Professional Documents
Culture Documents
breaking down
barriers
for the good of consumers
and their family caregivers
Collaboration is Key 5
Collective Impact 5
Key Presentations 6
CASE STUDIES 9
Lessons Learned 18
APPENDICES
Summit Participants 25
introduction and overview
Without hesitation, Alma and her family decide that they will offer Mom a home
with them for as long as she needs it. They know this is the right thing to do,
but they also understand that it will not be easy. Alma and her husband both
work full time and their son attends school. Consequently, Alma’s mother spends
a good deal of her waking hours alone.
Alma’s mother is a retired domestic worker and qualifies easily for Medicaid.
But getting Alma’s mother the home- and community-based services she needs
proves more difficult. Despite the fact that she now lives in one of the nation’s most
service-rich areas, Alma’s mother receives no services. Instead, she receives a place
on a Medicaid waiting list.
Alma does her best, but her mother’s condition continues to deteriorate. Doctor
and hospital visits become more frequent. Prescriptions multiply. Unfortunately,
Alma’s mother does not recover. After a few months of illness and family strain,
Alma’s mother dies. A few days later, Alma receives a call. Her mother has moved
up to number 176 on the waiting list for Medicaid waiver services.
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 1
The story of Alma and her mother is all too real and local professional associations; the aging
for millions of older Americans who, each year, network; hospitals and health systems; and
leave hospitals without the support they and their organizations that provide acute care, long-term
families need to help them transition back into the services and supports, housing, and home- and
community. All too often, initial hospitalizations community-based services. Our participants were
lead to rehospitalizations or, as in the case of policy makers, social scientists, social workers,
Alma’s mother, to extremely poor outcomes. nurses, physicians, researchers, case managers,
educators, students, business leaders, elected
Alma’s story has served as to galvanize the
officials, and marketing professionals — all the
Long-Term Quality Alliance (LTQA) since its launch
stakeholders we will need at the table in order to
in early 2010 because it puts a real face on the
truly reform the system through which consumers
heartbreaking challenges that many older people,
receive health care, services, and supports in their
their families, and their caregivers face each and
later years.
every day. The story spurred LTQA organizers to
action because it illustrated all too clearly our Despite their geographic diversity, participants
nation’s collective failure to help older consumers shared a common, and strong, interest in working
and their families understand and navigate a together to reform that health-and-service system
fragmented health care system. On a broader scale, so that Alma’s story would become a distant
it also illustrates our nation’s failure to fix that memory of the ways things “used to work.”
health care system by offering physicians, hospitals,
providers of long-term services and supports, and
community-based service providers the incentives Long-Term Quality Alliance
they need to step across the barriers that keep them
The Innovative Communities Summit represented
from working together for the good of consumers
the first of many opportunities for LTQA to serve as a
and their families.
neutral convener of broad-based groups concerned
Fittingly, Alma’s story also served to galvanize the about and committed to advancing change within
150 individuals who gathered in Washington, D.C., the nation’s health care system in order to improve
on December 10, 2010, to participate in LTQA’s effectiveness and efficiency of care and quality
Innovative Communities Summit. Hailing from of life while saving health care dollars. This was
all regions of the country, Summit participants the primary goal of the steering committee that
represented a wide variety of organizations evolved into the launch of LTQA in 2010 under
that create policies and provide services and the expert guidance of Dr. Mark McClellan, former
supports that impact the lives of older people administrator of the Centers for Medicare and
and people with disabilities. Participants came Medicaid Services (CMS) and currently director of
from organizations representing federal and state the Engelberg Center for Health Care Reform, and
government; advocacy and service organizations Leonard D. Schaeffer Chair in Health Policy Studies,
serving older consumers, individuals with at the Brookings Institution. That diverse steering
disabilities, and their caregivers; national, state committee sought to capitalize on the new mandate
2 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
in Washington to reform the current health care stakeholders pool their collective energy, break
system, primarily through the Affordable Care Act. down the silos in which they operate, and work
LTQA’s leaders hoped that such reform would create together to devise and implement strategies and
measures that help shed light on how consumers interventions that advance and improve care.
and family caregivers experience long-term services Those strategies and interventions must be
and supports and that gauge the quality of the aligned with the needs, preferences, and values
services they receive both at home and in health of consumers and their family caregivers.
and long-term care settings. LTQA also wanted to
LTQA is fully committed to helping communities
engage consumers and their caregivers in efforts
around the nation take this collective action. For
that improve care transitions and coordination,
this reason, community delegations of three-to-
promote earlier access to palliative and end-of-life
five individuals were invited to attend the Summit
care, and minimize unnecessary overuse of services.
and explore the possibility of participating in a
All the while, LTQA’s organizers were cognizant
multi-year project for which LTQA intends to seek
of the fact that no reform would be successful
funding. Such a project would be designed to
or sustainable unless and until we took steps to
provide a number of local Innovative Communities
introduce efficiencies into the system that would
with the support and assistance they need to create
trim costs and support and strengthen the workforce
multi-sector cooperatives. Those cooperatives would
that we depend on to provide critical care and
unite local health and service providers, as well as
services to older consumers.
consumers and their caregivers, in a broad-based
coordinated effort that advances LTQA’s mission to
increase the quality of and accessibility to care and
Establishing Innovative Communities
services that promote wellness and independence,
The Innovative Communities Summit focused a reduce unnecessary hospitalizations, improve care
spotlight on a central theme that drives the Alliance’s transitions, and save health care dollars.
work. While action on the national level is certainly
integral to health care reform, LTQA is convinced
that the most important health reform victories Avoidable Hospitalization
will take place at the local level, in cities and towns and Care Transitions
around the country. A broad range of community
It came as no surprise to participants at the
stakeholders — including physicians, hospitals,
LTQA Innovative Communities Summit that
Area Agencies on Aging, long-term and post-acute
hospitalizations and care transitions would be
care providers, visiting nurses, affordable housing
among the day’s major themes. That’s because
providers, adult day health programs, home care
transitions across care settings are common
agencies, and consumers, to name only a few —
occurrences for frail elders, particularly for those
is needed to help older people and people with
with complex medical conditions. The number of
disabilities remain healthy and independent. Health
patients discharged from hospital to home health
care reform will not succeed unless all of these local
care increased 53 percent between 1997 and 2006,
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 3
while the number of patients discharged to nursing Institute for Healthcare Improvement (IHI), sheds
homes or rehabilitation facilities increased by an important light on the serious nature of poor
25 percent during the same period.1 The real impact transitions and rehospitalizations. In a 2009 report
of these increases become apparent when you for The Commonwealth Fund about the STate
consider that nearly half of community-dwelling Action on Avoidable Rehospitalizations Initiative
older adults discharged from a hospital to a nursing (STAAR),4 Boutwell and her colleagues at
or rehabilitation facility experienced four or more IHI reported that more than a quarter (28%)
care transitions to another institution over the next of initial hospitalizations are avoidable while
12-month period.2 the same is true for 76 percent of Medicare
rehospitalizations.
Transitions across settings have become increasingly
recognized as critical junctures that can affect the Who is at highest risk for rehospitalization?
health and functional ability of vulnerable older According to the IHI report, it is patients with
people.3 When people are hospitalized or admitted chronic illnesses like heart failure and chronic
to a nursing home, they typically receive care from obstructive pulmonary disease; the frail elderly;
providers who are not familiar with their medical patients residing in nursing homes or who receive
history, medications, and care preferences. Older home health care services; patients nearing the
adults with temporary or permanent cognitive end of life; and individuals with psychiatric illness,
impairments who leave an institution may not substance abuse, and complex social challenges,
understand discharge instructions. Ironically, including poverty. As a group, individuals with
caregivers are often left out of the discharge process, more than five chronic conditions have the most
even though they play a critical role in providing complex medical conditions and highest rates
care following a stay in an acute- or post-acute care of rehospitalization.
facility. As a result, patients often fail to follow up
As mentioned earlier, hospitalizations and
with recommended care and medications, their
rehospitalizations are hard on patients, because they
primary care physicians are not kept informed of the
often compromise health and emotional well-being.
patient’s condition, and family caregivers endure
But they are also extremely expensive. Avoidable
additional strain. The real tragedy is that many
hospitalizations cost approximately $29 billion
hospitalizations are avoidable.
while avoidable rehospitalizations among
The work of LTQA Board Member Amy Boutwell, Medicare patients alone account for $15 billion
director of strategic improvement policy at the in spending annually, according to IHI.
1
Agency for Healthcare Research and Quality. 2008. “Hospital Discharge to Home Health, Nursing Homes Increasing.”
AHRQ News and Numbers, Oct. 23.
2
Ma, E., et al. 2004. “Quantifying Post-Hospital Care Transitions in Older Patients.” Journal of the American Medical Directors
Association, (5) 71-74.
3
AARP. 2009. “Chronic Care: A Call to Action for Health Reform.” Beyond 50.09. Washington, D.C.: AARP Public Policy Institute.
4
Boutwell, A., et al. 2009. STate Action on Avoidable Rehospitalizations (STAAR) Initiative: Applying Early Evidence and Experience
in Front-line Process Improvements to Develop a State-based Strategy. Cambridge, MA: Institute for Healthcare Improvement.
4 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
Collaboration is Key In such a fragmented system, it remains the
responsibility of the consumer to bridge the gap
Improving care transitions and reducing between and among providers. This is a challenge
rehospitalizations will not be easy, but LTQA for all health consumers. But in the case of frail
believes it is possible and a worthy strategy to or ill consumers and their overburdened caregivers,
improve quality of care and quality of life for older the results are often disastrous, as the figures
people and people with disabilities. Clearly, the presented here illustrate.
time is right for such an initiative. The Affordable
Care Act5 signed into law in early 2010 directs
Medicare to recover payments made to hospitals Collective Impact
for unnecessary readmissions within 30 days of
discharge. Beginning in October 2012, a hospital’s Despite these many challenges, LTQA remains
total Medicare payments could be reduced by convinced that collaboration is not only possible,
up to three percent over three years. The looming but is already taking place in a number of commu-
mandate could very well give hospitals the incentive nities around the country. Participants in the LTQA
they need to participate in the kind of multi-sector Innovative Communities Summit heard from three
collaboratives that LTQA would like to support. of those communities. (See page 9.) In addition,
each participant came to the Summit with an
Granted, our current health care system is not important resource that served as a backdrop for
wired for collaboration. Separate funding streams, much of the day’s discussions. That resource, a
regulations, and care practices in each sector have December 2010 article published in the Stanford
served to separate providers from one another, not Social Innovation Review,6 explored a new
unite them in the care of their common consumer. “Collective Impact” approach to community
By the time consumers require a hospitalization, change that could provide a model for the
therefore, they are receiving care from multiple Innovative Communities that LTQA would like
providers, who operate in different settings, receive to foster and support.
reimbursement from separate government programs,
follow different rules, and don’t communicate with In the article, authors John Kania and Mark Kramer
one another. Of primary concern is the fact that, describe the experiences of Strive, a nonprofit
operating in relative isolation, these providers are organization that has succeeded in using a
each developing separate care plans for the same community-wide collaborative to improve student
consumer, each giving that consumer different success in three large, cash-straps school districts in
instructions about self-care, and each writing Ohio and Kentucky. Despite its focus on education,
prescriptions that, taken together, could cause Strive’s success has many lessons for LTQA and its
overmedication or adverse drug interactions. Innovative Communities initiative. For one thing,
5
Read the full text of the “Patient Protection and Affordable Care Act (HR 3590)” at: http://www.gpo.gov/fdsys/pkg/BILLS-
111hr3590enr/pdf/BILLS-111hr3590enr.pdf.
6
Kania, John and M. Kramer. 2011. “Collective Impact.” Stanford Social Innovation Review, Winter.
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 5
both Strive and LTQA are focusing on an extremely process that united all the participants
complex problem that resists easy fixes. The authors through a common agenda, shared
suggest that Strive succeeded where others have measurement, continuous communication,
failed because “a core group of community leaders and mutually reinforcing activities.
decided to abandon their individual agendas
The experience of Strive, and similar initiatives
in favor of a collective approach.” Participants in
highlighted in the Stanford Review paper, suggest
LTQA’s Summit felt that similar efforts to “check
that large-scale social change comes from better
our egos at the door” would go a long way
cross-sector coordination, not from isolated inter-
toward building the same kind of success within
vention by individual organizations. LTQA could not
Innovative Communities.
agree more. The path we take in creating Innovative
Additionally, Summit participants agreed that the Communities may be different from the “Collective
reasons behind Strive’s success could easily become Impact” approach, but we believe this model is
the reasons behind our success: worth referring back to as we move forward.
6 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
the American Association of Homes and Services LTQA Board Member (ex officio) Dr. Paul McGann,
for the Aging, expressed his interest in seeing deputy chief medical officer in the Office of
Innovative Communities develop best practices Clinical Standards and Quality at CMS, described
“that demonstrate large-scale results, which can the transformational changes that have taken
be reported to the government and shared among place within his agency since the arrival of its
colleagues nationwide, and which say, ‘We can new Administrator Dr. Donald Berwick. But he
solve this problem.’” LTQA Board Member Amy encouraged participants to look to themselves,
Boutwell applauded participants’ willingness to rather than to government, for the solutions that
put consumers “at the center of what we do every will transform a fragmented health system.
day.” When providers can ask those consumers the
“I’m here to tell you that we want to be a partner,
right questions, and listen carefully to their answers,
and we want to help you in this effort,” he told
“they understand that their purpose is to make the
Summit participants. “But you are going to have
system work better for people over time and across
to find the leadership and the courage to lead a
settings,” she said.
new movement that is committed to people and to
LTQA Board Member (ex officio) Kathy Greenlee, quality. I can pledge to you that as long as I am at
the assistant secretary of aging, was on hand to CMS, we will be right behind you and do everything
demonstrate the Administration on Aging’s (AoA) in our power to help.”
interest in working with LTQA and the Centers of
Medicare and Medicaid Services (CMS) to improve
the lives of older consumers. In addition, Greenlee Organization of This Report
underscored the need to prepare for the impact
The remainder of this report attempts to give
that successful Innovative Communities could
readers a feel for the energy, optimism, and good
have on the aging network.
will that was on display during LTQA’s Innovative
“I believe strongly that the opportunity we have Communities Summit. Participants arrived ready to
now to work on Innovative Communities and care dream about a different future for older consumers
transitions is finally and appropriately a way to and consumers with disabilities. As the day
blend the medical model and the social model, progressed, an assembly of 150 separate individuals
to have a holistic approach for acute care, long-term became a cohesive group that worked together to
care, and social services,” she said. “But when devise cross-sector strategies that could someday
we are successful, we will create a huge demand allow us to successfully improve the quality of care
for the supportive services that AoA offers, including and quality of life for the people we serve and, in
meals, attendant care, and caregiver support. We the process, save health care dollars.
need to think about how we are going to support
these services. It will take all of us to get it done.”
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 7
The report you are about to read follows, as much
as possible, the Summit discussions as they evolved
throughout the day, including:
8 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
case studies
connections
based organizations, and consumers together to
make sure that older community residents and
citizens with disabilities get the services they need,
when and where they need them.
Patricia Sprigg, President and As a popular destination for retirees, and one of the
Chief Executive Officer fastest growing Medicaid spenders in the nation,
North Carolina and its individual counties have
Heather Altman, Project Director,
long been concerned about the impact that an
Community Connections
aging Baby Boom population would have on their
Carol Woods Retirement Community communities. In 2004, local leaders in Orange
County (where Carol Woods is located) faced
these issues head-on by developing a Master Aging
When construction of the Carol Woods Retirement Plan that identified the types of services that the
Community began in the mid-1970s, it wasn’t an county’s current and future aging population would
outside developer that designed the community’s need. Carol Woods President and Chief Executive
layout or obtained the necessary permits and Officer Patricia Sprigg, who co-chaired the county
financing. It was an active group of local residents, planning process, took seriously the conclusions of
many of them retired professors who had spent the Master Aging Plan, particularly its identification
many years living in Chapel Hill and teaching at of transitions between care settings as a major
the University of North Carolina (UNC). The group challenge for older citizens as their health care
banded together with the common goal to establish needs and level of functioning changes over time.
a place where they could live after retirement while In 2006, Sprigg led Carol Woods’ effort to apply
enjoying the amenities they desired, accessing for a one-year planning grant from The Duke
the services they needed, and remaining active Endowment that would support a formal assessment
members of the city they had come to love. of the factors impacting the health and safety of
older citizens in their community. That planning
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 9
grant led to a subsequent grant from the same workgroups that would begin addressing
foundation, which gave Carol Woods $996,000 those priority areas. Those workgroups
to create a community infrastructure that would continue to meet regularly and to include
educate consumers about local service options; participants from the original Community
foster better communication and collaboration Engagement Event.
among social service and medical organizations;
As a result of work by the “Patient
decrease fragmentation and duplication of services;
Advocacy at Transitions” workgroup,
and improve innovative transitional care supports.
for example, Community Connections
partners now serve on the Readmissions
Task Force at UNC Hospital and have
How It Works
spearheaded an initiative to provide
The first and most surprising finding from follow-up phone calls to older adults
Carol Woods’ one-year planning grant was that after hospital discharge. Community
the service-rich Chapel Hill community didn’t Connections partners are also involved
necessarily need to add more services to its safety in efforts to educate hospital discharge
net for older people. However, those services planners about community services that
were fragmented, duplicative, and often unknown can help older consumers transition back
to consumers. Based on that finding, the steering into the community after a hospital stay.
committee switched its approach from one solely The “Outreach Network to Consumers
focused on service development to one that and Providers about Services” workgroup
also included a focus on service integration supports an annual Resource Connections
and education. Specific programs and inter- Fair that provides information about local
ventions included: services to 200 community residents.
10 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
participate in the local Chatham-Orange cooperation among local care and service providers.
County CRC, which connects older For example, discharge planners trained through
consumers and people with disabilities Community Connections and the Chatham-Orange
to information about and referral to a CRC are now better equipped to guide consumers to
host of long-term services and supports. services that can ease their transition from hospital
The CRC infrastructure has also served to to home. Equally important, consumers experience
unite community agencies and providers a smoother transition to those services, thanks to the
around a common purpose and to CRC, workgroup activities, the annual resource fair,
provide a measure of sustainability to the and efforts within local agencies to cross-train staff
Community Connections initiative and the so they know about the services offered by a variety
partnerships that it helped launch. of agencies and organizations, not just their own.
Matching Funds and Seed Money. Service providers have benefitted from Community
Having almost $1 million to spend within Connections as well, according to a follow-
two counties has helped to elevate the up survey that the initiative conducted among
credibility of the Community Connections stakeholders. Almost all (89%) of the respondents
project among local stakeholders. said they have learned something new about
Community Connections funds have available programs and services as a result of
helped local partners implement and their involvement in Community Connections.
expand evidence-based programs that Ninety-four percent reported increasing their own
address hospital transition, chronic disease connections with their colleagues in other agencies.
self-management, and falls prevention; Two-thirds said that they had begun or increased
conduct a randomized-controlled trial to their focus on transition issues (64%) and that they
study the impact of a phone-call follow- had increased their partnerships with health care
up program for older adults discharged providers to improve transitions (66%).
from the UNC Emergency Department;
and launch a telehealth pilot at a local
community health center. In addition, Next Steps
Community Connections funds allowed Carol Woods recently received an additional
local partners, including the State of North $296,000 from The Duke Endowment to
Carolina, to garner more than $2 million continue the Community Connections
in additional grants for the region. initiative for another two years. This third
grant will focus Community Connections
on the task of developing best practices
Accomplishments around transitions from hospital to home
and helping CRC sites throughout the
Community Connections measures its success by
state implement evidence-based care
gauging how the experience of consumers who
transitions interventions.
use local services has been enhanced by a new
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 11
assessments conducted by Cathedral Square in
several of its 20 independent housing buildings tell
that story all too well: only 47 percent of residents
were able to pass a cognitive screening test,
Burlington,
37 percent reported that they had fallen in the
Vermont
past year, and 50 percent said they were taking
12 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
providers, transforming them from landlords into Association (VNA), a case manager assigned by the
advocates that monitor the health and well-being Area Agency on Aging (AAA), an intake nurse from
of their older residents and provide or coordinate the Program of All-Inclusive Care for the Elderly
services that allow those residents to remain (PACE), a community mental health provider, and
independent and safe in their own apartments. representatives of other home- and community-
based service providers. The University of Vermont
The program’s sustainability comes from the fact
(UVM), Albany School of Pharmacy, and the Area
that SASH was integrated into Vermont’s new
Health Education Centers Program at the UVM
health reform initiative after Cathedral Square
College of Medicine sent students, including
completed a business-case model that projected
a full-time geriatric fellow, to the SASH site.
a cumulative savings in Medicare expenditures,
net of all SASH program costs. Vermont’s health The SASH coordinator carries out a number of
care reform initiative is organized around a medical tasks that keep the SASH program on track at each
home model through which coordinated care site. He or she keeps tabs on resident well-being,
is provided by an interdisciplinary community especially high-need residents identified by the
health team that supports the patient’s primary care site team; tracks residents who are hospitalized or
physician. Beginning in July 2011, a Medicare- discharged from hospitals and nursing homes; and
funded SASH program will extend the capacity maintains resident health records and the team’s
of those community health teams in 112 housing communication logs. In addition, the coordinator
developments throughout the state. Vermont’s goal is responsible for bringing about transformational
is a true transformation of its long-term care system, change within the housing organization by
and full integration with the acute and primary care training and encouraging property managers,
delivery systems, through a scalable and sustainable custodians, resident services coordinators, and
housing-with-services model. activity directors to observe resident behavior,
notice changes in health or functional status, and
inform the SASH team about residents who require
How It Works additional support.
Funds from the Vermont legislature, the Vermont In addition to checking on ill residents, monitoring
Health Foundation, and the MacArthur Foundation vital signs, and supporting residents’ medication
allowed Cathedral Square to develop the SASH management, the wellness nurse will eventually
model and pilot test it in one apartment building serve as a liaison between SASH site teams and the
from August 2009 to August 2010. Key to the community health teams that the State of Vermont
design process was involving 60 elderly residents will designate to participate in its medical home
in the development of the model. The model model of health reform. This connection will help
revolves around a SASH site team comprised of SASH sites assist local medical practices in caring
a full-time SASH coordinator and a wellness nurse for residents with high needs.
employed by the housing development, an acute- When a resident joins the SASH program, he or she
care nurse assigned to the site by the Visiting Nurse is interviewed by the SASH coordinator and receives
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 13
a functional and cognitive assessment from the bring direct knowledge about high-needs residents
SASH team. Based on these assessments, the team to the team meeting and personally follow up
carries out two types of consumer-centered planning on team recommendations for additional health-
processes within the housing development: related interventions.
An Individual Healthy Aging Plan: Each site’s SASH team is connected to an umbrella
The SASH team uses the individual’s group called the Local Table, which consists of
assessment data to help the resident high-level representatives from SASH partners.
identify health-improvement goals that The Local Table meets several times per year to
he or she wants to pursue, such as losing share information about the work of each partner,
weight, getting more exercise, or eating track the progress of SASH teams, keep partners
a more nutritional diet. The team provides up-to-date on the progress of the state’s health
guidance and coaching to help the reform initiative, and ensure that the SASH initiative
resident meet those goals. is an integral part of this statewide systems change.
14 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
its statewide rollout in mid-2011. In addition,
service providers who work at the SASH test site
now endorse the program because SASH has Farmington Hills,
demonstrated that it can help them carry out their Michigan
missions more effectively.
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 15
50 years, leaving not only fewer people not only for the rest of Michigan, but for at-risk
within the metropolitan area, but urban areas throughout the nation. If efforts to
fewer services. reduce rehospitalizations can work in Detroit,
they theorize, they can work anywhere.
The city’s median income is $29,500,
compared to $37,000 for the nation as a
whole. At 34 percent, the city’s poverty
How It Works
rate is the highest in Michigan and the
highest among the nation’s cities. Thirty Based on the belief that hospitals cannot reduce
percent of the population is unemployed rehospitalization rates by themselves, the MI
and more than 17 percent is uninsured. STA*AR initiative is designed to create local health
Almost 20,000 residents are homeless. care/community cooperatives through which
providers of primary, acute, and long-term care, as
Detroit residents are more likely than
well as community-based service providers, come
other Americans to have heart disease and
together to take ownership for the safety of patients.
diabetes. Over 28 percent of residents
have a disability. Each of the 28 hospitals that joined MI STA*AR in
May 2009 — including the five hospitals in Detroit
One fifth of the population has no
— began the process to reduce rehospitalizations by
transportation and few residents have
building its own transition team. That team includes
access to a grocery store or pharmacy.
post-acute providers, physician offices, home health
Even though diet is a major risk factor
agencies, home- and community-based service
for chronic disease, half of the city’s
providers, consumers, and other local organizations
food stamp retailers are liquor stores,
deemed to have a stake and a role to play in
gas stations, and bakeries.
reducing rehospitalizations.
Detroit’s five hospitals are trying to change these
Once transition teams are established, the hospitals
statistics through a four-state pilot program called
are free to adopt specific strategies that the teams
STate Action on Avoidable Rehospitalizations
feel are best suited to the patient population and
(STAAR) that is directed by the Institute for
local community. Taking a “rapid cycle change”
Healthcare Improvement, with support from
approach, the typical hospital transition team
The Commonwealth Fund. The Detroit initiative
chooses to focus initially on one of the four
— called Detroit Community Action to Reduce
key STAAR strategy areas until all strategies are
Rehospitalization (Detroit CARR) — operates under
addressed. STARR strategies include: enhanced
the auspices of Michigan’s STAAR program (MI
admission assessment for post-discharge needs,
STA*AR), which is managed for IHI by MPRO,
enhanced teaching and learning, patient and family-
Michigan’s quality improvement organization, and
centered handover communication, and post-acute
the Michigan Health and Hospital Association
care and follow-up.
(MHA). MI STA*AR organizers believe that, if
successful, Detroit CARR could serve as a model
16 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
Next, the team chooses one or two hospital units some hospitals call patients 72 hours after
in which to test strategic interventions in order to discharge — and in some cases every
“get the bugs out.” When the intervention proves week for a month — to see how they are
successful in this small setting, it is then gradually progressing and to intervene, if necessary,
expanded throughout the hospital. Among the to prevent rehospitalization.
interventions that MI STA*AR and Detroit CARR
Working closely with post-acute
participants have tested in this way include:
providers. Several Detroit CARR hospitals
Before discharge. Several Detroit hospitals have developed working relationships
have found that beginning discharge with post-acute providers so that transitions
planning upon admission gives hospital to nursing homes are easier on patients. In
staff a chance to spend more time educat- one intervention, providers of post-acute
ing patients about discharge instructions care make hospital visits to patients who
and more time to order post-discharge will be released to their facilities. This
services that can take several days to arrange. visit helps ease the transition for patients
Using a “teach back” strategy, hospitals who may be frightened about the nursing
provide the patient with post-discharge home placement, gives the post-acute care
instructions regarding medication or provider a chance to talk to the hospital
other issues and then ask the patient team about the patient’s case, and sets
to repeat those instructions aloud. This the stage for ongoing communication
exercise allows hospital staff members to between the acute and post-acute settings.
check whether the patient understands In addition, Detroit CARR hospitals
the instructions and to evaluate the have devised a two-page transition form
effectiveness of teaching methods. that lists, in one place, the most critical
information needed to care for that person.
After discharge. In order to ensure
This standardized form travels with the
continuity in patient care after discharge,
patient between settings to ensure that all
several Detroit hospitals provide a three-
providers have the information they need
to-30-day supply of medication to the
to provide quality care.
patient at the time of discharge in order
to ensure that the patient continues to
take medications that were prescribed
Accomplishments
during his or her hospital stay. Other
hospitals will also make patients’ follow- Working together, hospitals in the Detroit area have
up appointments with their primary care succeeded in reducing rehospitalizations for heart
physicians in order to ensure that such failure by up to 20 percent since the Detroit CARR
visits take place within a reasonable period initiative began. Overall, the rehospitalization rate
of time. To further safeguard patient health, in the city has decreased by five percent among
adult patients.
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 17
Next Steps
lessons
learned
A new cohort of 31 hospitals is now
beginning the second phase of an effort
to expand the MI STA*AR initiative
statewide to 59 hospitals. In early 2011, in Vermont,
the new members of the MI STA*AR
initiative were busy creating their transition
teams, interviewing patients that were Michigan
readmitted to their facilities, and selecting
the strategy on which they will focus their
attention. Meanwhile, the five hospitals and North Carolina
participating in Detroit CARR are gearing
up to introduce additional interventions to
reduce rehospitalizations. These include the
development of a person-centered discharge
Patricia Sprigg and Heather Altman of Carol Woods,
planning initiative that will be implemented
Nancy R. Eldridge of Cathedral Square Corporation,
in partnership with the state Office of
and Nancy Vecchioni of MPRO have learned many
Services for the Aging.
lessons since the day they decided to become
catalysts for change within their communities.
Here are a few of those lessons:
18 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
Make the case for change. Inspiring stories and them powerful stories about how the health
convincing data are both powerful tools that system worked for — and failed — them,
Innovative Communities can use to convince as well as valuable insights into their concerns
partners that change is necessary. Nancy and preferences.
Vecchioni suggests that hearing stories about
real patients who “fell through the cracks” can
Don’t duplicate existing services. Vermont’s
SASH organizers made a concerted effort to
often convince partners to commit themselves to
ensure that their partners in the primary, acute,
breaking down barriers that stand in the way of
and long-term care sectors were “operating
coordinated patient care. Personal stories about
at their highest and best use and that there
the successes of Innovative Communities can
was no duplication,” says Eldridge. “We knew
also help keep partners on track. For example,
that creating new services within the housing
VNA and AAA executives strengthened their
organization would not be a viable approach
commitment to Vermont’s SASH program after
either from a financial or a political perspective.”
hearing personal testimony about the value of the
program from their nurses and case workers. Focus on sustainability. Cathedral Square
Corporation wasn’t interested in creating a
Learn about the health world. Cathedral Square
“boutique” project that would work well only
staff learned about the Medicaid program
in Burlington. “We probably could have gotten
in 2000 while developing a 28-unit assisted
the money to get all our sites up and running
living community during the first round of the
with SASH, but it would never have been
Assisted Living Conversion Program, sponsored
sustainable financially,” says Eldridge. “Instead,
by the U.S. Department of Housing and Urban
we took a systems change approach that is
Development. Those lessons came in very handy
doable in every corner of Vermont.”
while Cathedral Square worked on the SASH
initiative. “If you are going to do this kind of Celebrate small victories. Go for the low-hanging
cross-sector work, you really must understand fruit first, says Vecchioni. “Get those wins right
the sector you are planning to work with,” away and show them to the community,” she
says Eldridge. says. “Then you can plan out how you will
meet your longer range goals over time.”
Bring consumers to the table. Older adults,
Sprigg agrees. “Long-term processes will easily
adults with disabilities, and caregivers comprised
turn into apathy if you’re not showing and
one-third of the participants in the Community
celebrating the small victories and successes
Engagement Event sponsored by Community
along the way,” she says.
Connections to map community services and
identify pressing needs. Heather Altman said Get people talking. When a hospital complained
she recruited those consumers by identifying to Nancy Vecchioni that a chronic ventilator
“connected” older people who had a strong patient was continually bouncing back to the
social network upon which they could call. hospital from a local nursing home, Vecchioni
Consumers attending the event brought with recommended a simple, but revolutionary
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 19
solution. At her suggestion, hospital staff visited studying to be Certified Nursing Assistants.
the nursing home to see how they could help It also provided funds to educate 95 graduate
make the patient’s transition easier. The visit students in falls prevention and to offer programs
resulted in better training for nursing home staff on aging and ageism to 621 high school and
and a hospital-facilitated upgrade for the nursing middle school students.
home’s ventilator unit. “It’s all about working
Be patient. Innovative Communities don’t happen
together,” says Vecchioni. “We need to talk to
overnight. They often take years to take root.
one another and go on site visits. We really
Many organizations find change difficult and
encourage our partners to do that because it
often are afraid of it. Others need time to get
really opens their eyes.”
used to interacting and working with partners
Don’t forget about the workforce. Even the most with whom they have never worked, have had
coordinated and integrated system of services past disagreements, or view as competitors.
and supports will fail if there aren’t an adequate A few organizations will need to be convinced,
number of qualified frontline workers to deliver in a non-threatening way, that their processes are
those services, says Sprigg. That’s why Carol not working as well as they think. “It’s a ‘ah-ha’
Woods included a workforce component in its moment when these organizations realize that
Community Connections initiative. The initiative they aren’t connected with other providers and
supported over 132 internships and stipends that they need to change for the good of the
for students in aging services, including those patient,” says Nancy Vecchioni.
20 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
a vision for the future
Participants in the LTQA Innovative Communities Equal partners. All stakeholders — including
Summit were invited to create a common vision for providers of long-term services and supports
a more collaborative future for those who provide — will be welcomed as equal partners in local
care and services to older people and persons with health initiatives, including Accountable Care
disabilities. That vision included these features: Organizations. Innovative Community partners
will have common goals and will use common
Consumer empowerment. Every consumer will
metrics and common terminology. They will also
have an individual, coordinated life-care plan
share evaluation and measurement tools that
that is person-centered and developed with
focus on community outcomes.
the involvement of family. Consumers will be
empowered through a money-follows-the-person Independent and invested leadership. The
approach that puts them in control of their acute Innovative Community will be led by a local
care and long-term services and supports and champion who is viewed as a neutral party and
allows them to receive care at home, if that is who is deeply committed to the good of the
their preference. Consumers and their families community. This leader should be able to build
will be encouraged to become “better activists bridges among partners and motivate them to
for better health care.” work together toward common goals.
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 21
and independent. Funding streams will foster A robust workforce. Innovative Communities
cross-sector collaborations and partners will will take steps to strengthen the workforce in
have the freedom to spend funds for the best acute, post-acute, and community-based care
and highest use. Providers will not need special settings. All levels of staff working in the home
waivers to carry out interventions that have care field will receive enhanced training around
been proven successful in other locales. Block the challenges that patients face after leaving the
grants will allow local stakeholders to engage in hospital and will be educated about the long-
a collaborative process to determine how funds term services and supports available to ease
could be used locally to improve the quality of those transitions.
care and quality of life of consumers. Innovative
A strong volunteer network. All citizens will
strategies to keep consumers healthy will also be
be encouraged to participate in the work of
rewarded and encouraged.
Innovative Communities by volunteering their
Reinvestment of savings. Savings that result time so that service organizations can reach
from innovative and collaborative approaches more consumers at a lower cost.
to reduce rehospitalizations will be reinvested
Public education. A national campaign will
in services and supports so the aging network
educate the general public about the options
can respond to the anticipated demand for its
available to help people with chronic disease
services as more older people age in place.
and other illnesses manage their conditions while
The regulatory and enforcement system will be
living in the community. The campaign will also
attuned to consumer preferences and will serve
address the challenges that hospital patients
as a partner with health and service providers,
encounter when transitioning from hospital to
rather than an advisory.
home, and the resources available to ease that
Cutting-edge technology. Innovative Communities transition. At the local level, consumers will
will explore the ways in which care and service have access to all the information they need to
providers can use interoperable technology make informed decisions about long-term and
— such as electronic health records, remote post-acute care. The Innovative Community will
monitoring, and telehealth — to move care provide easy-to-navigate Web sites and databases
into the home and help larger groups of that include information on how and where to
consumers and their caregivers manage health access services and supports. An information
their health conditions, exercise control over database with a single-point-of-entry will ensure
their health care, and remain independent for that every consumer knows where to begin the
as long as possible. search for needed services and supports.
22 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
a role for LTQA
Participants in the LTQA Innovative Communities Help Innovative Communities identify federal
Summit welcomed the opportunity to collaborate and state sources of funding and advise them
with other stakeholders at the local level to improve on ways to access that funding.
care transitions and reduce avoidable hospitaliza-
Launch a national public relations campaign
tions. They also called for the establishment of a
designed to educate consumers about the
similar collaborative at the national level that would
challenges associated with hospital-to-home
provide a forum where fledging Innovative Com-
transitions and the community resources
munities could learn from organizations that were
available to ease those transitions.
already involved in successful local collaboratives.
Educate government agency staff, legislators,
Participants identified several major roles for LTQA
and policy makers about Innovative
in promoting and encouraging the creation of multi-
Communities so they understand the nature
sector Innovative Communities around the country.
of this transformative movement, the com-
They encouraged LTQA to:
ponents of the model, its benefits, and
Serve as a repository for information that could intended outcomes.
help local stakeholders create and support
Innovative Communities at the local level. In Advocate at the national level for public
particular, Summit participants called for the policies, regulations, and funding changes
development of a database of evidence-based that encourage flexibility, innovation, and
best practices, interventions, and toolkits — cross-sector collaboration in acute, post-acute,
from the U.S. and abroad — which Innovative and community-based care. These advocacy
Communities could adapt to their local needs efforts should include an emphasis on
and resources. To supplement this database, integrating multi-sector collaborations into
LTQA could create templates that Innovative the fabric of federal health programs so that
Communities could use to replicate those waivers become a thing of the past.
practices and interventions. Identify federal regulations that serve as barriers
Develop and promote a common language that to collaboration and cooperation across sectors.
multi-sector collaborators could use to communi- LTQA should work closely with government
cate better with each other and with consumers. agencies, including the U.S. departments
of Labor and Health and Human Services,
Serve as a cheerleader for Innovative Communities
to find ways to eliminate those barriers.
by coaching fledgling communities and convening
regular meetings where Innovative Community
partners could share ideas and best practices.
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 23
appendices
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 25
LTQA: Innovative Communities Summit Marybeth Fidler | Founding Partner
participant list (continued) Cygnet Strategy, LLC | Lancaster, PA
Kathleen Connors de Laguna | Health Insurance Analyst Katie Flannigan | Administrative Director,
Centers for Medicare and Medicaid Services | MI STAAR Project Manager
Baltimore, MD Sinai-Grace Hospital, Detroit Medical Center |
Royal Oak, MI
Paul T. Crowley | Executive Director
Greater Lynn Senior Services, Inc. | Lynn, MA Susan Feeney | Senior Director, Communications
and Public Policy
Bev Dahan | Vice President of Regulatory Affairs Kindred Healthcare | Washington, D.C.
Total Longterm Care | Denver, CO
Jean S. Fraser | Chief
Tsjenna Daley | Project Associate San Mateo County Health System | San Mateo, CA
America’s Health Insurance Plans | Washington, D.C.
Merrill Friedman | AVO, Advocacy
Linda Detring | COO and National Partnerships
Lutheran Senior Services | St. Louis, MO Amerigroup Corporation | Virginia Beach, VA
Damien Doyle | CP Medical Affairs/Medical Director Bridget Gallagher | Senior Vice President
Charles E. Smith Life Communities | Rockville, MD of Community Services
Jewish Home Lifecare | New York, NY
Joan Doyle | Executive Director
Penn Home Care and Hospice | University of Denise Gannon | Vice President and Managing Director
Pennsylvania Health System | Philadelphia, PA Eliza Jennings Senior Care Network |
Olmsted Township, OH
Kermit Eide | President
K.M. Eide and Associates | Williamsburg, VA Marla Gilson | President and CEO
Association of Jewish Aging Services | Washington, D.C.
Bob Eiffert | Long Term Care Program Manager
Fairfax County Health Department | Fairfax, VA Amy Gotwals | Director, Public Policy
and Legislative Affairs
Nancy R. Eldridge | Executive Director National Association of Area Agencies on Aging |
Cathedral Square Corporation | South Burlington, VT Washington, D.C.
Vance Farrow | Bureau Chief Kathy Greenlee | Assistant Secretary for Aging
District of Columbia Department of Health, Bureau of Administration on Aging, U.S. Department
Cancer and Chronic Disease | Washington, D.C. of Health and Human Services | Washington, D.C.
26 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
LTQA: Innovative Communities Summit Ruta Kadonoff | Program Analyst
participant list (continued) Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human
Susan Heisey | Hospital Elder Life Program Director Services | Washington, D.C.
Inova Fairfax Hospital | Falls Church, VA
Gail Kass | President and CEO
Robbie Hill | Executive Director NewCourtland | Philadelphia, PA
Hill-Rom/Liko | Batesville, IN
Lynn Kellogg | CEO
Anne Hinton | Executive Director Region IV Area Agency on Aging | St. Joseph, MI
Department of Aging and Adult Services |
San Francisco, CA Gavin Kennedy | Division Director, Div. of LTC Policy
HHS/ASPE, Office for Disability, Aging, and Long-Term
Jerry Hopkins | Chair Care Policy | Washington, D.C.
Long Term Care Coordinating Council
of the Fairfax Area | Oakton, VA Martin Kennedy | Secretary of Kansas Department
on Aging
Steve Hornberger | Senior Research Associate Kansas Department on Aging | Topeka, KS
LTG Associates, Inc. | Takoma Park, MD
Louis Kincannon | Vice President, Board of Directors
Laura Hopkins | CEO Capitol Hill Village | Washington, D.C.
Amerigroup Community Care of New Mexico, Inc. |
Albuquerque, NM Gail Kohn | Executive Director
Capitol Hill Village | Washington, D.C.
Steven B. Horner | Director, Division
of System Restructuring Mary Jane Koren | Vice President
Departments of Public Welfare/Aging; Office The Commonwealth Fund | New York, NY
of Long-Term Living | Harrisburg, PA
Randall S. Krakauer | National Medical Director
Jeff House | President and CEO Aetna, Inc. | Princeton Junction, NJ
Visiting Nurse Association of Southeast Michigan |
Oak Park, MI Dale Kreienkamp | Vice President, Human Resources
Lutheran Senior Services | St. Louis, MO
Gail Hunt | President and CEO
National Alliance for Caregiving | Bethesda, MD Nancy Kukovich | Chairman,
Southwest Partnerships on Aging
Joan Hyde | Senior Fellow Southwestern Pennsylvania Partnership for Aging |
Gerontology Institute, University of Massachusetts | Greensburg, PA
Boston, MA
Paul Lanzikos | Executive Director
Nancy L. Johnson | Senior Public Policy Advisor North Shore Elder Services | Danvers, MA
Baker, Donelson, Bearman, Caldwell & Berkowitz, PC |
Washington, D.C. Linda Lateana | Executive Director
Goodwin House Bailey’s Crossroads | Falls Church, VA
Tim Johnson | President and CEO
Frasier Meadows Retirement Community | Boulder, CO (continued on next page)
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 27
LTQA: Innovative Communities Summit Larry Minnix | President and CEO
participant list (continued) LeadingAge | Washington, D.C.
Lisa Mancini | Director, Aging and Adult Services Susanne Matthiesen | Managing Director
San Mateo County Health System | San Mateo, CA CARF International | Washington, D.C.
Regina Melly | Director of Business Development Deb Ondeck | Clinical Quality Specialist
Jewish Home Lifecare | New York, NY Veteran’s Health Administration | Washington, D.C.
28 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
LTQA: Innovative Communities Summit Mildred Reardon | Board of Directors
participant list (continued) Vermont Health Foundation | Burlington, VT
Lin Pekar | Vice President of Clinical Operations Mia Robinson | Executive Office Administrator
Visiting Nurse Association of Southeast Michigan | American Association of Homes and Services
Oak Park, MI for the Aging | Washington, D.C.
INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers | 29
LTQA: Innovative Communities Summit Mimi Toomey | Director, Policy Analysis
participant list (continued) and Development
Administration on Aging, U.S. Department of Health
Allison Silvers | Director, Strategic Initiatives and Human Services | Washington, D.C.
VillageCare | New York, NY
Tricia Tomkinson | Regional Director of Operations
Dawn Simonson | Executive Director Ciena Healthcare Management, Inc. | Southfield, MI
Metropolitan Area Agency on Aging | Saint Paul, MN
Ransom Towsley | Senior Director
Warren R. Slavin | President and CEO Southwestern Pennsylvania Partnership for Aging |
Charles E. Smith Life Communities | Rockville, MD Oakmont, PA
Katie Smith Sloan | Senior Vice President of Strategy Julie Trocchio | Senior Director, Community
LeadingAge | Washington, D.C. Benefit and Continuing Care
Catholic Health Association of the United States |
Pat Sprigg | President and CEO Washington, D.C.
Carol Woods Retirement Community | Chapel Hill, NC
Kim Jones Turner | Social Work Supervisor
Libby Stegger | Policy and Advocacy Associate Department of Family Services | Fairfax County, VA
National Coalition on Care Coordination |
Washington, D.C. Mary Tuuk | Director of Medical Services
Total Longterm Care | Denver, CO
Tammie Stranton | Associate Vice President
University of North Carolina Hospitals | Chapel Hill, NC Cara Unowsky | Corporate Director of Strategic Planning
Jewish Home Lifecare | New York, NY
Rob Sweezy | Senior Vice President
Mercury, LLC | Washington, D.C. Fay J. Van Hook | Public Health Analyst
District of Columbia Department of Health |
Joan Thomas | Social Services and Washington, D.C.
Admissions Director, Marketing
Birmingham Green | Manassas, VA Nancy D. Vecchioni | Vice President,
Medicare Operations
Camille Thompson | Vice President and COO MPRO | Farmington Hills, MI
Christian Living Communities | Greenwood Village, CO
Jack Vogelsong | Director of Public Education
Courtney Tierney | Director and Outreach
Prince William Area Agency on Aging | Woodbridge, VA Pennsylvania Department of Aging | Harrisburg, PA
Jane Tilly | Team Leader, Health and Dementia Programs Audrey Weiner | President and CEO
Administration on Aging, U.S. Department of Health Jewish Home Lifecare | New York, NY
and Human Services | Washington, D.C.
30 | INNOVATIVE COMMUNITIES: Breaking Down Barriers for the Good of Consumers and Their Family Caregivers
2519 Connecticut Ave., N.W. | Washington, D.C. | www.ltqa.org
For more information: Doug Pace, Executive Director, dpace@ltqa.org