Care Navigation Affinity Group

Session One

September 28, 2017

Comprehensive Care for Joint Replacement Model

Audio available through device speakers OR by dialing (800)832-0736

Conference Room:*4934891#Access Code: 092817#

Welcome

Harold Bailey, MSHSALearning and Diffusion Group

Center for Medicare & Medicaid Innovation

Hilarea Amthauer, MPH, BSN, RNCJR Learning System Team

The Lewin Group

2

Alicia Goroski, MPHCJR Learning System Team

The Lewin Group

Webinar Agenda

• Welcome & Logistics

• Overview of the CJR Driver Diagram

• Introduction to the Care Navigation Driver Diagram

• Presentation: Eric Lowe, Community Hospital East

• Questions & Discussion

• Announcements & Reminders

3

Comprehensive Care for Joint Replacement Model

Meeting Logistics

• All telephone lines are muted and will be unmuted during the discussion session

• We encourage comments and reactions via Chat throughout the presentation

• Participate!– Chat– Polls– Telephone (During Open Discussion)– Post-Event Survey

Comprehensive Care for Joint Replacement Model 4

Introduction to Adobe Connect

5

Download Available Resources

Closed Captioning

Comprehensive Care for Joint Replacement Model

To Ask Questions

or Send Messages

To View the Video

To Dial In Via

Telephone

To Raise Your Hand To Enlarge the Presentation

Introduction to Adobe Connect (Cont.)

• Use the Chat pod to submit any questions or comments

• Please use “@” if your question/comment is directed to a specific presenter

• Submit your question/comment by clicking the chat bubble icon

• Please share in Chat now:– Name– Organization– What you hope to learn from this

Affinity Group

6

Comprehensive Care for Joint Replacement Model

Care Navigation Affinity Group Goals

Convene on a monthly basis to:– Share care navigation and care coordination

tools and resources– Discuss successful strategies, challenges, and

lessons learned– Learn from each other

Comprehensive Care for Joint Replacement Model 7

Overview of the CJR Driver Diagram

Comprehensive Care for Joint Replacement Model 8

Introduction to the Care Navigation Driver Diagram: Primary Driver #1

Comprehensive Care for Joint Replacement Model 9

Introduction to the Care Navigation Driver Diagram: Primary Driver #2

Comprehensive Care for Joint Replacement Model 10

Poll 1

Are you using any change concepts or tactics in your care coordination/care navigation program that are not currently included in the driver diagram? [Select one option]• Yes (please share in Chat)• No• Maybe (I need to take a closer look at the Driver

Diagram)

Comprehensive Care for Joint Replacement Model 11

Interview with Eric Lowe, RN

Community Health Network Joint Care Coordinator

Community Health Network

• 5 hospitals– Indianapolis, IN

• (3 locations) in CJR – Anderson, IN– Kokomo, IN

• 1500+ Total Joints per year

13

Community Hospital East

• East side of Indianapolis, IN• 7 employed physicians & 2 independent• Employed hospitalist group

– Pre-op clinic and rounding • 300+ total joints per year

– 93 CJR episodes YTD• 18 of those fractures

14

Indianapolis Market

• MSA # 26900– Indianapolis, Carmel, Anderson– 24 CCNs

15

Joint Care Coordinators (JCC)

• 5 total – 2 at North– 1 at East– 1 at Kokomo– 1 at South

• All are Registered Nurses• Various Backgrounds

16

A JCCs’ Typical Day

• Pre-operative education on future patients

• Rounding on current patients

• Following-up on discharged patients

• Tracking various outcome measures

17

Patient Interaction

• Prior to surgery– Multi-disciplinary education class (2 hrs)

• How to prepare for surgery• Exercises • What to expect after surgery• Discharge planning

18

Patient Interaction (2)

• While in the hospital– Daily rounding

• PT & OT – Functional outcomes

• Case Management– Discharge barriers

• Patients– Satisfaction– Discharge planning

19

Patient Interaction (3)

• After discharged– SNF

• JCC follows up with the SNF on POD#7– Home

• Home PT sees the patient 3 x week for 3 weeks– Reunion Dinner

• All patients• 3-4 months after discharge

20

Post-Acute Interaction

• Home Health– Standing meeting every 6 weeks

• Review cases– Including episodic data

• Review barriers• Discuss opportunities• Refine orders

21

Post-Acute Interaction (2)

• SNF– Quarterly meeting with preferred providers

• Review cases– Including episodic data

• Review barriers• Discuss opportunities• Refine orders

22

Collaboration

• JCCs– Monthly

• JCCs, MDs, & Executive leadership– Quarterly

• Post-Acute Team– Every 6 weeks

23

Pre-Op Assessments

• RAPT (Risk Assessment Prediction Tool) – Surgeon’s office

• Patient Reported Outcomes– Pre-op Clinic

• NSQIP Surgical Risk Calculator– Pre-op Clinic

24

25

RAPT Article Screenshots

NSQIP Surgical Risk Calculator

26

Suggestions for Care Navigators

• We’re all in this together– CJR Connect– Other MSA’s in your region– Webinars– Summits– Surgeons– Patients

27

Questions & Discussion

• What questions do you have for Eric?• Did you hear anything today that you would be able to

implement with your CJR patients?• What tools or resources do you use to assess and

measure care coordination, patient engagement/activation, and/or navigator touchpoints?

• Do you stratify services or touchpoints based on risk score?

• As the care navigator, do you tailor your interactions based on risk score?

28

Comprehensive Care for Joint Replacement Model

Poll 2

Which of the following tactics does your organization use to coordinate care and facilitate communication and collaboration with post-acute providers and community organizations? [Select all that apply]• Host regular meetings with PAC providers (quarterly, monthly). • Share data with PAC providers to better monitor and track patients.• Cultivate and support primary care, specialty provider, and post-acute care

co-management with timely communication, inquiry, follow-up, and integration of information into the care plan regarding transitions-in-care and referrals.

• Collaborate to revise care protocols (e.g., expected LOS, timing and frequency of rehab, what to do in an emergency, etc.).

• Cultivate relationships and increase awareness of community-based services for patients as they transition back into the community.

• Other (please specify in chat).

Comprehensive Care for Joint Replacement Model 29

Announcements & Reminders

30

Comprehensive Care for Joint Replacement Model

Continue Discussion on CJR Connect

• Request to join the “Care Navigation” groupo Go to the “Groups” tab on CJR Connecto Click on the green plus sign to join the “Care Navigation”

group • Post a comment in the group, share resources with your peers,

or just respond to others!• To request a CJR Connect account, go to:

https://app.innovation.cms.gov/CJRConnect/CommunityLoginand click “New User? Click Here”

31

Comprehensive Care for Joint Replacement Model

Upcoming CJR Learning System Events

32

Comprehensive Care for Joint Replacement Model

If you have any questions about these events, send an email to LS-CJR@lewin.com

Reminders

• If you have any questions related to the Affinity Group, send them to LS-CJR@Lewin.com

• Send any technical or programmatic questions to CJRSupport@cms.hhs.gov

• Please take a few minutes to complete the Post-Event Survey

33

Comprehensive Care for Joint Replacement Model