Post on 17-Dec-2015
LEARNING SESSION NUMBER IJanuary 29th & 30th, 20148:00 AM – 4:15 PM
The Riley Center at Southwestern Seminary1701 W. Boyce Avenue, Fort Worth, Texas 76115Room 150
Care Transitions and Patient Navigation Learning Collaborative
January 29th, 2014
Learning Session Welcome and Introductions
Aubrie Augustus, RN, BSN, MHA; Senior VP Network Quality, JPS Health Network and
Administrative Director, Learning Collaborative
Agenda
8:30-8:40 Welcome and Introductions
8:40-8:50 Learning Session Overview
8:50-9:00 The Case for Improvement in Care Transitions and Patient Navigation in Region 10
9:00-9:10 Intersection Between the Learning Collaborative and DSRIP
9:10-9:20 Introduce Story Board Gallery Walk 9:20-9:30 Break
Agenda
9:30-10:15 Storyboard Gallery Walk: Meet the other Provider Teams
10:15-10:40 Model for Improvement, Part 1 Aim Statements, Monthly Measures, Run Charts
10:40-11:10 Team Meeting#1: Revise Aim Statement, Data Collecting Planning
11:10-noon The Model for Improvement, Part 2: The Plan- Do-Study-Act Testing Cycle Noon-1:00 pm Lunch
1:00-1:20 Overview of Change Package for Care Transitions: What do we know that works?
Agenda
1:20-2:00 Panel Discussion: The Patient’s World: Using the Patient’s Voice to Guide our Work
2:00-3:15 Introduction to Motivational Interviewing to Behavior Change
3:15-3:25 Break
3:25-3:55 Team Meeting 2 Planning for High Impact Change
3:55-4:10 Teams Share Their Plans for Action Period 1
4:10 Evaluation
4:15 Adjourn
Learning Session Overview
Gillian Franklin, M.D., MPHClinical Effectiveness & Integration Specialist
Project Manager & Performance Improvement Specialist, Learning Collaborative
Learning Collaborative Model (Breakthrough Series Model)
Learning Session Overview
The Learning Session
Goals And Objectives
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.
Learning OutcomesModel 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
Formative Feedback
» Knowledge
»New skills
» Immediate changes
» Steal Shamelessly
» Share Relentlessly
The Take Away
Wait, Wait Don’t Tell Me!!!
What is a proven way to test potential changes
without disrupting your organization’s day-to-day
operations?
Answer
Model for Improvement&
Plan-Do-Study-Act Cycle
The Case for Improvement :Care Transitions and Patient Navigation
Elizabeth Carter, MDSenior Vice President for Population Health
Director, Care Transitions Learning Collaborative
The Case for Improvement
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”
Medicare Cost Per Beneficiary and 30 Day Readmission by State
All Cause 30 Day Readmission Rates
» Sickle cell anemia- 31.9%» Gangrene- 31.6%» Hepatitis- 30.9%» Disease of white blood
cells-30.6%» Chronic renal failure-
27.4%
Conditions with Highest Readmission Rates
The Case for Improvement
Root Causes per Robert Wood Johnson:• Hospital computers don’t interface to community providers-
less reliable 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 qualify for a more generous Medicare payment rate
• Half of Medicare patients admitted within 30 days have not been seen by a physician in the interim
Reducing Readmissions for Value-Based Healthcare
Texas in the 4th 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
Avoidable Hospital Use and Costs
Affordable Care Act
Carrot
» 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
Stick
» Oct, 2012 reduced payments 1% readmission for CHF, AMI, pneumonia exceed target
» Transparent Physician level quality data
The Intersection of DSRIP and the Learning Collaborative
Mallory JohnsonManager RHP 10
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.
According to the PFM…. Our Learning Collaboratives should…
The continuation of the journey we have all been on together!
Over the last two years we have all experienced together…
What does the Learning Collaborative mean to Region 10 DSRIP Projects?
Shared Learning & New
Experiences
Newly fostered
relationships and
collaboration
Regional commitment to improve care across
the continuum
• 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
What can the Learning Collaborative mean to your DSRIP Projects?
Best practices CollaborationPerformance Improvement
Practices
Regional Impact
TEAM ME
Storyboard Gallery Walk Hunter Gatewood, MSW, LCSW
Break
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
Lunch
Overview of Change PacketWhat do we know that works for Care
Transitions and Patient Navigation
Acute Phase
Acute Care Episode
Population At Risk 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.
Post Acute/ Rehab Phase
Context for Transitional Care
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
Alternative or Supplemental Care for High-Risk Patients*• Hospice/
Palliative Care• Transitional Care
Models• Intensive Care
Management (e.g. Patient-Centered Medical Homes, HF Clinics, Evercare)
• Additional Cost for these Services
Improved Transitions and Coordination of Care
Reduction in Avoidable Re-hospitalizations
Cross-Continuum Team Collaboration
Evidence-based Care in All Clinical Settings
Health Information Exchange and Shared Care Plans
Patient and Family Engagement
What do we know that works?What do patients want?
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
Change Concepts
• 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
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
What Works? Systematic Review
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
Scott Walters, PhDUniversity of North Texas Health Science Center
School of Public Health
Introduction to Motivational Interviewing to Behavior Change
Break
Team Meeting #2: Planning for High-Impact Change, Drafting a PDSA Test
Teams Share Their Plans for Action Period 1
Evaluation
Adjourn