Transcript Care Transitions Learning Collaborative Learning Session
Learning Session Welcome and Introductions
Aubrie Augustus, RN, BSN, MHA; Senior VP Network Quality, JPS Health Network and Administrative Director, Learning Collaborative
8:30-8:40 8:40-8:50 8:50-9:00 9:00-9:10 9:10-9:20 9:20-9:30 Welcome and Introductions Learning Session Overview The Case for Improvement in Care Transitions and Patient Navigation in Region 10 Intersection Between the Learning Collaborative and DSRIP Introduce Story Board Gallery Walk Break
9:30-10:15 Storyboard Gallery Walk: Meet the other Provider Teams 10:15-10:40 10:40-11:10 11:10-noon Noon-1:00 pm 1:00-1:20 Model for Improvement, Part 1 Aim Statements, Monthly Measures, Run Charts Team Meeting#1: Revise Aim Statement, Data Collecting Planning The Model for Improvement, Part 2: The Plan Do-Study-Act Testing Cycle Lunch Overview of Change Package for Care Transitions: What do we know that works?
1:20-2:00 2:00-3:15 3:15-3:25 3:25-3:55 3:55-4:10 4:10 4:15 Panel Discussion: The Patient’s World: Using the Patient’s Voice to Guide our Work Introduction to Motivational Interviewing to Behavior Change Break Team Meeting 2 Planning for High Impact Change Teams Share Their Plans for Action Period 1 Evaluation Adjourn
Learning Session Overview
Gillian Franklin, M.D., MPH Clinical Effectiveness & Integration Specialist Project Manager & Performance Improvement Specialist, Learning Collaborative
The Learning Session
Goal: Participants will learn about the Model for Improvement .
Objective: Participants will understand the various aspects of the Model for Improvement and their functions.
Instructional Objective: Participants will work on parts of the Model for Improvement (Plan Do-Study-Act Testing Cycle) to test change.
Model for Improvement
Full engagement as early adopters
Strategies
Process Improvement NOT Research
Elements
“Best Practice” Changes Learning Collaborative Change Methodology Aim Statements; PDSA Testing Cycle; Monthly Measures; Run Charts etc.
Action Period 1
Inquiry-driven
The Take Away
»
Knowledge
»
New skills
»
Immediate changes
»
Steal Shamelessly
»
Share Relentlessly
What is a proven way to test potential changes without disrupting your organization’s day-to-day operations?
Model for Improvement & Plan-Do-Study-Act Cycle
Elizabeth Carter, MD Senior Vice President for Population Health Director, Care Transitions Learning Collaborative
Inadequate case coordination including care transitions responsible for $25-45 Billion in wasteful spending –
“layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful” IOM report “Crossing the Quality Chasm”
» » » » » Sickle cell anemia- 31.9% Gangrene- 31.6% Hepatitis- 30.9% Disease of white blood cells-30.6% Chronic renal failure 27.4%
• • • •
Root Causes per Robert Wood Johnson: Hospital computers don’t interface to community providers less relia ble hand-off Current payment policies may create disincentives for hospitals to invest in care transitions Medicaid low payment incentivizes NH to send patient back to the hospital to payment rate qualify for a more generous Medicare Half of Medicare patients admitted within 30 days have not been seen by a physician in the interim
Texas in the 4 th
quartile » Medicare 30 day readmission » » NH admissions and readmissions Home health admissions
Texas in 3rd quartile
» Admissions for Pedi asthma » Asthmatics with ED visit » Medicare admission for ACS
Carrot Stick
» » » Oct 2012, increase in Medicare payment if achieve or exceed performance (help at home, warning signs/symptoms, discharge instructions) Medical Home- pay providers for care transition services Demonstration projects- Monthly payments or per beneficiary per month for transitions processes/coordination » » Oct, 2012 reduced payments 1% readmission for CHF, AMI, pneumonia exceed target Transparent Physician level quality data
Regional plans should recognize the importance of learning collaboratives in supporting continuous quality improvement, RHPs will provide opportunities and requirements for shared learning among the approved DSRIP projects in the region. Learning collaboratives should strongly be associated with Performing Provider’s projects and demonstrate a commitment to collaborative learning that is designed to accelerate progress and mid-course correction to achieve the goals of the projects and to make significant improvement in the Category 3 outcome measures and the Category 4 population health reporting measures.
The continuation of the journey we have all been on together! Over the last two years we have all experienced together… Shared Learning & New Experiences Regional commitment to improve care across the continuum Newly fostered relationships and collaboration
• • • • A networking opportunity to learn how other similar projects are doing and best practices occurring in our community Focus on specific issues where multiple providers will collaborate to see improvement for all An opportunity to bring performance improvement practices (CQI) to your projects Recognition that it’s not just about the milestones, but the broader impact of participation in the Waiver, willingness to collaborate with peers, and show improvement at the individual, regional, and state levels Best practices Collaboration Performance Improvement Practices Regional Impact
Storyboard Gallery Walk Hunter Gatewood, MSW, LCSW
Storyboard Gallery Walk: Meet the Other Provider Teams
Model for Improvement: Part 1 Aim Statements, Monthly Measures, Run Charts Hunter Gatewood, MSW, LCSW
Team Meeting #1: Revise Aim Statement, Data Collection Planning
The Model for Improvement, Part 2: The Plan, Do-Study-Act Testing Cycle Hunter Gatewood, MSW, LCSW
What do we know that works for Care Transitions and Patient Navigation
Acute Care Episode Population At Risk Acute Phase Post Acute/ Rehab Phase Secondary Prevention Trajectory 1 (T1)
Relatively healthy adult with onset of new chronic illness
Trajectory 2 (T2)
Adult with multiple chronic conditions
Trajectory 3 (T3)
Adults at end of life Adapted from the National Quality Forum (NQF) steering committee on Measurement Framework: Evaluating Efficiency Across Patient-Focused Episodes of Care. The committee’s report presents the NQF-endorsed measurement framework for assessing efficiency, and ultimately value, associated with the care over the course of an episode of illness and sets forth a vision to guide ongoing and future efforts.
IHI’s Blueprint for Improving Transitions and Reducing Avoidable Re-hospitalizations Transition from Hospital to Home
• Enhanced
Assessment
• Teaching and
Learning
• Real-time Handover
Communications
• Follow-up Care
Arranged Post-Acute Care Activated
• MD Follow-up Visit • Home Health Care
(as needed)
• Social Services (as
needed) or
• Skilled Nursing
Facility Services Patient and Family Engagement Alternative or Supplemental Care for High Risk Patients *
• Hospice/Palliativ
e Care
• Transitional Care
Models
• Intensive Care
Management (e.g. Patient Centered Medical Homes, HF Clinics, Evercare)
•
Additional Cost for these Services Cross-Continuum Team Collaboration Evidence-based Care in All Clinical Settings Health Information Exchange and Shared Care Plans Improved Transitions and Coordination of Care Reduction in Avoidable Re hospitalizations
Very helpful interventions
• Speaking with a pharmacist about their medications especially true if patient had low literacy • Receiving a phone call 1-4 days after discharge – receiving these two interventions made them more comfortable with talking to their outpatient provider after discharge .
Courtney Cawthon, Sheena Walia, et al (2012) Improving Care Transitions: The Patient Perspective, Journal of Health Communication: International Perspectives, 17:sup3 312-324
• • • • •
Optimum Hospital Discharge Planning and Process Deliver Timely Access to Care Prior to the First Post-Hospital PCP: Prepare Patient and clinical team During the First Post-Hospital PCP visit: Assess Patient and Initiate New Care Plan At the conclusion of the First PCP Visit: Communicate and coordinate ongoing care plan
Navigation is often necessary because of the fragmented and complex health care system New accreditation standard for navigation process to address health care disparities and barriers to care by the American College of Surgeons’ commission on Cancer Multiple approaches to problem-solve, educate, define next steps
• • • •
36 randomized, controlled trials of Inpatient to Outpatient Hand-offs
Multiple components ( 94% of trials) Significant improvement in outcomes (69% of trials) Strategies before and after discharge (>50% of trials) Transition managers employed (72% of trials) – Care coordination – Patient education – Assessment of social and functional needs Hesselink G et al. Improving Patient handovers from hospital to primary care: A Systematic Review. Ann Intern Med 2012 Sept 18; 157-417
Panel Discussion: The Patient’s World: Using the Patient’s Voice to Guide Our Work
Introduction to Motivational Interviewing to Behavior Change Scott Walters, PhD
University of North Texas Health Science Center School of Public Health