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Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012
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Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

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Page 1: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Care Transitions : Are You in the Game?

Naomi Hauser RN, MPA

Director Care Transitions

Quality Insights of Pennsylvania

May 16, 2012

Page 2: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Welcome

What we’ll cover today: – Introduction of Care Transitions Program– The Role of HCA in the Community– Discuss Evidence Based Interventions to reduced

avoidable readmissions– Share Lessons Learned form 3 Year Pilot– Open Discussion

Page 3: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Why Are We Here?

To learn about and promote safe/effective transitions of care as patients navigate from one provider setting to another – or one caregiver to another

Develop partnerships

Page 4: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Integrated Care For Populations and

Communities

GOALTo promote safe/effective transitions of

care as patients navigate from one provider setting to another – or one caregiver to another

Page 5: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

30 Day Readmissions: The Problem Nationally – 17.6% of Medicare beneficiaries

discharged from the hospital are readmitted within 30 days.

More than 85% of these re-hospitalizations are unplanned.

20-40% of re-hospitalizations are possibly preventable.

64% of Medicare beneficiaries who are readmitted within 30 days do not receive any post-discharge care before readmission.

Page 6: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Mrs. B’s Story

Page 7: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

339 Days in the Life of Mrs. B Day 1 – New internal medicine physician, poorly controlled diabetes with neuropathy, HTN,

osteoporosis. To see physician q. 2 wks Day 15 – Sees physician, fully functional, assists with care of grandchild and husband Day 60 – Mrs. B falls on the ice, to ER, no fractures but abrasions. Referred to home health Day 68 – Not feeling well Day 69 – Hospitalized with Staph Septicemia, dehydration, ARF, CHF, A-Fib, PN and

uncontrolled diabetes Day 82 – Transferred to SNF for short-term rehab and wound care Day 182 – Discharged to home, depressed, abrasions healed, diabetes under good control Day 183 – Nauseated, can’t find her teeth, dgt intends to call home health Day 184 – Readmitted to the hospital for dehydration, CHF, A-Fib and diabetes Day 191-337 – Admitted to in-pt rehab then to nursing home Day 338 – Readmitted to hospital w/ ARF, CHF, ARF Day 339 – Mrs. B dies

Page 8: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Timeline for payment penalty for hospitals

Beginning October 2012 Medicare will apply penalties and will withhold payment for avoidable 30 day acute care readmissions with a progressively increasing scale for certain DRGs.

Page 9: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

July2008-August 2011

Pilot Project

Page 10: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

14 QIOs with 14 Target Communities

AL: Tuscaloosa CO: Northwest Denver FL: Miami GA: Metro Atlanta East IN: Evansville LA: Baton Rouge MI: Greater Lansing area NE: Omaha NJ: Southwestern NJ NY: Upper capital PA: Western PA RI: Providence TX: Harlingen HRR WA: Whatcom county

Page 11: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Targeted Community Higher than state average re-admission rate Located in southwestern PA, in a community surrounding the southern

Pittsburgh metropolitan area Community spans most of Westmoreland County and small portions of

Allegheny, Washington, and Fayette counties

Page 12: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

9th SOW Overview

CMS– 14 states

– Community cross-setting

– Transparent

– Remove silos

SWPA– 5 hospitals

– 8 home health agencies

– 15 nursing homes

– 2 AAAs

– 32 interventions

– 14% relative improvement

Page 13: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Structure of the Project

Cross-setting Community-based Collaborative

Page 14: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

The Shift to…

Chronic illness management Self-care management

– Empowerment– Responsibility– Accountability– Patient activation

Page 15: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Cross-Setting Goal

Develop a practical, cross-setting approach Unite providers from all settings Share vision of improved health care quality Equal voices Identify provider strength

Page 16: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

The Role of Agencies

•Home Health

•Hosicpe

Page 17: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Hospital Elements

Leadership buy-in Operational level leadership Education Silos Bureaucracy/slow to change Competitive Non-transparent

Page 18: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Hospital Interventions

Self reported readmission rate Discharge process Discharge instructions End of life options 48-hour follow-up call Schedule follow-up PCP visit CTI-AAA

Page 19: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

SNF Elements

Education Eager to learn Eager to share Share competence levels Family Physicians Turnover

Page 20: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

SNF Interventions

SBAR Communication transfer form Chart reviews End of life options/education POLST/AD Coach CTI

Page 21: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Home Health Elements

Focus on ACH vs. readmissions Medication management Low referral rates Educate on referral criteria Coaching Hands on in home care

Page 22: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Drivers of Hospital Readmission

Same for home care as other health care providers:– Patient activation– Standard, known processes– Transfer of information

Page 23: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Home Health Compare

Top 20% for this measure has maintained an unplanned hospitalization rate of 21% since last quarter

While stakeholders are focusing on reducing unnecessary hospitalizations, the data tells us that we still have work to do and…– What about those 30-day readmissions?

– Low-hanging fruit for home care to determine root cause and intervene in real-time—win-win for everyone

Page 24: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Home Health Compare

The latest Home Health Compare (HHC) scores were published on October 13th and reflect a data collection period of July 2010 - June 2011. Overall, the results have improved.

Hospitalization result has had a setback– Hospitalization worsened from 26% last quarter to

27%

www.Fazzi.com

Page 25: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Intervention HHA

Communication transfer sheet Front load visits Telehealth Phone monitoring Life line Chronic care education Coaching/partnering Depression screening Chart reviews

Page 26: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Best Practices

Home Health Quality Improvement National Campaign Best Practice Intervention Packages (BPIPs)

Focus on reducing ACH, improving management of oral medications and cross-setting collaboration– Simplified approach to use packages

– Standardized steps to follow for each publication

– Flexible for HHA implementation

BPIPs free to download at: http://www.homehealthquality.org/hh/default.aspx

Page 27: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

BPIPs Include Hospitalization Risk Assessment Emergency Care Planning Medication Management Fall Prevention Care Transitions Coaching Patient Self-Management Disease Management Telehealth Introduction to new ideas/topics: Patient Centered Medical Home;

Accountable Care Organizations and others

Page 28: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Learn more…Coach/HH nurse

Coaching and home health service Increase Medicare HH referrals Oasis takes time Coach non-clinical Different role Medication review… patient driven Complementary/respectful

Page 29: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Lessons Learned

Community focus Root cause analysis Communication Transparency Leadership buy-in

Collaboration Patient-centered Ongoing monitoring Community outreach Sustainability

Page 30: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Lessons Learned Re-Engineers the discharge

process (Project Red, Project Boost, Medication reconciliation)

Change the paradigm of patient education (Teach Back)

Improve information transfer (Cross setting transfer form)

Increase community outreach (Collaboration with community resources, Handover)

Increase post discharge process and support (PHR, Medication management, PCP f/u appointment and coaching)

Page 31: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

August 2011-July 2014

10th SOW

Page 32: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

AIMS and Goals

Strategic Aims

“What will be done”

Integrate Care for Populations• Care Transitions that reduce re-admissions by 20%

within 3 years.

Page 33: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

CMS 10th SOW for QIOs

Form a community coalition to ensure community-wide adoption of improved practices in care transitions

Assist communities in applying for the CMS 3026 CCTP funding opportunity

Form a Learning and Action Network (LAN) and provide evidence-based interventions associated with known drivers of hospital readmissions (Jan. 26, 2012)

Host quarterly LAN sessions; one in-person each year

Page 34: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

CMS 10th SOW for QIOs

Provide the community with a template for coalition charters to help the partners formalize structure and procedures

Assist the community with root cause analysis to identify community-specific causes for poor transitions and develop data reports to monitor progress

Assist in the selection of the most appropriate evidence-based interventions

Page 35: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

The Importance of Communities to Improve Health Care

Integrating Care for Populations and Communities

Page 36: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

CMS Defines a Community

Defined by contiguous zip codes– Medicare beneficiaries that live in those zip codes – Committed providers and stakeholders

Page 37: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Community Essentials

Developed around collaborative care delivery– Shared vision– Shared mission– Shared resources– Shared decision making– Environment of trust

Page 38: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

A Community

Social network analysis for Medicare beneficiaries in 2009– Allows visualization of relationships between

providers through network diagrams– Shows flow of transitions among providers– Senders, receivers, provider type and strength of

relationship

Page 39: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.
Page 40: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.
Page 41: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.
Page 42: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

4 Recruited Communities

Western Pennsylvania Lehigh Valley York Chester County

Page 43: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Building Community Leaders reach to other leaders Expand the circle of support Grow more resources Develop/sustain commitment Recruit people

The more volunteers or members who find purpose in the community -the more they will commit resources that you may never have known existed.

Page 44: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Community Development

CMS suggested communities Hospitals in contiguous Zip Codes Overlap of beneficiaries/penetration Desire to reduce re-admission rates Agree to collaboration/relationship Transparency Downstream Providers

Page 45: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Provider Responsibilities Leadership commitment Active involvement of provider teams including

leadership in meetings, conference calls, webinars and coalition activities

Implement improvement strategies using rapid cycle testing

Create new strategies that maximize improvement for all participants

Track, monitor and share real time data

Page 46: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Stakeholder Support

Are the cornerstone for the community Learn from the community Inform members of CT strategies Support/provide community education sessions Participate in quarterly calls Provide publications via newsletter Post information/links of CT on Web sites

Page 47: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Expand the Circle of Support… Motivating Call to Action

Page 48: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Community

Intervention Selection

Page 49: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Standard/Known Process

– BOOST (Better Outcomes for Older adults through Safe Transitions)

– TCM (Transitional Care Model)

– F/U appointment made at discharge

– Pharmacy

– Telephone F/U

– Document standardization

Page 50: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Based on discharges from 2007. Clinical Classification Software (CCS) 2008 downloadable from http://www.ahrq.gov/data/hcup/ .

Drivers of Readmissions

Page 51: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Lessons Learned

Key drivers of 30 day readmissionLow patient activationLack of standard processesInadequate transfer of information across care settings

Key strategies for 30 day readmission reduction Community organizationPatient activationMulti-provider process improvement

Page 52: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Of discharges of CT residents from the five targeted hospitals that result in a 30-day readmission to any acute care hospital during the last six months of life– 35% are discharges to a SNF

– 33% are discharges to home under the care of a HHA

– 23% are discharges to home or self-care

– 28% of all readmissions occur during the last six months of life

End of Life

Page 53: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Root Cause Analysis

Simply stated RCA is a process designed to help identify not only– What and how BUT– Why

Leads to interventions selection and ongoing identification of gaps in care delivery across settings.

Page 54: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Intervention Selection

Derived from root cause findings Monitor & Measure

– Process Measures• System Components

– Outcome Measures• Effect of change on patient

Page 55: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Intervention Selection by Driver

Patient ActivationStandard/Known ProcessTransfer of Information

Page 56: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

PROJECT RED(ReEngineered Discharge) Evidenced based toolkit. Developed by Boston University Medical Center Addresses key factors identified in RCA

– Delayed Transfer of Discharge Summary– Unknown Test Results– Patients Failure to Follow-up– Medication Interactions and Adverse Events

Page 57: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Transfer of Information

–Communication Re-design

–HIT

–SBAR

–Beneficiary and community outreach

Page 58: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Patient Activation

– INTERACT

– RED (Re-engineered Discharge)

– Medication Reconciliation

– Coaching

– Teach-Back

Page 59: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Coming together is a beginning.Keeping together is progress.Working together is success.

~Henry Ford

Page 60: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Community Care Transitions Program

Page 61: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

The Community–based Care Transitions Program (CCTP)

The CCTP, mandated by section 3026 of the Affordable Care Act, provides funding to test models for improving care transitions for high risk Medicare beneficiaries.

•Increasing rates of avoidable hospital readmissions will result in negative health outcomes for Medicare beneficiaries impacting their levels of safety and quality of care.

•The CCTP seeks to correct these deficiencies by encouraging communities to come together and work together to improve quality, reduce cost, and improve patient experience.

Page 62: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

CCTP: Program Goals Improve transitions of beneficiaries from the

inpatient hospital setting to other care settings •Improve quality of care •Reduce readmissions for high risk

beneficiaries •Document measureable savings to the

Medicare program

Page 63: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Eligible Applicants Are statutorily defined as: Acute Care Hospitals

with high readmission rates in partnership with a community based organization

Community-based organizations (CBOs) that provide care transition services

•There must be a partnership between the acute care hospitals and the CBO

Page 64: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

CCTP: Definition of CBO

Community-based organizations that provide care transition services across the continuum of care through arrangements with subsection (d) hospitals−Whose governing bodies include sufficient representation of multiple health care stakeholders, including consumers

Page 65: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

CCTP: Key Points CBOs will use care transition services to effectively

manage transitions and report process and outcome measures on their results.

•Applicants will not be compensated for services already required through the discharge planning process under the Social Security Act and stipulated in the CMS Conditions of Participation.

•Applicants will be required to participate in ongoing learning collaboratives

Page 66: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

CCTP: Application Guidance Applicants are required to complete a root

cause analysis The proposals must specify how the root causes

will be addressed The proposal will describe how they will work

with accountable care organizations and medical homes if applicable

The proposal will describe how they will align their care transition programs

Page 67: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

CCTP: Conclusion The program solicitation was announced in the

Federal Register and is now available at: http://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313

The program will run for 5 years with the possibility of expansion beyond 2015

If community progress is not occurring within 2 years of receiving funding, funding will be stopped

Please direct CCTP questions to: http://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313

Page 68: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

CCTP Website Visit the program website for daily updates on

program status at http://www.cms.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1239313

Do not forget to note Frequently-Asked Questions

On the Site

Page 69: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

What Actions Can You Take? Look at your process What do you already have in place? What strength do you bring to the community? Be a good team player How can you collaborate to

– Improve care delivery across the continuum

– Reduce errors and avoidable re-admissions

– Share resources and reduce cost

– Improve communication and information transfer

– Improve Care Transitions

Page 70: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

10th Scope of Work: The Opportunity for You…. Communities are developing

– Position yourselves

– Promote cross setting best practices you have implemented

– Integrate with upstream and downstream providers

– Be part of the discussion and strategic planning

– Let everyone know the role of home care and the services are critical to decreasing the rate of 30-day readmissions

– Be part of the solution!

Page 71: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.
Page 72: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

QIO Technical Assistance

Learning and Action Networks (LAN) on a state-wide level

Webinars provided and recorded Connect to downstream providers Provide current Medicare data to providers

Page 73: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

Resource Sharing

Upcoming conferences or meetings E-newsletters

– Share with us/success stories– Or how can we share an article with you?

Contact Krista Davis at [email protected] or

[email protected] www.qipa.org

Page 74: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

You must be the change you wish to see in the world

MahatmasGandhi

Page 75: Care Transitions : Are You in the Game? Naomi Hauser RN, MPA Director Care Transitions Quality Insights of Pennsylvania May 16, 2012.

This material was prepared by Quality Insights of Delaware, the Medicare Quality Improvement Organization for Delaware, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication number 10SOW-DE-ICP-KD-010612A. App. 1/12.