Table 1.

Southeast Michigan See You in 7 Collaborative Time Periods, Methods, Tools, and Evaluation Plan

Focus	Methods/Tools	Evaluation Plan	Meetings
Pre-Implementation period May - July 2013	Hospitals: Establish collaborative partnerships among hospitals serving Southeast Michigan beneficiaries   Hospital-to-Home “SY7”   Toolkit	Gap analysis	Kickoff Meetings 2 Conferences Calls/Webinars
	Planning Team Activity Pre-Implementation Data Submission CH Selection of “See You in 7” Process Measures
Test- Intervention period Aug - Jan 2013	SY7 Toolkit process goals: Identify HF patients prior to discharge:	Proportion of HF patients identified prior to discharge	2 Quarterly Meetings 4 Conferences Calls/Webinars
	Schedule and document a follow-up visit with cardiologist or PCP that takes place within 7 days of discharge.	Proportion of discharges with scheduled 7-day follow-up visit with Cardiologist or PCP
	Provide all patients with documentation of the scheduled follow-up appt.	Proportion of patients with documentation of 7-day follow-up appointments
	Identify and address barriers to keeping appointment.	Follow-up phone calls or risk assessments conducted to identify barriers
	Ensure all HF patients arrive at scheduled appointment within 7 days of discharge	Proportion of patients who had 7-day follow-up appointments scheduled Proportion of patients who kept scheduled 7-day follow-up appointments.
	Make discharge summary available to follow-up health care providers for all HF patients.	Proportion of discharge summaries transferred to PCP within 24 hours of discharge.
	Planning Team Activity Collaborative hospitals shared best practices. Quarterly Progress Reports
Evaluation period Feb – April 2013	Data and Information - Medicare fee-for-service claims data, aggregate and hospital level descriptive readmission and 7-day follow-up reports Policy - Hospital Compare Reporting, Hospital-wide Lessons learned shared among CH Quarterly Progress Report Post-Implementation Data Submission	Continued assessment and improvement based on rates of 7-day follow-up.	2 Conferences Calls/Webinars 1 Quarterly Meeting

Abbreviations: CH, collaborating hospitals; HF, heart failure; PCP, primary care provider