Welcome to the New England QIN-QIO Care Transitions Webinar!

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1 Welcome to the New England QIN-QIO Care Transitions Webinar! Thank you for joining. Our presentation will begin shortly. If you haven t already, please dial in to the audio line: Passcode: Slides are available for 1

2 Lessons Learned from a Southwestern Vermont Transitional Care Program Speakers: Gail Colgan, RN, BSN ~ Vermont Care Transitions Lead, New England QIN-QIO Barbara Richardson MS, RN-BC, CCRN ~ Clinical Nurse Specialist / Transitional Care Nurse, Southwestern Vermont Medical Center Stephanie Baker, MHA ~ Massachusetts Care Transitions Program Coordinator, New England QIN-QIO March 23, :00am 12:00pm This material was prepared by the New England Quality Innovation Network-Quality Improvement Organization (NE QIN-QIO), the Medicare Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy CMSQINC

3 Chat in Introduce yourself please type in your name, role, organization and state 3

4 Today s Speakers Gail Colgan, RN, BSN Vermont Care Transitions Lead New England QIN-QIO Barbara Richardson MS, RN-BC, CCRN Clinical Nurse Specialist Transitional Care Nurse Southwestern Vermont Medical Center Stephanie Baker, MHA Massachusetts Care Transitions Program Coordinator New England QIN-QIO 4

5 SVMCs Transitional Care Program Nurses as Architects of Integrated Healthcare Delivery Barbara Richardson MS, RN-BC, CCRN Clinical Nurse Specialist Transitional Care Nurse 5

6 SVHC is a Health System part of the Vermont Care Organization (a statewide ACO) 99 bed, rural hospital 150 bed, long term care/rehab Medicare dependent High Medicaid population Vermont = 2nd oldest state Medical Home 90% NCQA certified Health Service Area Bennington population 35,000 Total Service Area 75, Patient Centered Medical Homes Independent and Employed Practices 6

7 Healthcare Reform 7

8 Silos of Care 8

9 Future of Healthcare 9

10 Transitional Care Model Range of time limited services that compliment primary care and are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and cross settings. 10

11 Clinical Nurse Specialist (CNS) Role Redesign Acute Care Based Population Based Focused on Inpatient Care Delivery Focus on the Continuum of Care High Degree of Control Person Centric 11

12 VNA / Home Health & Hospice Case Management Sub Acute and Rehab Nursing Home Primary Care Office 12

13 Who really Controls Outcomes? The majority of health care occurs at the low-acuity end of the scale, where outcomes are controlled not by physicians or the system but by the everyday choices of individuals and families. The largest opportunity clinical staff have to influence health outcomes is to influence choices by partnering over time. 100 Patient/Family Control 0 Low Acuity The System High Ref: Gottlieb, Sylvester and Eby. Transforming Your Practice: What Matters Most. Family Practice Management. January

14 Challenges Turf issues Duplication of services Why a masters prepared nurse? 14

15 Patient is introduced to the TCN during a scheduled visit. TCN introduces the role of the TCN as an extension of the PCP office to assist with communication, education and support Patient Transitions to Subacute Care Primary Care Provider (PCP) Patient Transitions to Hospital TCN visits patient in subacute care within hours of notification TCN coordinates with the facility to prevent duplication of efforts and ensure a smooth transition. TCN visits patient as needed Patient Transitions Home TCN visit patient in hospital within hours of notification. TCN partners with hospital care team to provide additional information that may assist with care. TCN visits patient regularly. For patients discharged with home health support, TCN coordinates with the home health agency to prevent duplication of efforts and ensure a smooth transition. TCN visits patient within hours of notification to review discharge plan, assist with medication reconciliation, plan referral appointments, and provide additional teaching to supplement patient teaching down in institutional setting. 15

16 Village Primary Care 1 st partnership with primary care Focus on complex chronically ill, high risk patients Follow across continuum Disease self-management education Medication review and selfmanagement Evaluate social needs and connect with resources 16

17 IDR Redeployment of Hospital Resources Diabetes Educator 17

18 Lack of insurance/coverage Inability to pay for basic necessities (ex. medications) Homeless/safe housing Psychosocial support (connect with community resources) Substance abuse or mental illness Advance Directives Integrated Social Work 18

19 Clinical Pharmacists 19

20 Community Care Team 20

21 Hemoglobin A1C Level Diabetic Educators: Hemoglobin A1C Reduction Program Wide: Pre & Post Intervention % Reduction in average Hemoglobin A1C post intervention 257 total patients seen by educators 3 practice sites engaged Program Totals 7.16 Average Initial A1C Average Follow-Up A1C 194 patients with pre & post intervention Hemoglobin A1C s for comparison. N = 194 patients 21

22 Pulmonary Rehabilitation Goal: Improve quality of life, ability to manage illness & health status, and restore patient to highest functional ability 71% of participants completed the program Individuals who stayed in the Maintenance Program had a 0% readmission rate for the 3 months after graduation. January 2015 December 2016 N = 77 participants 22

23 Measuring Improvements 63.6% Improvement with dyspnea 67.3% 65.5% 67.3% Improved quality of life Improvement in functional ability to walk 10 meters Improvement in functional ability to walk for 6 minutes 23

24 INTERACT: Reducing LTC Readmissions COLST (Clinician Orders of Life Sustaining Treatment) Auditing & Completion Scheduled procedures & imaging Transfusions, x-rays, labs Hospice or palliative care intervention when appropriate The project described was supported by Funding Opportunity Number CMS-1G from the U.S. Department of 24 Health & Human Services, Centers for Medicare & Medicaid Services.

25 Interdisciplinary Rounds Transitional Care Nurses(TCN) Dieticians VNA Case Management Social Worker Respiratory Therapy Physical Therapy/Occupational Therapy Clinical Nurse Hospitalist Clinical Coordinator 48% of TCN Referrals 25

26 Program Totals: ED Visit Reduction N = 789 patients (August 2013 January 2017) 26

27 TCN Intervention: Reducing Inpatient & Observation Admissions 27

28 Program Totals: Inpatient & Observation Visit Reduction N = 789 patients (August 2013 January 2017) 28

29 Fresh Eyes can see clearly.. Standardized patient education Community Care Team ED Care Plan Medication Reconciliation Community Social Worker Integrated Diabetes Education 29

30 20% Clinical Care 80% Health Behaviors Physical Environment Social & Economic Factors 30

31 Food Insecurity Grateful Heart Project Healthcare Shares Meals on Wheels voucher Leftovers to Food Pantry Summer Meal Program VT Food Bank drop site Campus Garden (food donated to Transitional Care Program) 31

32 32

33 The Keys to Success Culture Communication Creativity 33

34 Partnering Magic Be Patient Educate Embrace Leverage Take Risks Nurse Driven Major Obstacles Housing Food Transportation Health literacy Polypharmacy Engage patients in decisions 34

35 Thank You Barbara Richardson (802)

36 Key Takeaways Evaluate the true needs in your community If you are only focused on clinical aspects of transitions you are missing the full picture Identify gaps Partners can make all the difference Track progress and share findings 36

37 We Want to Hear from You We will open the phone lines so you can pose your questions and share own experiences Review questions, comments, observations from chat 37

38 Interested in Learning More & Connecting with Others - Contact your QIO Care Transitions State Lead Connecticut Shelia Eckenrode seckenrode@qualidigm.org Maine Maureen Leary mleary@healthcentricadvisors.org Massachusetts Dawn Hobill dhobill@healthcentricadvisors.org New Hampshire Tim Boyd tboyd@qualidigm.org Rhode Island Kathy Calandra kcalandra@healthcentricadvisors.org Vermont Gail Colgan gcolgan@qualidigm.org 38

39 Antibiotic Stewardship Upcoming Learning Events Community-Based Approach March 28 th : Lessons Learned - One Provider's Community-Based Antibiotic Stewardship Experience Focus in Long-Term Care February 28 th : Introduction to Antimicrobial Stewardship in Long Term Care: What is Antimicrobial Stewardship and Why is it Important? March 28 th : Antimicrobial Stewardship: Strategies for Implementation April 25 th : Approach to the Patient with Suspected UTI June 1 st : Antibiotic Selection, De-Escalation, and Duration June 27 th : How to Get an A on Your Report Card: Prevention and Management of C. difficile and Other Healthcare Associated Infections July 25 th : Measure Your Success: Monitoring and Tracking Data Learn more, view archived events or register for upcoming session on our event page

40 Connect with the New England QIN-QIO on Social Media! 40

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