The OASIS Leadership Forum - Fazzi Associates · The OASIS Leadership Forum February 28 –March 2,...

The OASIS Leadership ForumThe OASIS Leadership Forum

February 28 – March 2, 2011San Antonio, Texas

©2011

The Management of Flow

Scenario Analysis of Problems That Emerge Each Day of the Process

Directed by:

Kay Wright

©2011

• Referral source satisfaction

• Patient care issues

• Patient satisfaction issues

• Marketing department frustrations

• Role clarifications

©2011

• Patient satisfaction

• Scheduling issues

• Patient error� Reporting

• Inappropriate use of Per Diem

• Do nurses work only until 3:00 PM?

• Productivity

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• Late paperwork

• Accountability

• Cash flow

©2011

• Accountability

• OASIS done in the home to assure accuracy

• Communication

• Interdisciplinary coordination

• Role clarification

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• Patient care

• Patient satisfaction

• Accountability

©2011

• Interdisciplinary coordination

• Late paperwork

• OASIS accuracy

• Accountability

©2011

• No paperwork

• Accountability

• Coordination of care

©2011

• Accountability

• Process flow deficiency

• Inter-office communication

©2011


• Who is accountable?

• Assessment done in the home

• Coordination between disciplines

• Compromises we make

©2011

• Accountability

• Interpersonal relations

• Processes

• Education

• OASIS outcomes

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• Corrections not back

• Accountability

©2011

M Item Nurse Therapist

1610 0 1

1820 1 0

1830 1 2

1860 2 3

1242 1 --

1400 -- 2

Difference in OASIS Scoring by Nurse and Therapist

©2011

• Coordination of care

• OASIS outcomes

• Accountability

• Corrections complete

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• Backlogs

• Processes

• Outcomes

• Accountability

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• Processes

• Accountability

• Outcomes

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• Accountability

• Cash Flow

• Processes

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• Processes

• Accountability


• Lost revenue

• Cash Flow

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How many days should this have taken?

to

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Impact of Collaboration

M Item Nurse Therapist Collaborative

1610 0 1 1

1820 1 0 2

1830 1 2 2

1860 2 3 2

1242 1 -- 3

1400 -- 2 3

©2011

Intake/Nurse Coder

780.79 Other-Malaise & Fatigue

728.87 Muscle weakness, general

V57.89 Care involving other specialized rehab procedure

715.9 Osteoarthritis, unspecified

715.9 Osteoarthritis, unspecified

788.3 Urinary Incontinence

788.3 Urinary Incontinence788.22 Gastrointestinal symptom, abnormal weight loss

401.9 Hypertension, essential NOS

Diagnoses - Codes

©2011

Changes in M Items Only

PPS Payment Data

1st ResponseCollaborative

Response

Case Mix Weight 0.85 1.17

HHRG C1F1S2 C2F3S2

PPS Estimated Payment

$2,313.55 $3,186.79

100 SOC: $87,324Note: These are hypothetical numbers only.

©2011

Changes in M Items and Coding,

No Change in Therapy

PPS Payment Data


Response


HHRG C1F1S2 C3F3S2


$2,313.55 $3,639.76


©2011

Changes in M Items, plus 2 Therapy Visits,

No Change in Coding

PPS Payment Data


Response


HHRG C1F1S2 C2F3S3


$2,313.55 $3,752.19


©2011

Changes in M Items, plus 2 Therapy Visits,

Plus Diagnoses Selection and Coding

PPS Payment Data


Response


HHRG C1F1S2 C3F3S3


$2,313.55 $4,205.16


An Insider’s View of OASIS

Angela A. Richard, MS, RNUniversity of Colorado

©2011

University of Colorado

Context

� In mid 1900’s, interest in assessing quality of care began; conceptual approaches were developed (Donabedian)

� Increased costs led payers to question how to evaluate the quality of the services they were purchasing

� Consumers (patients, etc.) began to request quality information for use in decision making

� As a result, measurement of performance data, including outcomes as a way to assess quality of care is now required to some extent for most care settings

Early OASIS Development and Testing

� OASIS was created as a method for reporting patient level outcomes for the purpose of QI

� OASIS is intended to measure outcomes of home health care regardless of the specific disciplines involved

� Many experts including therapists were involved in development and many rounds of testing

� Started with hundreds of data items!

� Items not used to measure outcomes were used for risk adjustment

OASIS History

� Implemented in 1999 for Medicare and Medicaid patients

� Original purpose was for agency quality improvement purposes

� Over the years, OASIS has come to be used for other purposes including payment (PPS), consumer reporting (HH Compare) and to aid in surveyor pre-survey prep

� Revised multiple times

OASIS-C

� Addressed industry concerns where possible on specific questions

� Expanded domains of quality that can be measured to include timeliness and process

� Harmonized several items with other care setting measures

� Eliminated items not used for outcome measurement and risk adjustment

Keep in Mind…

It is important to understand that OASIS was designed for assessing outcomes (and now

processes of care) in the aggregate

The Future of OASIS

� Continued evolution

� Ongoing emphasis on harmonization across care settings (CARE, etc.)

� Potential role in new payment systems

– Quality-based purchasing

Recommendation of Challenges and Recommendation of Challenges and Issues to Address by Members of the

2011 OASIS Leadership Forum

©2011

Management of Coding

1. How to ensure that there is enough information provided to Coders? (44)

2. How to improve clinician collaboration and communication? (39)

3. How to identify and improve accuracy of co-morbidity? (32)

4. How to ensure sufficient skill level of Coders? (31)

©2011

Management of OASIS Integrity

1. How to get buy-in from everyone? (77)

2. How to ensure accountability on all levels? (67)

3. How to ensure that staff do the actual documentation in the home? (50)

4. How to ensure effective interdisciplinary communication? (44)

©2011

Management of Rehab Services

1. How to ensure new regulations and documentation requires our out to staff by April 1. (61)

2. How to balance patient need with scheduling and availability. (46)

3. How to have the “team” own the OASIS assessment. (34)

4. How to reduce or eliminate assessment differences between nurse and therapist. (28)

©2011

Management of the Review Process

1. How to timeliness of documentation. (113)

2. How to establish and maintain staff competency. (91)

3. How to develop strategies and tactics for clinical manager effectiveness. (55)

4. How to motivate clinical staff. (24)

Analyzing Your Key Analyzing Your Key Performance Measures

Quality and Financial Matrix

©2011

• Home Health Compare

• Hospitalization Rate

• Home Health Process Measures

• Patient Satisfactions Measures

Quality Performance Measures ©2011

81%

82%

85%

85%

89%

Likelihood of

Recommending

Specific Care Issues

Communications Btwn

Providers and Patients

Overall Rating of Care

Care of Patients

Fazzi National Database

HHCAHPS: Initial Results

©2011

• Medicare Profit Margin: 11.61%

• CMW RAP: 1.25

• CMW Settled: 1.20

• Average Total Visits/Episode: 16

• LUPA Episodes: 12%

Key Financial Performance Measures

©2011

• Nursing Cost/Visit: $156

• PT Cost/Visit: $141

• Nursing Visits/Day: 4.2 billable

• PT Visits/Day: 5 billable

• Time in Home for SOC: 90 min

Key Financial Performance Measures

The “Lean Method” Approach to Performance Improvement

©2011

Tim Ashe, RN, MS, MBA

©2011

Your Operating Model

• The way work is done from Referral to Billing and Collections.

• Structure - Roles and Responsibilities.

• Measures of Success.

• Process Metrics – control.

• Standardization.

©2011

Culture eats everything else!

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How have you done it?

©2011

What are we trying to do?

• Provide great care?

• Produce financial results that allow us to invest in our staff, infrastructure, mission?

• Grow market share?

• Develop our staff?

• Achieve great patient satisfaction?

• All the above?

©2011

Why Lean Thinking and Lean Process Engineering?

• The heart of how an organization produces great results.

• Financial pressure.

• Quality pressure.

• Strategic position.

• Competitive differentiation.

©2011

Our workflows are efficient…Really?

In 1996 we lost Mrs. Jones….

©2011

Lean Programs Were Developed From TPS (Toyota Production System)

Order Cash

(Reduce by removing non-value-added wastes)

Simple, very clear focus

“All we are doing is looking at the time line; from the moment the customer gives us an order to the point when we collect cash. And we are reducing that time line by removing the non-value-added wastes.” Taiichi Ohno

©2011

There is nothing so useless as doing efficiently that which should

not be done at all.

~Peter F. Drucker

©2011

Lean Methodology

A + B + C = D

A + B = D

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Well, clearly Technology is the solution…right?

©2011

The first rule of any technology used in a business is that

automation applied to an efficient operation will magnify the

efficiency. The second is that automation applied to an inefficient

operation will magnify the inefficiency.

~Bill Gates

©2011

Lean Methodology

• A lean program is a way of thinking.

• Lean is a way of doing more with less. Less human effort, less equipment, less material, less time, and less space.

• Lean Programs strive to provide customers with exactly what they want, when they want it.

• At the heart of Lean Programs are flexible, motivated, invested team.

• Visual Management and Measurement.

©2011

The House of Lean Methods

GoalCustomer Focus

Highest quality, lowest cost, shortest lead time

by continually eliminating muda

Just-in-time Jidoka

Involvement

Flexible, motivated team

members continually

seeking a better way

Standardization

Stability

©2011

Jidoka

• Intelligent workers identifying errors and taking quick counter measures.

• Defect free processes by continually strengthening:

• Process capability

• Defects are quickly identified and contained in the area

• Feedback, so quick countermeasures can be taken

©2011

Maintaining Flow

• To deliver just what patients need when they need it, everything must flow.

• Whether it is the:

• Flow of Information…

• Flow of Product…

• Flow of People…

• All things must work together to create satisfied and loyal customers.

©2011

Lean Toolbox

• Kaizen

• 6-sigma

• Plan-Do-Study-Act

• Standard Work

• 5S

• Value Stream Mapping

©2011

Standard Work

• Provides process stability – replicable.

• Clear start and stop for each process.

• Organization learning – no gap if someone leaves.

• Audit and problem solving ability.

• Employee involvement and poka yoke.

• Kaizen – continuous improvement and root cause identification.

• Training for new employees or for back-up.

©2011

Value Stream Mapping

It helps you to see and understand the flow of material and informationas a product idea makes its way through the value stream. It helps you see waste. More importantly, it helps you see the sources of waste.

©2011

7 Forms of Waste

1. Transportation- of materials or information between processes or storage facilities inside or outside the company.

2. Inventory- in a system where materials flow in a steady flow from raw materials to finished product directly to the customer.

3. Motion- includes all unnecessary operations, movement, and steps taken by people.

4. Waiting- happens when delays occur in the process.

©2011

7 Forms of Waste (Continued)

5. Overproduction- is when we produce too much, too early, or in excess of customer demand.

6. Over processing- is doing more work than is necessary to perform an operation or transaction.

7. Defects- include the creation of items, information, or services that don’t meet customer specifications and require scrapping, repair, or rework (correction).

©2011

“The greatest waste is the waste

we do not see”

Shingo

©2011

Kaizen WorkshopsKaizen (KI-zen)

“Kai” to take apart, “Zen” to improve so as to help others

Kaizen

PlanCounter-measures

RealityCheck

MakeChanges

Celebrate!

MeasureResults

Make Thisthe Standard

DocumentReality

VerifyChange

Start here

Identify Waste

Do It Again

©2011

How to conduct a Lean Project

1. Obtain Management Sponsorship

2. Define the scope and scale of the

project

3. Define the Project Team

4. Do the work!

©2011

Management Sponsorship for the Kaizen

• Preparing:

• Allocating the time and resources for training

• Establishing precise project scope, scale, targets

• Providing clear incentives for team’s success

• Executing:

• Constantly communicating with the team and monitoring progress

• Maintaining flexibility as the team learns more

• Removing roadblocks and allocating funds

• Following up:

• Staying engaged throughout the process

©2011

Project Team Selection and Training

• Team Selection:

• Involve representative employees from the department with at least one person from each functional area

• Maximum 12 people

• Bring in a pair of “Outside Eyes”

• Facilitator(s)

• Team Leader – focused and influential

• Team Training:

• Lean principles

• Understanding how to use the Project Profile and Target Sheet

©2011

Lean Process Project Agenda

• Understand the current state Value Stream:

• Gemba (go to where the work is)

• Identify waste and areas of opportunity

• Try-storm ideas to address waste:

• Break and “go to work”

• Regroup and report back on how things went

• Try-storm new ideas if initial ideas didn’t work, or if more is learned

• Document Future State Value Stream

©2011

Role of Lean Facilitator

• Fostering trust.

• Gemba:

• Outside eyes extreme

• Ask the 5 whys

• Driving team success:

• Monitoring and tracking progress

• Managing team meetings

• Managing “fear”

©2011

GembaGo to where the work is

“The place where something is done”

• Go to the place where the work is done and observe to understand the process and issues.

• Develop “Eyes for Waste”

• Understand the production, materials, and information flow.

• Comprehension!!!

• What is really happening? Why?

©2011

A real world example

• Event Description.

• Value Stream Mapping - Current State.

• Value Stream Mapping - Future State.

• Try-storming.

• Progress towards targets.

©2011

Event Description

Improve Referral to Admission Process and eliminate non-value-added work.

©2011

Preliminary Objectives

• $150K cost reduction.

• Appropriate use of resources – match skill set to the task.

• Reduce the cycle time of data transfer (minimize walking distance).

• Right equipment for the staff.

• Real time access to vital information.

©2011

Value Stream Mapping

Current State

©2011

Pilot Future State Ideas

• Trials:

• Clerical Person addition in hospital setting

• Wireless trial

• Admission planning consolidation after 5 pm

• Eliminate Access database (duplicate to McKesson):

• Worked with McKesson to get reports (removed)

©2011

Value Stream MappingFuture State

©2011

Progress Toward Targets

• Matching skill set to job duties - Nurses doing clerical work:

• Created New Patient Specialist position

• Technology enhancements:

• Add VPN and reduced by 11 laptops

• Simplification of process and elimination of duplication:

• Eliminated Access database

• Maximized McKesson functionality

©2011

Progress Toward Targets

• Decentralized Admission Planning.

• Enhanced coding process.

• Reduced walking time.

• Improved customer satisfaction by consistency in care.

• Savings Year 1: $103K.

• Savings Year 2: $275K.

©2011

References

• Dennis, Pascal. 2002, Lean Production Simplified: A Plan Language Guide to the World’s Most Powerful Production System, Productivity Press, Portland.

• Ohno, Taiichi. 1978, Toyota Production System Beyond Large-Scale Production, Diamond Inc, Toyko.

• Shingo, Shigeo. 1985, The Sayings of Shigeo Shingo: Key Strategies for Plant Improvement, Productivity Press, Portland.

• Tapping, D, Shuker, T. 2003, Value Stream Management for the Lean Office, Productivity Press, New York.

©2011

Setting the Stage for AccountabilityStart With the Measures of Success

1. Job Expectation Rule: Make sure staff know what they are expected to do. Measures of Success.

2. Skill Development Rule: Make sure staff person is trained and has the skills to succeed.

3. Accountability Rule: Hold staff person accountable for meeting the job expectations you know they can do.

©2011

Seven Goals of Supervision

1. To clarify job expectations, i.e. how success will be measured – Measures of Success.

2. To assess the competency levels of your staff and train them to meet job expectations.

3. To delegate responsibilities to your staff based on their proven competency levels and hold them accountable.

4. To support your staff on the job.

5. To build the confidence of your staff.

6. To increase staff satisfaction and retention.

7. To help your staff grow personally and professionally.

©2011

The Supervisory ProcessClarify Job Expectations

+Provide Training/Skill Development

+Provide Direction and Support

+Hold Staff Accountable

They Come Through

They Don’t Come Through

RewardsPraise

Recognition

Acknowledgement

Greater Authority/Control

ConsequencesReprimand

Tighter Monitoring

Shorten Time Lines

Less Authority/Control

©2011

Outcome Management SystemHow Does the Agency Make Their Goals?

• CEO must be held accountable for achieving the agency’’’’s measurable goals.

• Department leaders must be held accountable for achieving the department’’’’s operational goals that support the organization’’’’s goals.

• Supervisors, managers and staff must have performance or measurable work outcomes that help ensure their department meets their operational goals.

Don’t Let the Challenges and Barriers Get You Down

©2011

Management of Coding

1. How to ensure that there is enough information provided to Coders? (44)

• Establish mandatory standards for required information at intake

• Full utilization of the capability of the point of care system

2. How to improve clinician collaboration and communication? (39)

• Develop, implement, and educate an electronic handshake to acknowledge and accept coding recommendations

©2011

Management of OASIS Integrity

1. How to get buy-in from everyone? (77)

a. Reward/recognize good behavior

2. How to ensure accountability on all levels? (67)

a. Identify behaviors to be evaluated on performance appraisal

©2011

Management of Rehab Services

1. How to ensure compliance with new therapy regulations by April 1 and ongoing. (61)

• Practice reassessment timeframes now

• Assess documentation content and tools

2. How to balance patient need with scheduling and availability. (46)

• Utilization assessment

• OASIS review

©2011

Management of the Review Process

1. How to improve timeliness of the OASIS flow. (113)

• Ensure the process and expectations are clear and standardized and staff are accountable.

• Ensure that staff conducting OASIS are deemed competent.

2. How to establish and maintain staff competency. (91)

• Establish your OASIS competency using a combination of co-visits and record audits using competency tool & skills testing

• Consistent training and testing

• Receive Referral

• Register Patient

• Verify Insurance

• Obtain Initial Visit

Authorization PRN

• Obtain Referral

from Intake

• Assign Patient by

District

• Complete Admit

Log (in system)

• Notify Other

Disciplines PRN

• Admit Visit within

24 hours

• Complete Admit

and OASIS within

24 hours of Visit

• Log Admission

Paperwork

• Notify Clinical

Manager of Late

Paperwork

• Admission Review

485

• OASIS Review

• Care Manager

• Approves POC

• Visits/Disciplines

• ICD-9 Coding

• Enters OASIS

(PRN) and 485

data, Print 485

• Send RAP from Billing

Community

Referrals

Hospital Referrals

ERRORS

NO ERRORS

• Corrects Errors

Immediately

ClinicianM.R. / Data Entry

Clinical ManagerOASIS Reviewer /

Care Manager ERROR• Review 485 and Signs (in

absence of electronic

signature)

NO ERRORS

M.R.

Intake T.A. Clinical Staff T.A.

• Mail / Fax / Portal 485 to MD

• 485 Document Tracking

Day 1 Day 2

Day 2 Day 3 - 4

Day 5 - 6

Fazzi Associates Recommended Admission Flow

March 2011

Why Won’t They Just DO it?

Strategies for Getting Buy-in for Changes

National Home Care Leaders Forum

San Antonio, TX

March 2, 2011

Your most challenging employee

• Turn to your table members and discuss for 3

minutes, your most challenging

employee...the one that just won’t DO it!

Copyright Amber Mayes Consulting, 2011, All rights reserved.

Don’t let it get you down...

You will walk away with...

• Strategies for engaging resistance and building

energy for change.

• Tangible things YOU can do when you walk out

the door to implement change successfully.


Moral of the stories...

The answer to

“how can I change them” starts with...

YOU


ENGAGE

• Explore the root

• Name your own part in the resistance

• Get on the same page

• Ask the resistors for input

• Gather allies by building the case for change

• Energize the system for forward-movement


Common reasons people resist

• Lack of understanding of the “why” or the

urgency for change

• They don’t like or they disagree with the

change being proposed

• Emotional reaction...fear of how the change

will impact them

• They don’t trust you

Adapted from Beyond the Wall of Resistance. 2011. Rick Maurer.


Tips: Building the case for change

• Address all levels of resistance – communicate

the why, address the emotional impact, build

trust

• Generate urgency by addressing what people

care about in their current context

• Build the plan or the “how” with stakeholders

• Reinforce and model the importance of the

change positively and consistently


Questions?

• At your tables, come up with one question you

have about managing resistance or getting

buy-in for change.

• Choose one person who will be ready to ask

the question should your table be selected.


Remember...Begin with YOU

• Think about that original resistant employee

or your change situation in general...

What is one new thing YOU can do when you

walk out of this room to positively engage

people in the changes you are implementing?

• Share this with one other person at your table.


Resources

• Maurer, R. 2010. Beyond the Wall of Resistance: Why 70% of Changes Still Fail –

and what you can do about it. Austin: Bard Press. (The most common reference

on managing resistance to change. Recently revised.)

• Lencioni, P. 1995. The Five Dysfunctions of a Team: A Leadership Fable. San

Francisco: Jossey-Bass. (A framework for dealing with the common dysfunctions of

a team written in fable form)

• Covery, S. 2006. The Speed of Trust: The One Thing that Changes Everything. New

York: Free Press. (A great guide to nurturing trust as a leader)

• Tuckman’s Stages of Team Development Model (This is the team development

model I referenced. It has been around and consistently used since the 60’s.

Google references. There are many.)

Please feel free to email me for more information or resources:

[email protected]


New Realities

Dr. Barbara Balik

New Realities – 1

Patient Centered Medical Homes Accountable Care Organizations

Barbara Balik RN, EdD

March 2, 2011

Barbara Balik [email protected]

• Identify:

– Emerging healthcare system initiatives that will shape home care’s future (or that home care can shape)

– Characteristics of the changes

– Opportunities for Home Care action/Risks of inaction

– What actions to take next

What We Will Accomplish


New Realities – Key Points

• Co-creation: Patient/family partnerships

• It Takes a Village: Strong, meaningful community partnerships

• Beyond the Usual: Care management for navigation, seamless transitions, and self-management support

• Useful Data: clinical information systems that integrate useful data


Scenarios for Home Care

• Where:– Medicare FFS is not the model

– Medicaid post-acute model is replaced by patient-centered, chronic care self-management

– Different customers/partners exist

– Therapy based home care visits are replaced by value creating partnerships

– People and their healthcare needs (populations) are described to aid in care delivery, not by site of care


Triple Aim

• Institute for Healthcare Improvement work – intent:

–Optimize the health system taking into account three dimensions:

• the experience of the individual; the health of a defined population; per capita cost for the population


Value in Healthcare

Value should always be defined around the customer . . . Value depends on results . . . And is measured by achieving outcomes

What is Value in Health Care?

Michael Porter, PhD

New England Journal of Medicine

363:2477-2481; December 23, 2010


Patient Centered Medical Home

• NCQA Criteria – see resources– A program to improve primary care

– A PCMH is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and the patient’s family

– Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically manner


Patient Centered Medical Home

• NCQA Criteria – see resources– The criteria intends to give practices information about organizing care around patients, working in teams and coordinating and tracking care over time

– 6 Standards, 27 Elements, 149 Factors

• Enhance Access and Continuity

• Identify and Manage Patient Populations

• Plan and Manage Care

• Provide Self-Care and Community Support

• Track and Coordinate Care

• Measure and Improve Performance


Accountable Care Organizations

• What would accountable care organizations be accountable for and what would they do differently? Harold Miller

• Payments for outcomes

– Value not volume

• Assumes the ability to understand population and individual needs; to measure, improve, coordinate, and deliver value

• Options:

– To support accountable acute care

– To support accountable medical homes and specialty care

– To support accountable cross-continuum care


Accountable Care Organizations

• Relationships not structure

• Focus:

– Affecting large numbers

– Evidence of high cost over-use

– Low-cost high-impact interventions

– Effective clinical leaders

• Examples:

– Avoidable rehospitalizations & ED use

– Appropriate use of drugs & diagnostics (e.g. imaging)


Lessons from the Field

Your learnings

What you can do


Resources

Center for Healthcare Quality and Payment Reform

http://www.chqpr.org/

How To Create an Accountable Care Organization

http://www.chqpr.org/downloads/HowtoCreateAccountableCareOrganizations.pdf

Transitioning to Accountable Care

http://www.chqpr.org/downloads/TransitioningtoAccountableCare.pdf

Network for Regional Healthcare Improvement

http://www.nrhi.org/

Collaboratives

http://www.nrhi.org/downloads/RegionalHealthImprovementCollaboratives.pdf


Center for Medical Home Improvementhttp://www.medicalhomeimprovement.org/

NCQA Patient Centered Medical Home http://www.ncqa.org/tabid/631/Default.aspx

Triple Aimhttp://www.ihi.org/IHI/Programs/StrategicInitiatives/TripleAim.htm


Resources

New Realities – 2

Chronic Care Model

Care Transitions Program Naylor Model

STAAR and Hospitalization Reduction Initiatives

Barbara Balik RN, EdD

March 2, 2011


Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

E. Wagner; MacColl Institute

Care Transitions Program

• Developed by Dr. Eric Coleman• A self-management model• During a 4-week program, patients with complex care needs receive specific tools, are supported by a Transitions CoachTM, and learn self-management skills to ensure their needs are met during the transition from hospital to home

• Value Proposition:– Reducing rehospitalization helps contain costs for complex patients and improves hospital bed capacity for patients admitted with more favorable DRGs.

– The program is self-sustaining.– The program is consistent with both Medicare Advantage and Medicare fee-for-service financial incentives.

– The program promotes better performance on new JCAHO initiatives aimed at post-hospital care.


Care Transitions (cont)

• Care Transitions Program Interventions

– Medication self-management

– Use of a dynamic patient-centered record, the Personal Health Record

– Timely primary care/specialty care follow up

– Knowledge of red flags that indicate a worsening in their condition and how to respond

http://www.caretransitions.org


Naylor Model

Transitional Care Model includes ten essential elements:

1. The Transitional Care Nurse (TCN) as the primary coordinator of care to assure consistency of provider across the entire episode of care

2. In-hospital assessment, preparation, and development of an evidenced-based plan of care

3. Regular home visits by the TCN with available, ongoing telephone support (seven days per week) through an average of two months post-discharge

4. Continuity of medical care between hospital and primary care physicians facilitated by the TCN accompanying patients to first follow-up visits

5. Comprehensive, holistic focus on each patient's needs including the reason for the primary hospitalization as well as other complicating or coexisting events


Naylor Model (cont)

Transitional Care Model includes ten essential elements:

6. Active engagement of patients and their family and informal caregivers including education and support

7. Emphasis on early identification and response to health care risks and symptoms to achieve longer term positive outcomes and avoid adverse and untoward events that lead to readmissions

8. Multidisciplinary approach that includes the patient, family, informal and formal caregivers are part of a team

9. Physician-nurse collaboration

10. Communication to, between, and among the patient, family and informal caregivers, and health care providers and professionals


Naylor Model (cont)

Key Components

• Focus on Patient and Caregiver Understanding

• Helping Patients Manage Health Issues and Prevent Decline

• Medication Reconciliation and Management

• Transitional Care, Not Ongoing Case Management


STAAR

State Action on Avoidable Rehospitalizations

• Institute for Healthcare Improvement

• Funded by the Commonwealth Fund

• Multi-state project to reduce avoidable

• Rehospitalizations focusing on two components:

– A multi-state learning community to improve transitions of care; and

– Targeted technical assistance to address systemic barriers to reducing avoidable re-hospitalizations


STAAR Learnings

• Key elements for Successful Transitions Home:

– Perform enhanced admission assessment for post-hospital needs

– Provide effective teaching and enhanced learning

• Who is the learner?

• Teach Back

– Conduct real-time patient and family-centered handoff communication

• Emphasis on medications

– Ensure post-hospital care follow-up


STAAR Learnings

• Transitions to Clinical Office Practice

– Provide timely access to care following a hospitalization

– Assess patient and initiate new plan of care at first post-discharge office visit

– Coordinate care across outpatient providers and settings


STAAR Learnings

• Transitions to Skilled Nursing Facility:

– Ensure a flawless transition

– Reconcile the treatment plan and medication list

– Engage the resident and family members in a partnership to create an overall plan of care

– Obtain a timely consultation when the resident’s condition changes


Lessons from the Field

Your learnings

What you can do


Resources

Chronic Care Model – MacColl Institute for Healthcare Innovation

http://www.grouphealthresearch.org/maccoll/maccoll.html

Care Transitions Program – Dr. Eric Coleman

http://www.caretransitions.org/

Transitional Care Model – Dr. Mary Naylor

http://www.transitionalcare.info/

STAAR and How-To Guides

http://www.ihi.org/IHI/Programs/StrategicInitiatives/STateActiononAvoidableRehospitalizationsSTAAR.htm?TabId=4


Strategic Management Model

What have we

learned?

What should weWhat should we

do about it?

What does it mean

to our agency?

©2011

• Receive Referral

• Register Patient

• Verify Insurance

• Obtain Initial Visit

Authorization PRN

• Obtain Referral

from Intake

• Assign Patient by

District

• Complete Admit

Log (in system)

• Notify Other

Disciplines PRN

• Admit Visit within

24 hours

• Complete Admit

and OASIS within

24 hours of Visit

• Log Admission

Paperwork

• Notify Clinical

Manager of Late

PaperworkCommunity

Referrals

Hospital Referrals

Clinical ManagerOASIS Reviewer /

Intake T.A. Clinical Staff T.A.

Day 1 Day 2

Fazzi Associates Recommended Admission Flow

• Admission Review

485

• OASIS Review

• Care Manager

• Approves POC

• Visits/Disciplines

• ICD-9 Coding

• Enters OASIS

(PRN) and 485

data, Print 485

• Send RAP from Billing

ERRORS

NO ERRORS

• Corrects Errors

Immediately

ClinicianM.R. / Data Entry

OASIS Reviewer / Care Manager ERROR• Review 485 and Signs (in

absence of electronic

signature)

NO ERRORS

M.R.

• Mail / Fax / Portal 485 to MD

• 485 Document TrackingDay 2 Day 3 - 4

Day 5 - 6

March 2011

The OASIS Leadership Forum - Fazzi Associates · The OASIS Leadership Forum February 28 –March 2,...

Documents

Transcript of The OASIS Leadership Forum - Fazzi Associates · The OASIS Leadership Forum February 28 –March 2,...