice. 1998;1(1):2-4.

Community investment goals
Community Investment Goals

  • The 2020 Commission created specific goals for the community

    • A decrease of 15% in the number of low acuity (non-urgent) visits to emergency rooms

    • A decrease of 25% in the number of admissions for Ambulatory Sensitive Conditions that are manageable in outpatient settings – 2350 admits in 2011

    • A decrease of 20% in the number of low acuity admissions to Monroe County hospitals of residents from outlying communities

  • Recommended creation of the 2020 Performance Commission to guide community activities to reach the established goals

Three dimensions of value
Three Dimensions of Value



  • Readmissions


of Care

Per Capita


  • Access

  • CAHPS surveys

  • ED use

  • PQI admissions

  • Admissions from outlying communities

August 21, 2014


Measures defined by 2020 performance commission
Measures Defined by 2020 Performance Commission

  • Agreed Upon Measures for 2014:

    • PQI admissions: goal to decrease by 25%

    • Low acuity ED visits: goal to decrease by 15%

    • Low acuity admissions to Monroe County hospitals: goal to decrease by 20%

  • Implied goal: have the right bed available 99% of the time (this was the measure used to calculate the beds needed to determine bed need)

Cms community wide care transitions intervention

Reducing Avoidable Admissions:Disease Condition as a Variable

  • Hospitalizations

  • per 100,000 population, Percent of

  • age adjustedAll PQI Admissions

  • Respiratory Condition 657.7 (<US) 43%

  • Heart Conditions 439.3 (<US) 29%

  • Diabetes 153.7 (<US) 10%

  • Other 278.0 18%

  • All Adult PQIs 1,528.7 (<US) 100%

Cms community wide care transitions intervention

Reducing Avoidable Admissions:Insurance Status as a Variable

Cms community wide care transitions intervention

Reducing Avoidable Admissions: Geography as a Variable

Cms community wide care transitions intervention

Reducing Avoidable Admissions:Ethnicity as a Variable

Pqi finger lakes region
PQI – Finger Lakes Region

  • Adult Respiratory and Circulatory conditions account for over 70% of all PQI Admissions in the six county Finger Lakes Region.

  • Between 2004-2006, 13% of all hospital discharges were PQI discharges.

  • Each day 295 hospital beds in the region were filled by patients who potentially could have avoided hospitalization.

  • This equates to 10% of Hospital charges for these admissions (charges not costs).

Conclusions from flhsa data
Conclusions from FLHSA Data

  • Patients with PQI admits are generally older and insured

  • Rochester’s inner city has significantly higher rates of PQI admits

  • African-Americans and to a lesser degree Latinos experience increased PQI admits

  • Lower socioeconomic status is an important contributor to PQI admits

  • Reaching the target reduction in PQI admits requires decreasing PQI admits in the white population as well as in underserved minority populations

Cms community wide care transitions intervention

Conclusions from National Data

  • Rehospitalization is the low hanging fruit of PQI hospitalization reduction

  • Most admissions are related to cardiovascular and respiratory diseases

  • Major factors in reducing Medicare re-hospitalizations are:

    • Having a primary care practitioner

    • Seeing that practitioner often post discharge

    • Having a team to coordinate care

Cms community wide care transitions program goals
CMS Community-Wide Care Transitions Program Goals

  • Improve transitions of Medicare FFS beneficiaries from the inpatient hospital setting to home or other care settings

  • Improve quality of care

  • Reduce readmissions for high risk beneficiaries

  • Document measurable savings to the Medicare program and expand program beyond the initial 5 years

Cms community wide care transitions intervention

The Care Transition Intervention

Coaching models, when applied to transitions in care, have been shown to reduce readmissions by 20-40%.

Patient/family coaching actively engages patients and their families to be full partners in insuring improved health and decreasing unnecessary dependence on hospitals and emergency departments.

Community organizations and home care agencies will lead the effort, fulfilling Wagner’s model of optimally treating chronic conditions.

Our phased approach to a community wide care transition intervention
Our Phased Approach to a Community-wide Care Transition Intervention

  • Insurers pilot Commercial and Medicare Advantage

  • Monroe Plan for Medicaid Services pilot for Medicaid HMO

  • HEAL 19 funds the uninsured and Medicaid FFS patients

  • CMS CTTP grant for Medicare FFS patients target launch June 2012

Self reported aggregate coaching data
Self – Reported Aggregate Coaching Data Intervention

*Based on coaching organizations data tracking, not health plan data

Initiatives at hospitals
Initiatives at Hospitals Intervention

  • Identify and Track Reasons for Readmissions

  • Risk Assessment Stratification

  • Medication Reconciliation

  • Provider Checklist for High Risk Patients

  • Teach backs

  • Community Standards for Discharge Planning

  • Timely PCP Follow up Appointments

  • Hospitalist to SNF Communication

Flhsa cms community wide process
FLHSA CMS Community-wide Process Intervention

  • Coordinated community meeting: 60 regional representatives

  • Agreed to scope of work:

    Build upon previous experience; expand & spread

  • Defined work

  • Determined patient eligibility criteria based on data review

  • Designed and Clarified hospital integration with CTI

  • Integrated Community based services

  • Calculated costs of intervention and ROI

  • Designed tracking and reporting processes

  • Talked, talked, talked, and…… talked more!

Our cms community wide care transitions intervention
Our CMS Community - Wide Care Transitions Intervention Intervention

  • Lifespan ; an AOA –funded non-profit organization

  • Five hospitals:

    • Rochester General, Unity, Strong Memorial, Highland and Newark-Wayne

      Target Population:

      Medicare FFS beneficiaries with an active PQI diagnosis having

      2 or more characteristics at risk of re-hospitalization:

    • 3 co-morbid chronic illnesses

    • 5 prescription medications

    • 2 hospital admissions within the last 12 months

    • Failure to teach back

    • Special Circumstances subject to interdisciplinary judgment

Putting your plan into action
Putting your plan into Action Intervention

  • Secure and maintain leadership commitment

  • Form multi-disciplinary workgroups

  • Analyze root cause analysis

  • Understand processes

  • Anticipate and confront resistance / barriers

  • Identify improvement opportunities

  • Develop a measurement plan

  • Estimate ROI

  • Employ and Commit to Continuous Quality Improvement

  • Establish Trust

  • Go for it!!!

Cms community wide care transitions intervention

Establish and Maintain Trust Intervention

Clearly define and agree to your goals

Explicitly define guiding principles and adhere to core values

Use data to guide and inform your work

Anticipate concerns, encourage and solicit input, and provide a feedback loop

Thank you

Thank You!!! Intervention

Melissa Wendland

Associate Director, Planning and Research

Finger Lakes Health Systems Agency

1150 University Avenue

Rochester, New York 14607-1647

Cms community wide care transitions intervention

Finger Lakes Health Systems Agency Intervention

The triangle represents our agency’s role as a fulcrum—the point on which a lever pivots—boosting the community’s health by leveraging the strengths of all stakeholders. The fulcrum is also a point of equilibrium, reflecting our ability to balance the needs of consumers, providers and payers on complex health matters. The inner triangle also evokes the Greek letter delta—used in medical and mathematical contexts to represent change—with a forward lean as we work with our community to achieve positive changes in health care.

Give me a lever long enough and a fulcrum on which to place it,

and I shall move the world. —Archimedes

1150 University Avenue • Rochester, New York • 14607-1647

585.461.3520 •