Transcript Slides

Health Care Home
and Care Transitions
March 15, 2013
Hosted by RARE Operations Partners:
Institute for Clinical Systems Improvement, Minnesota Hospital Association, Stratis Health
Our host today will be…
Kattie Bear-Pfaffendorf – Minnesota Hospital Association
Kattie Bear-Pfaffendorf is a patient safety/quality
specialist with Minnesota Hospital Association.
She focuses or Transforming Care at the Bedside,
Partnership for Patients, Readmissions, and
Perinatal Safety. Kattie holds a MBA and Lean Six
Sigma Green Belt. Kattie has over 7 years of
experience in the clinical laboratory including;
pathology, cytology, histology and microbiology.
Why RARE Conversations?
Share
Networking
opportunities
Engage
Learn
Conversation
March’s Conversation…
Health Care Home
And
Care Transitions
Sharing their work:
Fairview Medical Group
More about the presenters…
Leanne Roggemann, RN, MPH
Leanne Roggemann, RN, MPH, is the Director
of Nursing for the Fairview Medical Group
(FMG).
She is the Health Care Home lead for
FMG. This work includes the implementation of
care coordination and partnering across the
system to establish a smooth process for care
transitions from the hospitals and other care
settings.
Leanne has worked for FMG for 26 years in
many roles including the inpatient setting and
the ambulatory clinic setting.
More about the presenters…
Vicki Weber, RN, MSN, CMC
Vicki has spent the last 12 years in care management
leadership, and is currently working as the system
director of care transitions for Fairview Health
Services. During the past year Vicki led the
implementation of a system-wide care transitions
strategy focused on assuring the highest quality patient
and family support experience. She has a 21 year
history in case management and is recognized for
program development, building cross-continuum care
teams and administering patient-focused care models.
Vicki is a graduate of Loyola University, New Orleans,
with a MSN in Health Care Systems Management. She
also holds a bachelors degree in nursing graduating
from College of St Catherine, St Paul.
Health Care Home
and
Care Transitions
Leanne Roggeman, RN, MPH
Director of Nursing
Fairview Medical Group
Vicki Weber, RN, MSN, CMC
Director of Care Transitions
Fairview Health Services
March 15, 2013
Health Care Home Standards
1) Access
2) Panel Management
3) Quality
4) Care Coordination
5) Care Planning
Detailed components of the standards
Access
Panel Management
• 24/7 access
• Disease specific patient
lists
• Alternative visits:
telephonic, MyChart, RN
MTM, behavioral health
clinicians
• Communication/handoffs
between care teams
9
• Reporting workbench
• Population management
tool
Detailed components of the standards
Quality
Care Coordination
• Clinical outcome data
• High risk referral
management
• PDSA cycles at the local
level to improve
flow/clinical outcomes
• Patient
experience/satisfaction
• Patient partners
10
• Care transition handoffs
• Health maintenance
reminders
• Pre-visit planning
Detailed components of the standards
Care Planning
• After visit summary
• Disease specific action
plans
• Complex care plans
• Emergency care plans
11
Supportive Program Components
Care Transitions
Transition/Hand-Off Communication
•Summary of event
Physician Summary
After Visit Summary
Phone call/email/face-to-face discussion
Clearly telling the patient story, what occurred, and what
suggested/required care interventions need to occur
•Results in
Immediate information related to the patient’s hospitalization
Confirmation of post-discharge needs
12
Why Focus on Care Transitions?
•Personalized care management focused on patient-centered
goals (use of HCH POC)
•Enhanced alignment of continuum of care management
•Outcomes driven
Serious unmet needs resulting in poor satisfaction with care
High rates of preventable readmissions
40% (4/10) in hospital beds do not need to be there
(Improvement in Science Research Network)
13
Care Transitions Process
1)Risk Stratification – identify the patient’s risk level – this will
determine what level of transition services a patient may need.
2)Assessment/Triage – complete a clinical and/or psycho-social
assessment to determine probable post-event needs.
3)Patient Story – understand:
What led to this event,
What level of understanding the patient has about the event,
The patient’s clinical/psychosocial history that impacted the
event,
The patient’s ability and willingness to work on changes to
maintain care in his/her home setting, and
What support the patient may need to carry out the plan.
14
Collaborative Partnerships
Clinics
•Clinic Care Coordinator role
Partner with Care Transitions Specialist during the patient’s hospital stay
Communicate transition plan to physician and health care team members
Post-hospital, work with patient to make adjustments in Medical Home
Care Plan
Act in the role of Patient Advocate to support care needs
Hospitals
•Care Transition Specialist role
Partner with Clinic Care Coordinator on transition plan and patient’s
continuum needs
Facilitate communication among all health care providers, proactively
preparing for the transition
Partner with patient/family to review Medical Home Care Plan, identify
new goals, prepare for transition back to primary care provider
15
Successes/Challenges
Identified Successes
Assurance that follow-up needs will be met due to personalized
hand-off with clinic/community partners
Greatly improved communication between hospital and clinic
Patients and families are more engaged in planning transitions
Easy identification of patients who are considered high risk, resulting
in improved focus on those with the highest need
Identified Challenges
We want to share information with non-Fairview providers
More work to be done, particularly in our emergency departments
Skilled nursing facility transitions need a different type of hand-off
(plan of care, why is the patient coming to them, medication
reconciliation, orders confirmation)
16
Questions?
17
Upcoming RARE Events….
• RARE Rapid Action Learning Day,
April 23, 2013, (8:30 a.m. – 3:30 p.m.)
Mpls. Marriot Northwest, Brooklyn Park,
MN
• RARE Webinar, ICSI will be hosting the May
2013 webinar. Stay tuned for more details.
Future webinars…
• To suggest future topics, contact
Kathy Cummings at
[email protected]