Care Transitions in Georgia: Partnering with your community to move readmissions Jennifer Hodge RN MSBA Aim Lead, Integrating Care for Populations Communities Alliant Georgia Medical Care Foundation
Dec 28, 2015
Care Transitions in Georgia: Partnering with your community to move readmissions
Jennifer Hodge RN MSBAAim Lead, Integrating Care for Populations Communities Alliant Georgia Medical Care Foundation
Objectives
► Participants will be able to articulate 2 changes in the QIO program
► Participants will be able to discuss 2 advantages to partnership with other community stakeholders to improve care delivery
► Participants will be able to name the community health care connections meeting nearest to their home
Georgia’s Strategy
► Change focus of established regional meetings
► Engage wide variety of providers
► Grow local leaders ► Spread interventions that
work► Identify links in other
CMS quality work ► Partner with others
Georgia Performance by ZIP Code
GA Score Card. LEFT: Report Date: 12/31/11 RIGHT: Report Date: 10/31/13
What’s The impact of all our work in Georgia?
► In the yellow communities, readmissions have been reduced by 21.60%
► Statewide readmissions have fallen 20.79%
► In Georgia 7292 fewer readmissions occurred in 2013 than in 2010
QIN Statement of Work: 4 Key Roles for QIO
1. Results-Oriented: A Multi-State and Local Change-Agent Champion ► Data driven► Active engagement of patients and other
partners► Proactive, intentional innovation spread
that improves and “sticks”
2. Learning and Action Networks: A Facilitator of Learning and Action ► Implement an “all teach, all learn”
approach to share clinical QI expertise
QIN Statement of Work: 4 Key Roles for QIO (cont’d)
3. Technical Assistance: A Teacher and Advisor► Consultation and education in QI science
and process improvement► Knowledge management so learning is
never lost
4. Communication: A Highly Effective Communicator and Trusted Partner► Optimal learning, patient activation and
sustained behavior change► The “Go To” for health care transformation
Clinical Focus of 11th SOW ActivitiesImprove Cardiac Health and Reduce
DisparitiesImprove Coordination of Care
Reduce Disparities in Diabetes Care Reduce Adverse Drug Events
Collaborate with Regional Extension Centers and Promote Meaningful Use of HIT
Support Quality Reporting with an Emphasis on Improvement
Reduce Healthcare-Associated Infections in Hospitals
Perform Quality Improvement Initiatives as Requested
Reduce Healthcare-Acquired Conditions in Nursing Homes
Opportunity to Propose Projects That Meet Regional Needs
How They Want the Work Done (cont’d)
► Beneficiary engagement
– Included as component of every aim
– Work directly with beneficiaries and include beneficiaries in meetings
– Target racial and ethnic minority beneficiaries, dual-eligible beneficiaries, rural beneficiaries and the community providers who serve them
How They Want the Work Done (cont’d)► More focus on physician and physician
practices─ Technical assistance for quality reporting─ Promote use of EHRs and electronic data
reporting
► Leverage “virtual” activities such as learning and action networks─ Work with communities that cover 60% of
beneficiaries─ Work with 75% of nursing homes─ Integrate efforts across aims
► Plan for sustainability from the start
Note to Self: Supporting individuals in
their communities as they age will
take more effort than any single entity can provide.
Different Communities,Different Discharge Plans
Com 4 Savannah0
10
20
30
40
50
60
70
44.9
59.06
22.45
13.93
24.49
15.7
5.44 3.556.6
11.44
HomeSNFHHHospiceRead. Rate/ 1000 Beneficiaries
This material was prepared by Alliant GMCF, the Medicare Quality Improvement Organization for Georgia, 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 No.