Improving Care Transitions in Northwest Denver (Text Version)

Slide Presentation from the AHRQ 2011 Annual Conference

On September 21, 2011, Risa Hayes made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (4.8 MB). Plugin Software Help.

Slide 1

Improving Care Transitions in Northwest Denver

Improving Care Transitions in Northwest Denver

Risa Hayes, CPC
Program Manager, CFMC
Integrating Care for Populations and Communities
AHRQ Annual Conference
September 21, 2011

Slide 2

Our Equation

Our Equation

Screen shot showing their "equation" for hospital readmissions and admissions.

Slide 3

Northwest Denver Community

Image: A map shows the Northwest Denver Community.

Slide 4

Who is the Community?

Who is the Community?

  • Acute Care Hospitals.
  • LTACs.
  • SNFs.
  • Home Health Agencies.
  • Non-medical Home Care companies.
  • Senior Resource Centers.
  • Physician Offices.
  • Patient Advocates.
  • Hospice providers.
  • Palliative Care providers.
  • Medical Society.
  • Mental Health.
  • AAA.
  • QIO.
  • Hospitalists.
  • Physician management group.

Slide 5

Why are people readmitted?

Why are people readmitted?

Provider-Patient interface

  • Unmanaged condition worsening.
  • Use of suboptimal medication regimens.
  • Return to an emergency department:
    • Unreliable system support:
      • Lack of standard and known processes.
      • Unreliable information transfer.
      • Unsupported patient activation during transfers:
        • No community infrastructure for achieving common goals.

Slide 6

The Project

The Project


  • Improve care transitions for Medicare beneficiaries in 44 zip codes in NW Denver.
  • As evidenced by:
    • 2% reduction in 30 day all-cause readmission rate.

What we did:

Community Action Teams:

  • Standardized Community PHR.
  • Post-acute Care Options Tool.


  • PAM®-tailored CTISM.
  • Volunteer Advocates.

Slide 7

Personal Health Record Form

Image: A blank personal health record form is shown.

Slide 8

Community Unity

Community Unity

  • A true NW Denver Partnership.
  • Involved a large group of community providers.
  • 21,000 printed copies.
  • Available online for future use.

Images of all the community partner logos are displayed on the page.

Slide 9

Community Developed Tools

Community Developed Tools

Image: The Post Acute Care Decision Support Tool is shown.

Slide 10

Timeline: Care Transitions in NW Denver

Timeline: Care Transitions in NW Denver

Image: The Care Transitions timeline from 2008 to 2011 is shown.

Slide 11

Outcomes: Care Transitions Intervention and Patient Activation Measure

Outcomes: Care Transitions InterventionSM & Patient Activation Measure®

  • Coleman CTISM model1.
  • >300 patients coached.
  • Measurement:
    • Patient Activation Measure® (PAM®; Insignia Health)2

Level 1

Starting to take a role.

Individuals do not feel confident enough to play an active role in their own health. They are predisposed to be passive recipients of care.

Level 2

Building knowledge and confidence.

Individuals lack confidence and an understanding of their health or recommended health regimen.

Level 3

Taking action.

Individuals have the key facts and are beginning to take action but may lack confidence and the skill to support their behaviors.

Level 4

Maintaining behaviors.

Individuals have adopted new behaviors but may not be ale to maintain them in the face of stress or health crises.

Image: A bar chart shows two surveys taken with the percentages of patient activation measures in a sample size of 49.

Slide 12

Mr. H: A Patient Story

Mr. H: A Patient Story

"I feel that I must tell someone about how greatly I benefited from and appreciate the services of the nurse who follows up on patients discharged from your hospital.
She comforted me and helped make several forceful phone calls, and soon all was well. What a great help! What a relief! Thanks."

Slide 13



Image: A line graph of the 30-day readmissions per 1,000 eligible beneficiaries in the target community from 2007 to 2010 is shown.

Slide 14

Northwest Denver: Campaign

Northwest Denver: Campaign

Foundation: Determine community
Kick off: Community meeting
Peak: Form Action teams
Peak: Create PHR, PAC tool, Palliative/Hospice curriculum and community talks
Peak: Celebration meeting—June 21st
Outcome: Reduce hospital readmissions and improve patient activation
Evaluation & Next Steps: Apply for CCTP funding AND...

Slide 15


Northwest Denver Connected for Health: Story of Now

Image: A poster titled "How a community came together to reduce readmissions and activate patients...".

Slide 16



Page last reviewed October 2014
Internet Citation: Improving Care Transitions in Northwest Denver (Text Version): Slide Presentation from the AHRQ 2011 Annual Conference. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.