Care Transitions: Driving Program Change thru Data

Transcription

1 Care Transitions: Driving Program Change thru Data Frederick Regional Health System Heather Kirby, Director Care Management 1

2 The Journey Engaged multidisciplinary/multi-agency group in 2010 to discuss need to improve patient transitions (post acute facilities, Department of Aging, HHC, private duty, physician practices, etc. on board at this point). 6 month pilot program in 2011 focused on reducing HF readmissions (40% reduction) July 2012 began efforts to expand the pilot across all patients and into the community 2

3 3 Focused Work Plan

4 Care Transitions Model Integrated with Care Management Department Dedicated Care Transitions Team, consisting of: 2.5 Care Transition RNs 2.0 ED Care Transition Social Workers 1.0 Care Transition Pharmacist Close collaboration with HF/COPD Nurse Practitioner Comprehensive community service provider participation, including: Post acute nursing and AL facilities Department of Aging AERS Home Health Services Hospice Walgreen s Pharmacy Community Physician practices Immediate Care Private duty services 4 Butler Medical Services

5 The Process Patient screened by Case Management If screened + for high risk for Readmission a referral is made to the Care Transitions Team (if goal is to return home) RN and or Pharmacist provide comprehensive education re. disease management and patient compliance - develop Personal Health Record with patient Offer to assist with making post discharge physician appointments (if patient agrees also ensure dc summary and instructions are sent to physicians) Work collaboratively with CM team on discharge plan, including referrals to home health care and securing prescriptions At discharge patients receive a series of post discharge phone calls (1 per week x 4 weeks) vs. a follow up home visit by members of the team 5

6 Dashboard 6

7 Using data to drive program change Discharge planning referrals to HHC Patients refused referrals Change = Care Transitions team now making home visits Opportunities identified during follow-up calls and readmission interviews: Prescription access and affordability Follow up appointments timing and compliance Partnership with Walgreen s to have medications delivered to the bedside prior to discharge Follow up physician visits Access to timely visits coupled with affordability Clinic expansion 7 Partnership with physician practices for follow up care

8 Dashboard 8

9 Using the data to identify key opportunities Acute Workgroup: 9 Disease specific focus: HF, COPD, Sepsis, Diabetes Comprehensive multidisciplinary patient education Develop partnerships with specialty physicians/providers in the community Inclusion of specialty service area expertise, including: pulmonary/respiratory care, cardiac rehab, rehab, clinical diabetic educators, etc. Improve hand off communication / transitions Monitor LOS and other KPIs, including core measures, PPC, etc.

10 Using data to strengthen partnership with post acute providers: Disease specific programs coordination across the continuum Led to the development of consistent treatment protocols and education materials Exploring the opportunity to develop a post acute facility liaison intervention, communication, discharge planning Facility specific RA rates reported to the hospital and shared with appropriate committees 10 Drove internal exploration of strategies to reduce unnecessary readmissions as well as appropriateness of ED utilization Engagement of a facility-based SNFist program Led to improved triage process prior to transferring to the ED Expanding availability to admit patients directly from home within the 30 day window

11 Key Stakeholder Involvement Executive Team: KPI s (page 1 of dashboard) 30 minute meeting held monthly Key focus areas (work plan and dashboard) What do we need from the C Suite Care Transitions Operations Council (page 1 and 2 of dashboard): 60 minute monthly meeting Multidisciplinary/Agency meeting (comprehensive community representation) Review the dashboard (Ex. Summary and detailed data report), subcommittee report outs and discussion re. needs, concerns, and new focus areas/opportunities 11

12 Key Take Away s Include IT early in the discussion they will be critical to your data collection efforts Avoid manual data collection Develop documentation process that allow for direct data extraction vs. data entry processes Think big it is important to collect high level metrics early on, however you will find the deeper data dives will be equally important as the program matures Identify the key stakeholders across the continuum, and communicate frequently with them: - Consistently speak to the data being OUR data (i.e. data across the continuum supports the idea that all of the agencies involved have an important role in improving the health and wellbeing of the community). 12