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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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.”
Resources and policies
Organization of Health Care
Clinical information systems
Delivery system design
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.
August 21, 2014
Reducing Avoidable Admissions:Disease Condition as a Variable
Reducing Avoidable Admissions:Insurance Status as a Variable
Reducing Avoidable Admissions: Geography as a Variable
Reducing Avoidable Admissions:Ethnicity as a Variable
Reducing Avoidable Admissions: SES as a Variable
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.
*Based on coaching organizations data tracking, not health plan data
Build upon previous experience; expand & spread
Medicare FFS beneficiaries with an active PQI diagnosis having
2 or more characteristics at risk of re-hospitalization:
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
Associate Director, Planning and Research
Finger Lakes Health Systems Agency
1150 University Avenue
Rochester, New York 14607-1647
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 • www.FLHSA.org