DECEMBER 2013 • A SOLUTIONS CENTER PROJECT

Reducing Hospital Readmissions through Stakeholder Collaboration

By Jeremy Nobel, MD, MPH; Nita Stella; Erika Flores Uribe, MPH; Sadiqa Mahmood, BDS, MPH; Carlos Duarte, MD, MPH; Laurel Pickering, MPH

1 EXECUTIVE SUMMARY

As CMS and others continue driving improve the ability to identify patients the hospital readmission reduction at high risk for readmission, lead to agenda forward, many stakeholders more efficient use of clinical support have stepped up to the plate to begin resources, and deliver better success at to implement solutions. Such efforts engaging and activating patients. include hospital-based transition For an integrated collaborative approach planning, post-acute care management, to be successful, a multi-stakeholder care coordination initiatives, data cooperative care model needs to be analytics and technology solutions. All better defined. Developing that model of these initiatives require significant brings the following requirements into investment, and the challenge lies focus, all of which need to be more fully in determining whether they can assessed and developed: reduce preventable readmissions in a sustainable, replicable way. • Requirement One Collaboration in Clinical Outreach Northeast Business Group on Health and Care: Stakeholders must (NEBGH) convened stakeholders in a leverage their respective analytic DECEMBER 2013 series of work group sessions to discuss and clinical assets appropriately to the opportunities and challenges in best identify high-risk patients and implementing readmission avoidance support them through the transition programs and the role that the various of care process. REDUCING stakeholders—health plans, hospitals, suppliers, employers and patients— • Requirement Two HOSPITAL play in the success of these programs. Business Sustainability: Financial READMISSIONS This work, which included a review of models must allow all economically existing models, points to an approach involved stakeholders to thrive. THROUGH that focuses on fostering a mutually • Requirement Three accountable environment where Employee Engagement and STAKEHOLDER multiple quality and cost issues are Communication: Employees addressed in a collaborative way, instead and their caregivers must be fully COLLABORATION of simply penalizing health systems for engaged by embracing new models any readmission. It was our finding for communication and activation. A SOLUTIONS CENTER PROJECT that this approach could potentially leverage assets and resources from all stakeholders with less duplication Requirement One: of effort and a greater likelihood of Collaboration in Clinical success. Outreach and Care Currently, health plans and health Through the data they have access systems typically pursue independent to, health plans and health systems and unaligned readmission reduction each have a unique vantage point activities, including independent from which to view a patient and his data analysis and unilateral patient clinical needs. Pooling the clinical and outreach and support. It is our view analytic assets of both would likely that if health plans and health systems create a more complete picture, and -- encouraged by employers through enable both health systems and health performance payments -- pursued a plans to better leverage their skills and more collaborative path in tackling resources to identify patients at risk readmission reduction and similar for readmission, and then coordinate care coordination challenges, the care and actively monitor them more financial and clinical benefits could be effectively. Clinical building blocks significant. In our opinion, pre-planned key to most effectively leverage this shared management activities would effort are: a) Risk Identification and 2 Measurement, b) Collaborative Care Questions such as: “Who will pay?” appropriate care management and care Clinical Model, and c) Outcome “Are resources being best deployed?” coordination. Bottom line, employee Measurement. “Do the incentives align to sustain engagement and communication are as The consensus from HRRP participants improvement?” and importantly, “Is much a part of readmission reduction was that sharing data between there really a return on investment?” as an effective care model, and a health plans and health systems can all need to be addressed in a business sustainable business model, and need to lead to a more robust and effective sustainability discussion. A clear be part of a coordinated approach going risk identification and outcome and shared vision for a definition of forward. measurement methodology. Similarly, “success” among all collaborators will be this shared data set will allow for more required, as will defining performance- Summary: based contracts that incorporate some predictive measurement systems that Achieving a Shared Sense could span multiple care settings and form of shared risk/reward. address measures often not tracked but Employers, as purchasers, can play a of Opportunity around critical for purchasers, such as return- pivotal role in facilitating the business Collaboration—and Moving to work and employee productivity. sustainability discussion and providing Forward Data sharing will also aid in designing the basis for a new business model by Health systems and health plans are a cooperative care clinical model that encouraging health plan and health both working to reduce preventable includes strategies to promote effective system discussions that embrace readmissions but in different ways and patient engagement and activation, collaborative models, and associated typically, with separate and unaligned defines requirements for adherence contracts that reward success. initiatives. Though many employers to medical regimens, and leads to have yet to focus on readmission improved outcomes. There is no simple Requirement Three: reduction, they are in an important solution for reducing preventable position as purchasers to drive change. admissions, but better identifying high- Employee Communication Employers can help set the readmission risk patients, developing a joint care- and Outreach reduction agenda and facilitate dialogue coordination model with appropriate Patients and their families play a central around new business arrangements that resources, engaging patients, and role in driving resource utilization and enable health systems and health plans measuring success are all essential medical regimen adherence, yet are to work collaboratively in developing components of a successful program. often overlooked as new models of care more effective and efficient approaches. are being deployed. The successful While many readmission reduction Requirement Two: execution of a coordinated care program efforts are currently underway in the Business Sustainability, an involves engaging the patient and marketplace, they typically lack the Essential Underpinning of ensuring he is equipped with the right shared data analytics, integrated care information and tools to be involved in models, robust employee outreach Collaboration readmission avoidance from the onset. and communication, and economic Achieving health plan and health Patients should be given appropriate sustainability features we believe system collaboration will require new resources to adhere to their medical are essential to success. It is timely processes, tools and possibly even regimens and deal with behavioral and to address those shortfalls now and personnel, introducing the need for social challenges that might otherwise determine whether current pilots can be an underlying economic model that lead to readmission. Importantly, the amended to include them, or whether ensures long-term sustainability. patient’s caregiver should be seen as a new pilots should be explored that valuable resource that can help facilitate incorporate those missing elements.

3 plans, health systems, and employers. THE NEW OPPORTUNITY: HEALTH PLAN AND Frequently, health plans and health HEALTH SYSTEM COLLABORATION TO PREVENT systems pursue independent and AVOIDABLE READMISSIONS unaligned readmission reduction activities, including payment penalties CMS and other important health of these very different types of based on proprietary data analysis and care stakeholders have highlighted organizations—health plans in their siloed care coordination and patient the challenge of improving patient administrative role and health systems outreach. These independent efforts care transitions from hospital to home in their direct contact with the patient. often result in inefficient duplication of as a national health care imperative. In future phases of its Readmissions effort and fragmentation of services as According to CMS, approximately Reduction Project, NEBGH envisions well as patient confusion. In addition, two-thirds of U.S. hospitals will a set of demonstrations to explore health plans have valuable information receive penalties for excess hospital sustainable models of improved care about readmissions that is often not readmissions of up to 1% of their coordination. reimbursement for Medicare patients. Unnecessary and In the private sector the impact is Our research—and existing successful models— preventable hospital point to an alternate approach that, instead of simply also significant. An earlier report readmissions are a penalizing health systems for avoidable admissions, from the Northeast Business Group major problem in the focuses on fostering a mutually accountable on Health’s (NEBGH) Hospital U.S. health care system. Readmission Reduction Project These events are costly, environment where multiple quality and cost issues found that 8% of hospital stays in occur far too frequently, are addressed in a collaborative way, leveraging assets New York State in 2008 that were and place vulnerable and resources from employers, health systems, health paid by private insurance resulted in patients in dangerous plans, and even employees to better ensure success. readmissions, which accounted for situations. As patients 16.5% of total admissions. Payments move from one care for these readmissions cost private setting to another, notably from the payers, including employers, $568.9 hospital setting to the ambulatory and shared with health systems, leading to million. While the importance of both facility-based and ambulatory narrow interventions. A large health reducing preventable readmissions post-acute setting, they often experience system shared with NEBGH that they is widely recognized, the question is gaps in the coordination, quality, discovered their perceived readmission whether the current methods employed and cost-effectiveness of the care they rates based on internal data were half by Medicare and other insurance receive. These care deficiencies include the actual rates, upon analysis of claims entities fully address the problem clinical complications such as health data. Patients were being readmitted or provide a sustainable business care-associated infections, patient or to neighboring hospitals, generating solution. Our research—and existing caregiver confusion regarding the care data known by the health plan but not successful models including the process, medication mistakes, and necessarily shared with health systems. integrated systems of Geisinger and unnecessary and inefficient resource Similarly, the health system often Kaiser Permanente and approaches use. Successful efforts to reduce hospital has information on patients, gleaned to care coordination and transitions readmissions already deployed in the from clinical interactions— including of care such as the Transitional Care field all emphasize the need for care care preferences and nonadherence Model (TCM)—point to an alternate coordination between ambulatory to medical regimen—that the health method that, instead of simply and post-acute providers and hospital- plan is not aware of. The health plan penalizing health systems for avoidable based clinicians during the course of a would need access to this information admissions, focuses on fostering a transition as well as systematic and clear to establish a complete picture of mutually accountable environment communication between clinicians, readmission risk for any individual, where multiple quality and cost issues patients, and caregivers. Health plans as well as to launch effective and are addressed in a collaborative way, also have the opportunity to play a personalized outreach. leveraging assets and resources from more active role supporting providers in If health plans and health systems were employers, health systems, health plans, these care-transition activities. to pursue a more collaborative path in and even employees to better ensure tackling readmission reduction and success. The opportunity exists for Prior work done on this issue by NEBGH highlighted the opportunity similar care-coordination challenges, collaboration between health plans and financial and clinical benefits would health systems in care coordination to to improve the effectiveness and efficiency of hospital readmission be realized, including an improved reduce risk for readmission, by taking ability to identify high-risk patients, advantage of the varied capabilities reduction programs by promoting active collaborations between health better coordinated care for patients, 4 and more efficiently used clinical resources. The employer’s role is also REQUIREMENT ONE: COLLABORATION IN critical, facilitating collaboration CLINICAL OUTREACH AND CARE opportunities by encouraging health plans to introduce performance- A collaborative clinical process and often have a high level of trust and based contracts that reward reducing measurement approach to reducing confidence in their direct-care provider, preventable admissions and promoting preventable hospital readmissions is which improves adherence to treatment patient engagement through employee attractive for many reasons. Health guidelines as well as post-discharge self- education. Moreover, through benefit plans and health systems bring care activities. design, the employer can incentivize different assets and capabilities to the employees to more actively participate challenge, yet these organizations often Coordination of Differing in risk-reducing care and education function independently of each other. strategies. When connected and coordinated, Clinical Capabilities To further explore the possibilities they complement each other to target Because health plans and health of enhanced collaboration among and address readmission risks with systems review internal clinical employers, health plans, and health information and outreach efforts, information independently, they systems, NEBGH performed an which, as independent activities, are typically have an incomplete picture extensive literature review, interviewed often fragmented. A collaborative of the patient. Combining the varied experts in the field, and convened approach allows both the health plan clinical and analytic assets of both the multistakeholder roundtables, with and health system to improve quality health plan and health system offers representation from health systems, of care, reduce costs, and provide an a more complete picture. Through health plans, employers, and other improved care experience to the patient. collaboration and appropriate clinical stakeholders. NEBGH discovered data sharing, both health systems and that to address readmission reduction Health Plans and Health health plans can better leverage their effectively, a collaborative approach is skills and resources to identify patients an attractive and achievable option. Systems’ Differing Clinical at risk for readmission, coordinate Conceptually, a collaborative approach and Data Capabilities care, and actively monitor them more could enable sustainable change by Health plans, because of their effectively. integrating the analytic and care- administrative role, track and maintain coordination activities within a well- By working together rather than an accurate record of services accessed designed framework of business and independently, both a health system by the patient. This administrative clinical considerations. and health plan can pool their assets to claim flow typically includes sufficient identify a more appropriate risk pool of However, for an integrated collaborative clinical information to identify site of patients, develop a stronger coordinated approach to be successful, the following service, type of service delivered, and care plan with minimal duplication requirements would need to be more some limited clinical information. of resources, and achieve better fully explored and any challenges Often coupled with claims-based outcomes of care. Achieving effective identified and addressed: analytics and an evidence-based rules collaborative care models will require • Requirement One engine that filters quality and severity the development of three independent Collaboration in Clinical Outreach of illness measures, this information but synergistic capabilities, which can and Care: stakeholders leveraging can be predictive of the patient’s be considered as building blocks: their analytic and clinical assets underlying risk for readmission as • Building Block A well as provide knowledge about the appropriately to best support the Risk Identification and presence and severity of conditions and patient Stratification: Identifying and comorbidities. • Requirement Two stratifying readmission risk for each Business Sustainability: financial Health systems, since they are patient models that allow economically fundamentally in the business of • Building Block B providing care, also have the important involved stakeholders to thrive A Coordinated Care Model: role of direct contact with the patient. • Requirement Three Designing and managing a They can identify an extended range Employee Engagement and collaboration-oriented clinical of underlying risks for readmission, Communication: fully enlisting program including socioeconomic factors like employees and their caregivers poor health literacy or the lack of home • Building Block C through new models of support, that are known to drive up Measurement: Assessing program communication, engagement, and readmission rates. Moreover, patients process and outcomes activation. 5 Risk Identification include information from laboratory testing, diagnostic images, medication WHAT’S LIKELY and Stratification prescriptions, and patient interviews. TO INCREASE These risk-stratification models are A variety of factors determine a patient’s rarely standardized or collaborative and READMISSION RISK? readmission risk, such as the underlying as a consequence may under-assess or • Prior history of frequent health of the patient, the complexity of over-assess risk, handicapping various hospitalizations and emergency the clinical issues dealt with during the risk-management approaches. department visits hospitalization, and a broad spectrum To achieve a more robust and • Prolonged length of stay during a of psychosocial issues (see sidebar). collaborative risk-identification hospitalization Currently there is no standardized methodology requires health systems • Multiple chronic comorbidities approach used by health systems or and health plans to develop a shared health plans to identify patients at high risk-assessment tool or methodology • Limited social support risk for a readmission, which highlights that incorporates the data each has • Elderly, disabled, and mentally or an area that could be focused on access to and combines those data- cognitively impaired patients productively. driven insights in a meaningful • Patients with low health literacy or Most health systems and health plans way. Inevitably, there will be some English proficiency have ongoing activities aimed at using complexity in establishing risk scores for the data they can access to better specific disease and patient populations, • Patients from lower socioeconomic understand and manage the populations but the starting point can be based backgrounds they serve, including assessing on a collectively-agreed-to set of data • History of poor medication readmission risk. Within health plans, and data-collection opportunities compliance; polypharmacy the data used for the risk-stratification rather than on independent scoring • No established primary care or model include services billed for and methodologies. There are risk analysis medical home provider providers visited, length of hospital stay, models in the industry, like those acuity of the disease, and comorbidities. developed by Truven, 3M, Verisk Within health systems, the data Health, and Optum, that can be used as a base and extended in a collaborative way between the health system and Table 1. Developing A Shared Data Platform: the health plan. Risk-stratification Information Collaboration models can be modified to incorporate both health plan and health system HEALTH PLANS HEALTH SYSTEMS data but still require analytic resources and technologies from both entities to Utilization Data from Claims: Medical Record: assemble and report findings effectively and link analytic insights into care- • Presence of conditions that increase • History of previous conditions and coordination workflow. readmission risk comorbidities Table 1 illustrates general categories • Multiple comorbidities in any one • Clinically detailed reason for of information where health plans and patient admission and readmission health systems could collaborate in • Behavioral health risk factors as • Lab values developing a shared data platform to identify patients at risk for a hospital available in claim data • Functional and cognitive status readmission. • Total cost of care per admission • Medication reconciliation per member • Psychosocial status and social • All hospitalizations and length of stay support system • All emergency department utilization • Health literacy status • Pharmacy data, including specific • Reliable patient contact information classes and volume of prescriptions; adherence to prescription data • Use of durable medical equipment (DME), such as wheelchairs • Utilization of long-term or transitional care in the past

6 A Coordinated through Safe Transitions (BOOST), the e. Clear medication adherence Bridge Model, Guided Care, Geriatric program and follow-up: One Care Model Resources for Assessment and Care of of the highest drivers for Elders (GRACE), and Project RED readmissions is medication When care is poorly coordinated—with (Re-Engineered Discharge). Many of mismanagement. Clear roles and inaccurate/incomplete transmission these approaches have demonstrated responsibilities are described to of information, inadequate improvement in reducing readmission ensure appropriate patient and communication, and inappropriate rates, yet they have been developed family education and support follow-up care—patients who see from the perspective of the health around medication adherence multiple physicians and providers are system only, with no attention to (see sidebar). at risk for medication errors, hospital opportunities for readmissions, and avoidable emergency health plans and health We are confident that the opportunity exists to build on department visits. The effects of poorly systems to work jointly these successful approaches to reduce readmissions, coordinated care are particularly evident to reduce readmission as health plans and health systems collaborate in care for people with chronic conditions risk. We are confident coordination by taking advantage of their varied capabilities. and those with multiple illnesses, who that the opportunity often fail to successfully navigate a exists to build on complex health care system. Preventable f. A multidisciplinary team focused these successful approaches to reduce hospital readmissions are due in part to on patient/caregiver education readmissions, as health plans and health this lack of effective and personalized from admission to transition: systems collaborate in care coordination care coordination and represent an Leveraging the right individuals by taking advantage of their varied important area for improvement. The in a joint effort to educate and capabilities. good news is that research has shown support the patient and family that improved coordination of care is In assessing existing models, we through all their various care- achievable, and when implemented well, identified the key elements of successful coordination needs. readmissions are reduced. care coordination and transition of care g. Quality improvement process to programs: We assessed several models of care track root causes of readmissions: coordination and transitions of a. Agreement on standard protocols Continuous monitoring and data care. These models include the Care and procedures: Joint committees analytics to identify opportunities Transitions Intervention (CTI), to create a system-wide approach for improvement. Transitional Care Model (TCM), to risk stratification and care h. Continuous evaluation of the Better Outcomes for Older Adults coordination. readmission reduction process: As b. Proactive collaborative care needs of the population change, PREVENTING plan: Shared process to enable the resources and protocols appropriate follow-up, patient must be flexible to adjust to the MEDICATION ERRORS and family education, care requirements. One of the most common problems in coordination, and community Employer-driven discussions can help readmissions is patients’ inability to support. motivate health plans and health manage their medication regimens— resulting in nonadherence or “medication c. Timely care coordination before systems to establish a coordinated misadventures.” This requires that first patient discharge: Ability to clinical program that includes those we understand the factors affecting identify patient needs pre- critical elements. The discussions should adherence, e.g., knowledge deficit, discharge, especially for high-risk, also include how to support those financial constraints, pill burden, fear of/ vulnerable cases, and trigger key components financially. But even actual side effects. Then, we need to appropriate follow-up in the when organizations are motivated, it’s devise creative ways to help patients take community setting. not a simple task to collaboratively their medication as directed, using targeted d. Clear definition of roles and decide how best to deploy their and personalized patient education, analytic and clinical resources. While incentives, financial assistance programs, responsibilities: As patients transition from one setting to the overarching goal is minimizing additional clinical resources such as redundancy and inefficiencies while pharmacists included in the discharge- the next, the roles of the various striking a balance between the needs support care team, and checklists and individuals should be clear, with other quality management systems. This minimal duplication of effort. and preferences of often competing support would help ensure that patients The care map should include the organizations, the most important understand and follow their often complex responsibilities not only of the care consideration is what is right for the medication regimens. providers but also the patient and patient. caregivers. 7 transitions between settings, timely and Measurement complete discharge by the right level of staff, consistent patient education TARGETING THE LEADING CAUSE Measurement is essential to any throughout the care plan, and return clinical program’s success, including on investment (ROI) for the resources OF HOSPITAL readmission reduction initiatives. deployed to support the patient and READMISSIONS Without accurately measuring his or her caregiver. Most importantly, key processes and outcomes, it’s the measures used should be easily Acute Coronary Syndrome and Heart impossible to verify progress or identify collected, shared, and consistent across Failure remain the leading cause of opportunities for further improvement. multiple health systems and health hospital readmissions, at 23.6% in 2011. To date, most measurement efforts plans. (See Appendix, Table 3, for Nearly one in four patients hospitalized with heart failure and one in five patients related to readmissions have been sample measures.) hospitalized with acute myocardial created independently by health plans While the opportunities for a infarction (AMI) are readmitted within 30 and health systems and reflect the coordinated clinical program are days of discharge. Higher readmissions processes those organizations typically compelling, there are significant barriers rates, associated with lower patient engage in by themselves or via data to establishing such a program. These satisfaction, are estimated to cost feeds and sources easily accessible to include uncertainty about ROI for Medicare more than $17 billion per year in them. Consequently, most health plan current initiatives, financial limitations hospital payments. Various interventions measurement approaches are claim to proactive resource deployment, have proven effective for reducing based and track clinical events and limited consensus-building capability readmissions for these patients, including costs from claims, while health systems, between entities unaccustomed to using a checklist that helps remind both which have access to richer clinical collaboration, lack of standard data patients and doctors about steps that can data, can track and evaluate pertinent collection, and many others. These be taken to manage the condition: medical issues from that perspective. In barriers can best be addressed in a • Medications and their appropriate dose a collaborative approach, the combined setting where joint business incentives • Dietary and lifestyle change coaching data sets will allow more robust analysis and clinical goals come together within • Counseling and monitoring intervention of process and outcomes. a business model that rewards success. (self-management) No one solution is • Follow-up instructions (patient With well-coordinated care, it is reasonable to expect the answer, but better education) that chronic illnesses will no longer be a major driver of identifying high-risk • Assigning a nurse as a clinical manager patients, developing a potentially preventable readmissions. • Coordination of transitional care in a joint care-coordination safe and timely manner. model with appropriate Many of these interventions have proven Collaboration between health systems resources, and measuring success to decrease readmissions by 15% in three and health plans should aim at selecting are essential steps for establishing a years. important elements that need to be successful coordinated care program. measured across the continuum of care. The measures used should follow Case Study: Sentinel Chronic Conditions— that might offer specific opportunities. national standards and benchmarks Diabetes, COPD, Acute Coronary Syndrome As a result, we found that various but also reflect metrics that can In addition to considering these chronic conditions have management help evaluate the effectiveness of the general opportunities for readmission considerations that merit specific new collaborative nature of the care reduction, we assessed a number of attention. The conditions that we programs. Such metrics or measure clinical conditions to identify areas explored include diabetes, chronic domains would include successful care obstructive pulmonary disease (COPD),

8 heart failure, and acute coronary syndrome. Chronic diseases such as diabetes, heart failure, and COPD play a large role in preventable hospital readmissions in New York State and the rest of the country. Chronic conditions often require enhanced care management to avoid exacerbation during the vulnerable post- discharge period. These exacerbations can lead to preventable readmissions, treatment for both the chronic aspect reduction activities, whereas in other representing a burden to the patient and of the disease and also for acute flare- cases it might make more sense for family as well as excess cost. ups. For patients with acute coronary the health system to take the lead. A syndrome, it means verifying that the coordinated care model that avoids medications are up to date and conform duplication of effort and measures THE CHALLENGE OF to most recent clinical guidelines. the effectiveness of the program DIABETES Educating patients during the against established benchmarks is Diabetes is the second leading cause of pre-discharge period is essential, essential. With well-coordinated care, all readmissions in New York state—at especially if there has been a change in it is reasonable to expect that chronic 21% at 90 days post discharge—and medications that have been prescribed illnesses will no longer be a major driver is associated with 15.2% of total state for outpatient use after the hospital stay. of potentially preventable readmissions. readmissions costs. Over 8% of the U.S. For diabetes, this could mean training workforce suffers from this disease. patients in how to give themselves COPD IS COSTLY— Employers spend on average $4,413 more insulin shots and to recognize the BUT PILOT PROGRAMS per diabetic employee as compared to symptoms of low and high blood sugar. controls, with more than 30% of these COPD patients could be shown how to SHOW DECREASED costs attributable to work absences and use an inhaler, which requires a bit of READMISSIONS diabetes-caused disability. practice to master. Patients with acute COPD is the third leading cause of coronary syndrome need to understand readmissions—with a 20.5% 30-day What’s required is a standardized any new medications and be fully comfortable with how best to take readmission rate. In fact, 40%–50% approach to identifying patients with a of COPD patients are readmitted to chronic condition early in their hospital them. the hospital within a year of discharge. stay and then executing effective Providing outpatient monitoring Each of these readmissions, on average, protocols for appropriate medical and support once patients leave the management and patient engagement hospital is also imperative, especially costs 18% more than a COPD index, during the discharge period, followed to ensure that medications are taken or initial, admission. Employers also by outpatient monitoring and support. as prescribed. Failure to adhere to a pay for these readmissions indirectly in Health systems and plans are working medication regimen is a leading cause reduced productivity, presenteeism— together to bridge this care gap by of preventable readmission. Patients when employees are at work but not drawing on the unique capabilities of with diabetes also need to know how to fully engaged—and absenteeism. each. test their blood sugar at least daily and Readmissions are more likely for some Identifying patients early and executing adjust medication levels accordingly. groups of patients, including those with standardized and effective clinical- COPD patients must continue their multiple chronic conditions, previous care paths provides an opportunity medication and appropriate use of their substandard transitions into post- to evaluate each patient to make sure inhalers, as well as avoid allergens and hospitalization care, or other risk factors, other pulmonary irritants. Patients they are receiving the right treatments such as depression, cognitive impairment, with acute coronary syndrome need to related to their chronic illness. For or a history of readmissions and weak diabetes, this includes assessing whether adhere to their prescribed medication regimen and recognize the symptoms of social support. However, promising data they are being adequately managed from several readmission reduction pilot on oral medication or would benefit a potential worsening of their condition programs have demonstrated a decrease from the use of insulin, given only by as well as how to seek emergency care. in hospital readmission rates from 20% to injection. For patients with COPD, In some situations, the health plan can this means ensuring that they have be responsible for these readmission 15% within two years. 9 come to the table ready to engage in REQUIREMENT TWO: BUSINESS SUSTAINABILITY, conversations around new contracts, AN ESSENTIAL UNDERPINNING OF COLLABORATION new reimbursement and/or incentive models, new metrics, new resources, NEBGH research has concluded that at a significant cost and diversion of and clinical collaboration. Though these effective, active collaboration in efforts financial resources. conversations may be difficult, they can to reduce readmissions is needed to help pave the way to a better business To promote more effective readmission model that leverages the best of all integrate workflows that currently fail reduction for commercially insured to address all aspects of the problem. organizations and offers the likelihood lives, important business issues need to of substantially reduced aggregate costs. Active health plan and health system be resolved, such as: Who will pay, are collaboration will require new processes, resources being best deployed, do the The underlying question for all these tools, and possibly even personnel, incentives align to sustain improvement, discussions is how best to balance introducing a need for an underlying and importantly, is there really a return the new costs of addressing the economic model that ensures long-term on investment? readmission challenge with the expected sustainability. This section discusses the downstream benefits of cost reduction. business sustainability challenge and As they discussed elements of a identifies key areas of activity that merit Payer/Provider Collaboration sustainable business model (see chart), further attention. Provides Opportunities to the NEBGH workgroups identified Bolstered by the success of a number of Better Manage Costs— basic building blocks of a sustainable care transition and care-coordination But a Sound Business coordinated model for avoiding hospital readmissions: demonstrations, CMS and the Patient Model Is Essential Protection and Affordable Care Act • Building Block A (PPACA) launched payment reform The prevailing fee-for-service payment Establishing a clear and shared initiatives aimed at controlling model for hospital-based care does vision and definition of “success” preventable readmissions, including the not directly fund the costs associated among all collaborators with preventing avoidable hospital bundled payment ACE demonstration, • Building Block B readmissions—a well-recognized which showed readmission reduction. Defining new performance-based challenge for both contracts that incorporate some public and private With two-thirds of U.S. hospitals being penalized for excess form of shared risk/reward purchasers of care. readmissions, it’s clear that the solution to this intractable Yet payer/provider • Building Block C problem will require going beyond payment reform. organizations such as Recognizing that “perfection is the Geisinger and Kaiser enemy of the good”—Don’t wait. But with two-thirds of U.S. hospitals Permanente have in fact demonstrated Start now, improve as you go. being penalized for excess readmissions, that through an integrated approach Though perhaps not the only it’s clear that the solution to this to managing readmission risk, requirements for achieving business intractable problem will require going readmissions can be reduced while sustainability in hospital readmission beyond payment reform. Early pilot also covering the incremental costs. reduction efforts, these essential design studies generally concluded that To extend this success beyond the few components were commonly thought to successful readmission reduction fully integrated payer/provider models be essential for getting started, allowing programs require incremental resources, in the United States, health systems, for adjustments as programs begin to such as dedicated care coordinators, health plans, and employers must take shape. social workers, and pharmacists, and in-home assessments for high-risk individuals. The studies also found that care-coordination support is required to assist in overcoming socioeconomic barriers to successful follow-up after discharge. Companies in a burgeoning new cottage industry are dedicated to support for discharge and care coordination. But with nonpayment for certain readmissions, these incremental services are not reimbursed, so for most institutions all these activities come 10 Establish a Clear How can we get to a shared vision? • Go beyond just measuring Achieving it requires the active avoidable hospital readmissions to Shared Vision participation of payers, providers, identifying and quantifying the employers, and even employees, causes that lead to them Historically, the health care system fostering an environment where people • Better engage and incentivize all has not focused on true, care-directed and institutions are motivated and stakeholders, including patients and collaboration between health systems energized to work together to achieve caregivers, to be fully engaged in and health plans. Consequently, it is not common goals. Employers in particular effective care processes surprising that there is no shared vision can play a pivotal role in facilitating that to support such collaboration, nor an shared vision by encouraging health • Gather and share appropriate and easy recipe for determining appropriate plan and health system discussions that timely data in a secure and cost- financial incentives to each stakeholder rethink boundaries and imagine new effective manner or for achieving the secure and timely collaborative models and new contract • Agree on a long-term financial sharing of longitudinal data required to models that reward success. In a shared model that rewards success but also guide and reward high-value care. But vision of a collaborative care model, provides the necessary resources to general market forces and experience stakeholders recognize that achieving achieve it. with PPACA are spurring interest in optimal care rarely rests solely with All parties should feel enabled and establishing a collaborative approach any one entity. Instead, a shared vision empowered to proactively share to containing health care costs while mandates a broader look at integrated information and participate in also addressing system-wide quality and solutions, requiring employers, health supporting the care needs of patients efficiency. Stakeholders increasingly systems, and health plans to embrace as they move through their transitions, recognize that a shared vision is clinical process redesigns, success-based and—just as importantly— feel essential to creating a sustainable financial incentives, and other contract confident that the economic model will business model that assures them that terms that deliver the best outcomes. adequately reward all involved. that the economic risks they are being In short, it compels all stakeholders to asked to bear are reasonable. establish shared goals that:

HEALTH SYSTEM: EXTREMELY/VERY IMPORTANT FACTORS IN DEVELOPING A LONG-RUN BUSINESS MODEL*

Aligning with physicians to integrate them 98% fully in the clinical redesign efforts Aligning with physicians to preserve and 94% expand market share Improving quality to take full advantage of pay for performance incentives such as CMS value purchasing 92% Innovative deployment of health information 92% technology across the continuum of care Preparing the organization to accept more financial risk in stages; first by managing readmissions and quality scores 89% Redesigning clinical care processes using lean, six sigma, or other workflow redesign methods 88% Rationalizing supply chain through standardization of clinical equipment and supplies including orthopedics, cardiovascular, and oncology 87%

Focusing on managing readmissions 86%

Partnering with alternate site providers across the 77% continuum of care Partnering with other organizations, such as insurers, to help manage risk 76% Differentiating on quality and service to appeal to affluent, well-insured consumers 60% Owning and operating alternate site providers, such as home health care and skilled nursing facilities 43%

Owning and operating health plan function 26%

Raising prices on commercial payers 25%

* 2012 KMPG 11 Performance- Blue Shield of Massachusetts, through their Alternative Quality Contracts NEW BUSINESS Based Contracts (AQC), which included global provider MODELS BECOMING payment and incentives based on Employers, as purchasers, have a unique quality and patient satisfaction, has THE NEW NORMAL opportunity to lean on health plans to demonstrated reductions in medical The health care landscape is fertile put pressure on care-delivery systems cost trend and reductions in hospital with new collaborative arrangements: through contractual arrangements that readmissions, compared to non-AQC include expanded quality initiatives contracts. The global payment model • Accountable Care Organizations and aggressive shared-savings scenarios. initiated a dialogue that encouraged • CMS Star Ratings Program Well-constructed contracts can cut various players to design and implement through much of the confusion about solutions with a shared goal of better • Patient-Centered Medical Home who is responsible for managing care and lower cost. Appropriate model unnecessary hospital readmissions financial rewards allowed parties with • The Leapfrog Group by establishing clear accountabilities. previously conflicting objectives to • Bridges to Excellence This may involve new assignments of come together for mutual gain, and responsibility, modifications to existing patients and purchasers also benefitted. • Catalyst for Payment Reform network arrangements, and agreement on new metrics. • BCBSMA Alternative Quality Contracts Since these efforts introduce new Immediacy: Don’t business models, focused effort will Wait, Start Now • CMS Value-Based Purchasing be required to support and educate pilots organizations traditionally not The full array of contract decisions • CMS Bundled Payments for Care accustomed to assuming financial and care-process improvements needed Improvement initiative contract risk, sharing data, or active to reduce avoidable readmissions are partnering. Fortunately, almost all complex and will require time to • PROMETHEUS Payment health care organizations are moving sort out. But why wait? Even while • Geisinger ProvenCare model rapidly along a path where the ability designing and implementing broad to manage alternative contractual system changes and drafting new (See Appendix Table 2 for details reimbursement and/or incentive models contracts, some simple collaboration about these business models.) and deliver superior outcomes within approaches can be applied. Baby these new business models is becoming steps—that can be taken before a the “new normal.” total solution is developed— include while providing a platform to evaluate New contractual models require funding clinical personnel to serve success and leverage insights in future purchasers, in discussions with health as care coordinators to assist in post- collaborative designs. Unless excessive, systems and providers, to agree on the hospitalization care coordination, the costs for these interim solutions can type of savings and risk-based models establishing cross-function workgroups likely be shared, with each stakeholder best suited for both short and long to define and quantify performance allocating either personnel or capital term. Fortunately, a marketplace is improvement opportunities and as more detailed contract models are developing where stakeholders can agree benefits, and identifying opportunities developed, initiating an important and on mutual financial goals, designing to reduce communication and data much-needed collaborative process to contracts to include shared-savings or barriers between various facilities. immediately generate momentum on shared-risk models—and there is some Well-chosen, these incremental quality improvement. early indication of success. Blue Cross activities can deliver immediate value

12 communicated. Collaborating with REQUIREMENT THREE: EMPLOYEE COMMUNICATION and educating the caregiver may be just AND OUTREACH as important— or even in some cases more important— than informing the patient. The integrative approach Successful models of care transition how to effectively communicate with involves understanding the challenges that prevent rehospitalization clearly employees about the need to engage in of being a caregiver, who may suffer demonstrate that involving patients self-care programs. Despite outreach as much confusion, lost productivity and their families is critical. Engaging efforts and incentives, engagement and at work, and emotional distress as the and educating the patient ideally starts enrollment in the programs remain patient. Therefore ideally, education, before admission, involves shared lackluster, and employees continue to support, and benefits should address decision making, and extends well past evince a general mistrust of their health caregiver needs as well. Modifying discharge from the hospital. Patients plan. In a collaborative effort between programs already in the workplace play a central role in driving utilization health plans and health systems, to support employees— Employee and compliance and it is very important providers can communicate with Assistance Programs (EAPs)—would to consider how best to partner with the employee in a timely and trusted be an innovative way to help patients and involve them. manner, increasing the likelihood of and caregivers alike. EAP-like post- engagement. hospitalization support programs could be developed and introduced It’s essential to increase patients’ and families’/caregivers’ Employees should be to employees as a way to provide awareness of opportunities for patients to participate in made aware of the them and their caregivers support and their own care. Employers have a role to play in raising that importance of planning guidance in care coordination after a awareness, by combining targeted employee education ahead. Through hospital discharge. Additionally, expert appropriate education and outreach efforts with benefit designs that reward resources dedicated to helping patients and incentives, active participation in care programs. and caregivers could be made available employees could be telephonically or online to address made increasingly care-coordination issues proactively and In the Robert Wood Johnson aware of centers of excellence and more efficiently. Foundation Report on U.S. Hospital high-quality providers with a proven Readmissions, 32 interviews were track record in avoiding readmissions. conducted with patients about their Networks could steer patients towards KEYS TO SUCCESSFUL experience with readmissions. In many these high-performing facilities and of their stories, the common themes providers. OUTREACH were not receiving information, rushed Before going to the hospital for an discharge processes, lack of follow-up elective admission, employees should Supporting employees to be more active care, and even patients treating the be encouraged to educate themselves in self-care and readmission reduction hospital system as their own primary about what to expect and how best to efforts often will not mean providing care facility. What is clear is that a prepare the home for their return after more clinical care but instead helping patient and family’s perspective on what discharge. Needed care coordination, is “broken” is not always how the health whether sophisticated clinical home them resolve social issues and address system views what needs improvement. care or just having someone assist financial or emotional needs. These are It’s essential to increase patients’ and with meals, should be anticipated and complex issues to address but if done families’/caregivers’ awareness of established well before admission. opportunities for patients to participate effectively, everyone benefits. A good in their own care. Employers have a starting point is communicating with role to play in raising that awareness, by Addressing the appropriate language so employees combining targeted employee education caregiver’s needs better understand what they can do to and outreach efforts with benefit The caregiver is often a big influence on avoid returning to the hospital and how designs that reward active participation how well a patient does at home after in care programs. best to plan ahead for their elective stays. a hospitalization. Sometimes a family Another solution is to implement benefit member, often a friend or neighbor, Increasing employee these unpaid “care assistants” can designs that encourage engagement with awareness and engagement ensure that care plans and medication post-hospital support programs perhaps regimens are carried out and that any tied to a reward or incentive program. Employers and their partner health problems are quickly identified and plans have long been challenged by 13 SUMMARY: ACHIEVING A SHARED SENSE OF URGENCY AROUND COLLABORATION—AND MOVING FORWARD

There is a new, heightened awareness support when they are discharged from of immediate opportunities to the hospital. reduce hospital readmissions and the Based on these findings from our latest challenges involved. What lags is explorations, NEBGH believes now is awareness of the need for improved the time to begin a set of demonstration coordination between health plans projects to explore sustainable models and health systems—a collaborative of improved care coordination. While model that will allow the various many readmission reduction efforts stakeholders to move forward effectively are underway in the marketplace, few, to resolve these issues together. While if any, have the shared data analytics, health systems and health plans are integrated care models, robust employee sustaining the momentum toward outreach and communication, and the coordination, they’re each advancing at economic sustainability features we a different pace and often with different describe in this report. motivators. Employers, as While many readmission reduction efforts are underway in purchasers, are well the marketplace, few, if any, have the shared data analytics, positioned to promote improvement in integrated care models, robust employee outreach and readmission reduction, communication, and the economic sustainability features demanding better we describe in this report. collaboration between health plans and providers, with matching performance Though many employers have yet to payments to all involved. The solution fully engage on readmission reduction, to avoidable hospital readmissions lies they are in a critical position to promote in harnessing the power of collaboration a sense of urgency around these issues. and in the ability of leaders in each of Employers can help set the agenda and the stakeholder groups to drive the pace facilitate dialogue around new business of readmission reduction even faster. arrangements that enable health systems and health plans to work collaboratively in developing aggressive solutions to improve the way care is delivered today. Employers can serve as the catalyst to enable action, even before new business arrangements and contract terms are fully worked out. Pressure from public sector purchasers will increase the sense of urgency around the need to reduce preventable readmissions. Moreover, consumerism in health care will likely make patients and caregivers more aware of their choices and also give them a voice to express their dissatisfaction with the current status quo and demand more

14 • APPENDIX • PROJECT PARTICIPANTS • REFERENCES

15 APPENDIX Table 2. Business Models

Program Description Pros Cons Sample Programs Pay for Hospitals and providers Multiple programs exist Resources are required • CMS STARS program Performance can receive payment that can be extended to track and submit • PCMH Model and Quality increases if they achieve to include the new performance data. Monitoring or exceed performance readmission avoidance- Looking at a single • Leapfrog targets for certain quality based measures. metric will not address • Bridges to Excellence measures. the systemic issues; a group of measures will need to be considered. Value-Based Establishes pay-for-value Value-based contracting Requires management • Catalyst for Payment Purchasing payment incentive as part provides for greater price and measurement of Reform of contracting model. transparency. value and execution of • BCBSMA AQC Contracts, new contracts. • CMS Value-Based Purchasing pilots • Commercial pay-for- performance programs Episode- Single payment to one Fosters collaboration Need to develop strong • CMS Bundled Payments Based Bundled entity for entire episode of between providers and strategic partnerships. for Care Improvement Payments care. institutions. Requires cooperation Initiative Addresses issues for among multiple • Acute Care Episode (ACE) readmission across the parties and significant Demonstration entire care continuum modifications to existing • ProvenCare and allows for flexibility in contracting and business execution of care. arrangements. Shared Savings An incentive to adjacent Provides a more Requires new business • Accountable Care organizations to coordinate positive incentive for agreements between Organizations care and share in savings collaboration. Also providers and hospital • Risk-Stratified Care over benchmark. affords flexibility in systems. Management execution. New measurement models require calculation of appropriate benchmarks. Capitation A percentage of premium This model aligns Most provider is passed on to a provider incentives for reducing organizations do not organization for members medical expense by have the resources receiving care within the placing responsibility for to invest in the provider organization’s both the total cost and infrastructure required network. The provider quality of care with the to manage capitation organization is responsible provider organization. arrangements and/or the for administering all risk tolerance to assume benefits and managing and manage captitation. associated medical expense. Any savings generated are retained by the provider organization and any losses incurred are the responsibility of the provider organization.

16 (Adapted from Health Affairs Health Policy Brief, “Improving Care Transitions,” September 13, 2012) APPENDIX

Table 3. Essential Measures Health Plans

• Rates of all member admissions to facilities and ED visits • Rate of readmission with valid risk adjustment • Post-discharge complications resulting in readmission • Time window for readmission • Correlation between post-acute facility and readmission rates • Medication adherence • Cost of readmissions across networks over time (e.g., pre and post interventions)

Health Systems

Clinical Process Measures 1. Continual Optimization and Evaluation • Medication reconciliation post discharge • Presence of test result follow-up after discharge • Timely follow-up with primary care physician and other providers • Post-discharge calls/visits for high-risk patients • Root cause analysis of readmission 2. Patient Risk/Perception Assessment • Readmission assessment scores • Percentage of patients who received post-discharge medication instructions • Percentage of patients and caregivers given discharge instructions • Satisfaction with discharge instructions • Activation of community services • Presence of PCP • Patient Activation Measure • Percentage of behavioral health patients, homeless patients, ESRD, HIV or other complex, high-risk populations 3. Organizational Structure and/or Systems • Percentage of clinical staff utilizing accredited patient engagement and education techniques Outcome Measures • Percentage of avoidable readmission, risk adjusted • Detailed clinical resource utilization data • Clinical data to determine disease burden and severity • Cost of readmission to the health system • Cost of dedicated care-coordination team

17 PROJECT PARTICIPANTS

• Gail Amato • Jim Cummings • Joanne Kramar, RN, MS Strategic Account Executive Employer Account Executive Senior Clinical Account Director Boehringer-Ingelheim Boehringer-Ingelheim Empire Blue Cross Blue Shield • Aliyah Ansari • Christine Cunningham, RN • Alan Landauer Administrative Manager Senior Staff Nurse Senior Vice President Memorial Sloan-Kettering Cancer Center NYU Langone Medical Center Landauer Metropolitan • Ruth Antoniades • Annette Cutrino • Jared Lewis Executive Director Vice President of Strategy & Innovation Senior Manager, Corporate Benefits Labor Health Alliance VillageCare Curtiss-Wright • Gregory Barbero • Denise Davin • Coleen Lyons Regional Account Executive VSVP/CHRO and Labor Counsel US Healthcare & Wellness, Manager NovoNordisk Visiting Nurse Service of New York American Express • Mark Bardi • Svetlana DeBellis • Michelle Martin Senior Regional Account Director Director, Business Development and Director, Health & Welfare Benefits AstraZeneca Managed Care CBS Corporation • Randy Blum Mt. Sinai • Margaret Meagher Vice President, Network Lead • Dominic DePiano Director of Benefits UnitedHealthcare Director, Network Management NYU Langone Medical Center • Mary Bradley Empire Blue Cross Blue Shield • Anne Meara, RN, MBA Director of Healthcare Planning • Maria Dugandzic, PharmD Director, Care Management Solutions Pitney Bowes Associate Director, Healthcare Quality & Montefiore CMO • Scott Breidbart, MD Outcomes • Ronald B. Menzin, MD Chief Medical Officer Boehringer-Ingelheim Chief Medical Officer Empire Blue Cross Blue Shield • Steve First Cigna • Lili Brillstein Vice President, Global Benefits • Tom Moore Senior Director, Medicare & Retirement Pfizer Senior Vice President UnitedHealthcare • Elizabeth Garofalo Healthix • Sara Butterfield, RN, BSN, Associate Director, Managed Markets • Greg Mulford, MD CPHQ, CCM Marketing Chief Medical Officer Senior Director, Health Care Quality Boehringer-Ingelheim Morristown Memorial Hospital/Atlantic Improvement, Project Leader, CMS Care • JoAnn Goetz Health System Transitions Initiative Clinical Coordinator • Sarah Munson, MPH IPRO Episcopal Church Medical Trust Director, Program Implementation • Kathleen Byrne • Terry Golash, MD Network Integration Senior Manager Senior Medical Director NYU Langone Medical Center Montefiore CMO Aetna • Alan Murray • Mark Calderon, MD • Ann Marie Gothard President Vice President and Chief Medical Officer Director, Communications Strategy Northshore-LIJ CareConnect Insurance Horizon Blue Cross Blue Shield of NJ EmblemHealth Company, Inc. • Donald E. Casey, Jr., MD, MPH, MBA, • Kathryn Haslanger • Doreen Nelkin-Warantz FACP, FAHA CEO Executive Director Chief Medical Officer, NYUPN Clinically JASA Mt. Sinai IPA Integrated Network • Theresa Hayde • Eliza Ng, MD NYU Langone Medical Center Nurse Manager Senior Medical Director • David Cobden, PhD, MPH, MSc NBCUniversal EmblemHealth National Clinical Account Director • Richard Heitner • Michael Norton AstraZeneca Director, Business Advisory Services & Director, Managed Care • Sanford Cohen, MD Managed Care NovoNordisk Chief Medical Officer, Northeast Region Atlantic Health • William O’Donnell UnitedHealthcare • Michael Johns Vice President, Contracting • Claudia Colgan Senior Director, Business Development Cigna Vice President, Quality Initiatives VHA Empire – Metro / UNYHEALTH • Pat Orchard Mount Sinai • Jill Kalman, MD Director, Clinical Operations for Health • Mary Ellen Connington, RN Director, Cardiomyopathy Program Affairs Senior Vice President of Managed Care Mt. Sinai Horizon Blue Cross Blue Shield of NJ Visiting Nurse Service of New York

18 REFERENCES AND SELECTED READING

• Jennie Pao Altman, S. (2012, September). The lessons of Laderman M., Loehrer, S., McCarthy, D. Manager, Health Care Planning Medicare’s prospective payment system show (2013, February). STAAR Issue Brief: The effect Pitney Bowes that the bundled payment program faces of Medicare readmissions penalties on hospitals’ Health Affairs efforts to reduce readmissions: Perspectives from the • Nicola Pitter challenges. (31)9, 1923–1930. doi:10.1377/hlthaff.2012.0323 field. Cambridge, MA: Institute for Healthcare Director, Business Development and Improvement. Available at: Available at: http://content.healthaffairs.org/ Managed Care http://www.ihi.org/knowledge/Pages/Publications/ content/31/9/1923.abstract?sid=31e36273-fd39- Mt. Sinai effectofMedicareReadmissionsPenalties.aspx 4459-a038-3555a4beacc5 • Lisa Polk Marks, C., Loehrer, S., and McCarthy, D. (2013, Berenson, R.A., M.D., Paulus, R.A., M.D., Director, New York City Health September). Hospital readmissions: Measuring and Kalman, N.S. (2012, April 12). Medicare’s Benefits Program for improvement, accountability, and patients. readmissions-reduction program — A positive The Commonwealth Fund and the Institute for City of New York, Office of Labor Relations alternative. The New England Journal of Healthcare Improvement. Available at: • Matthew Press, MD Medicine, 366, 1364–1366. http://www.commonwealthfund.org/~/media/ Doi: 10.1056/NEJMp1201268 Senior Manager Files/Publications/Issue%20Brief/2013/Sep/1703_ Available at: Weill Cornell Medical College Marks_hosp_readmissions_ib_FINAL_v3.pdf http://www.nejm.org/doi/full/10.1056/ • Martha Radford, MD NEJMp1201268 Mitchell, R. (2013, March 26). Slow progress Chief Quality Officer on efforts to pay docs, hospitals for “value,” not [followed Geisinger’s Proven Care Model] NYU Langone Medical Center volume. Kaiser Health News. Retrieved from: • John Roefaro Brown, R.S., Peikes, D., Peterson, G., Schore, J., http://www.kaiserhealthnews.org/Stories/2013/ Director, Regional Hospital and and Razafindrakoto, C.M. (2012). Six features March/26/employers-value-volume-purchasing. of Medicare coordinated care demonstration Ancillary Contracting aspx programs that cut hospital admissions of high- Naylor, M., Aiken, L.H., Kurtzman, E.T., Olds, Horizon Blue Cross Blue Shield of NJ risk patients. Health Affairs, 31(6), 1156–1166. D.M., and Hirschman, K.B. THE CARE SPAN: • Angela Scott doi: 10.1377/hlthaff.2012.0393 The importance of transitional care in achieving Provider Relations Director Chollet, D., Barrett, A., and Lake, T. Reducing health reform. (2011, April) Health Affairs, 30, 1199SEIU Benefit & Pension Funds hospital readmissions in New York State: A 746–754. doi:10.1377/hlthaff.2011.0041 • Shelley Sinclair simulation analysis of alternative payment ReEngineered Discharge (Red) Toolkit: incentives. (2011, September). New York Assistant Director, Health & Welfare http://www.ahrq.gov/professionals/systems/ State Health Foundation. Available at: http:// Ernst & Young hospital/toolkit/ nyshealthfoundation.org/uploads/resources/ • Michael Sturmer reducing-hospital-readmissions-payment- Rutherford, P., Nielsen, G.A., Taylor, J., Bradke, Senior Director Clinical Operations incentives-september-2011.pdf P., and Coleman, E. (2013, June) How-to Cigna Guide: Improving Transitions from the Hospital The Commonwealth Fund Commission on to Community Settings to Reduce Avoidable • John Tesoro a High Performance Health System. (2013, Rehospitalizations. Cambridge, MA: Institute for Assistant Vice President, Network Contracting January). Confronting costs: Stabilizing U.S. Healthcare Improvement. Available at: Aetna health spending while moving toward a high http://www.ihi.org/knowledge/Pages/Tools/ performance health care system. Available at: • Anne Travisano TransitionstoReduceAvoidableRehospitalizations. http://www.commonwealthfund.org/ Senior Director, Medical Management aspx Publications/Fund-Reports/2013/Jan/ EmblemHealth Confronting-Costs.aspx?page=1 Stensland, J., Lisk, C., and Glass D. (2013, March • Ralph Ullman 7) Refining the hospital readmissions reduction Goodman, D.C., M.D., Fisher, E.S., M.D., program. Washington, DC: Medicare Payment Director, Research & Analysis M.P.H., and Chang, C.-H. After hospitalization: 1199SEIU Benefit & Pension Funds A Dartmouth Atlas report on readmissions among Advisory Commission. Available at: http://www. medpac.gov/transcripts/readmissions%20Public. • Michael Vecciarelli Medicare beneficiaries. (2013, February). Robert pdf Regional Account Executive Wood Johnson Foundation. NovoNordisk Available at: U.S. Department of Health and Human Services. http://www.dartmouthatlas.org/pages/ Health Care Leader Action Guide to Reduce • Fred Verde readmissions2013 Avoidable Readmissions. Available at: Managed Markets Director http://www.innovations.ahrq.gov/content. Health Affairs Health Policy Brief. (2012, AstraZeneca aspx?id=3289 September 13). Improving care transitions. Better • MaryJo Vetter coordination of patient transfers among care sites U.S. Department of Health and Human Services. Vice President, New Product Development and the community could save money and improve Partnership for Patients: Better Care, Lower Costs. Visiting Nurse Service of New York the quality of care. Available at: http://partnershipforpatients.cms.gov/ • Patrick Wormser http://rwjf.org/content/dam/farm/reports/issue_ briefs/2012/rwjf401314 Director, Downstate Contracting EmblemHealth Joynt, K.E., M.D., M.P.H., and Jha, Ashish K., M.D., M.P.H. (2013, March 28). A path forward on Medicare readmissions. New England Journal of Medicine, 368, 1175–1177. doi:10.1056/NEJMp1300122. Retrieved from http://www.nejm.org/doi/full/10.1056/ NEJMp1300122

19 About the NEBGH Solutions Center Northeast Business Group on Health (NEBGH) is well positioned to act as an information gatherer and knowledge disseminator at a general level, but more importantly, facilitate discussions, relationships, and knowledge-sharing about best practices, all of which need to be explored at the local level. As one of the largest purchasers of health care services, employers play a major role in forcing the health care system to deliver value. To better participate in the creation of value in health care, NEBGH has launched the Solutions Center (SC) as a new opportunity to identify and evaluate effective solutions; investigate and NEBGH works with employers in: disseminate innovative ways to improve the quality and value of health care for • NEW YORK employees, retirees, and dependents; and implement these solutions. • NEW JERSEY Acknowledgements • CONNECTICUT NEBGH gratefully acknowledges • MASSACHUSETTS AstraZeneca, Boehringer Ingelheim, and Novo Nordisk for their unrestricted financial support of this publication and the related activities that contributed to its content and direction. We also recognize them as important stakeholders in the system-wide quest for safe, high-quality, and value-driven health care in New York, New Jersey, Connecticut, Massachusetts, and nationally. About NEBGH In addition, we would like to express our gratitude to the stakeholder contributors– Northeast Business Group on Health is a listed as Project Participants–who Northeast Business Group on Health network of employers, providers, insurers, made this project work possible. Their and other organizations working together 61 Broadway, Suite 2705 enthusiastic and insightful participation to improve the quality and reduce the cost and collaborative spirit were crucial to the New York, NY 10006 of health care in New York, New Jersey, success of this investigation. Connecticut, and Massachusetts. A not- for-profit coalition comprised of nearly 200 The authors are solely responsible for Phone: 212-252-7440 x223 members and over a million covered lives, the conduct of the research, analyses, NEBGH speaks with one voice for quality, and content of the manuscript. NEBGH Fax: 212-252-7448 accountability, and value in the region’s also recognizes Ms. Louise Kertesz for www.solutionscenter-nebgh.org health care system. NEBGH helps large, her contributions to the editing of this midsize, and small businesses by informing publication as well as Mr. Robert Murphy www.nebgh.org health care decisions, improving the health for fashioning the report’s formatting, care delivery system, and controlling costs. graphic design, and layout.

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