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The Problem: Hospitalized older adult diabetics w/Medicare are 72% more likely to be readmitted within 30 days than non- diabetics (19% vs. 11%). Further, this group’s length of stay is 5.4 days longer on average than the Medicare Geometric Mean Length of Stay.

Quality reputation and vision vs. public data

LOS cost opportunity: $3.4 million annually

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Results of Environmental Scan What I learned:

We are learning more every year about diabetes

Do WITH and not TO the patientCare transitions: start somewhere

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Target Population Hospitalized diabetics (primary or secondary

diagnosis) age 65+ with Medicare Admitted by hospitalist or internal medicine

resident Returning to community after D/C Multicultural/multilingual population:

Caucasian Latino (Spanish-speaking) African American Chinese (Mandarin/Cantonese-speaking) Armenian

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Approach to the Problem

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Process and Outcome Measures Process Measures:

Patients referred vs. eligible and not referredCare transitions – service dates vs. standards

Outcomes Measures:Collected at completion of service delivery:

○ Coleman’s Care Transitions Measure (CTM-3)○ Lorig’s Chronic Care Self Management Scale

Collected ongoing:○ 30-day readmissions○ Length of stay

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Program Timeline

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Implementing the Program Leveraging:

CTI statewide pilot participant 2007-08Strategic Operating Plan: care transitionsRelated care transitions initiativesPursuit of Magnet Designation by

American Nurses Credentialing Center (ANCC)

Health Care Reform

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Implementing the Program (cont’d) Engaging the Stakeholders:

Patients & Families: feedback (surveys)Professionals—Strategic communications,

periodic interim outcomes reports:○ Nursing○ Physician Groups○ Social Work / Discharge Planning / UM○ Ambulatory Care & Senior Care Network

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Perceived Facilitators/Barriers

Facilitators:Initiative ChampionsRisks of doing nothing:

○ Quality and patient satisfaction○ Threat of payment penalties○ Cost opportunity

Barriers:Identifying patients timelyCultural norms & scope of practice concernsPotential for confusion—related initiatives

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Preliminary Data

Readmission19%

No readmission

81%

Targeted Population

Readmission No readmission

General Population

No Readmission

89%

Readmission11%

Readmission No Readmission

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Preliminary Data

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Readmission19%

No readmission

81%

Targeted Population

Readmission No readmission

Sustaining the Program

Outcomes measures: quality improvement and return on investment

Develop business case for continuation Plan next steps to expand program

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What I Have Learned Leading means…

Focusing on the goal and remaining flexibleMaintaining hopeHelping the group find and cross bridges

We have the privilege to serve and the obligation to improve

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Question… What wisdom can you share with me

about implementing care transitions in an environment that expects medical interventions?

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