Coordination of Care Initiative East Metro Community

Transcription

1 Coordination of Care Initiative East Metro Community Community Meeting January 17, 2019 Download meeting agenda and slide handout: Agenda Presentation 2 1

2 Welcome Introductions 3 Meeting Agenda and Objectives Discuss coordination of care efforts across MN and review updated data for East Metro beneficiaries Learn how the Post-Acute Mental Health workgroup successfully completed a three-episode behavioral health video training series for post-acute care providers and family caregivers Participate in discussion on how the videos and training can be used across health care settings 4 2

3 Coordination of Care Initiative Update 5 Coordination of Care Initiative Goals Improve quality of care for Medicare beneficiaries who transition among care settings Reduce 30-day hospital readmission rates and admission by 20% by 2019 Increase the number of days at home Establish sustainable, transferrable transition practices across the spectrum of care 6 3

4 Coordination of Care Communities 7 Success Stories Webinar Series This six-webinar series highlights the innovative work the Lake Superior QIN COC partners have done across care settings and in the community to improve transitions of care and reduce readmissions. Successful Strategies for Sustained Community Improvement Tuesday, January 22, 2019, 12 1:00pm More At Your Service: Benefits of Home Health Agencies Working with their QIN Tuesday, February 26, 2019, 12 1:00pm More Using Data to Drive Community Quality Improvement Efforts Tuesday, March 26, 2018, 12 1:00pm Register Home-based Innovative Strategies to Prevent Readmissions Tuesday, April 23, 2019, 12 1:00pm Register Changing the Culture: Improving Recognition and Management of Sepsis Thursday, May 30, 2019, 12 1:00pm Register Achieving Community Goals by Partnering with Aging and Disability Resource Centers Tuesday, June 25, 2019, 12 1:00pm Register Download the webinar series flier. 8 4

5 Other Upcoming Events Webinar: Tobacco Cessation and Lung Cancer Screening (Free) Wednesday, January 9, 11 12:00 pm Register Webinar: All Cause Harm Prevention in Nursing Homes: Applying Strategies from the New CMS Change Package (Free) Thursday, January 24, 2 3:00 pm Register Webinar: Clinical Laboratory Tests, What Do the Results Mean? (Free) Tuesday, January 29, 12:00 1:00 pm Register Partner Event: 2019 Minnesota Cancer Alliance Summit ($60-85) Thursday, February 28, McNamara Alumni Center (U of M) Register 9 Community Scorecard 10 5

6 The Community 11 Admissions (community) 12 6

7 Admissions (comparative) 13 Admissions (vs. goal) 14 7

8 Number of Fewer Admissions Needed to Meet Goal This community had 20,074 admissions in the most recent 12 months (Q Q2 2018). Need to be at 18,785 admissions for final measurement (Q Q3 2018), which is 1,289 fewer readmissions than the current rate. That s 430 fewer admissions/month if continue at current rate. 15 Readmissions (community) 16 8

9 Readmissions (comparative) 17 Readmissions (vs. goal) 18 9

10 Number of Readmissions Needed to Meet Goal This community had 3,578 readmissions in the most recent 12 months (Q Q2 2018). Need to be at 3,203 readmissions for final measurement (Q Q3 2018), which is 375 fewer readmissions than the current rate. That s 125 fewer readmissions/month if continue at current rate. 19 ED Visits (community) 20 10

11 ED Visits (comparative) 21 Next Community Meeting Date and time of the next community meeting is to be determined. Stay tuned for an announcement from Stratis Health

12 Featured Presentation Mental Health Video Training Series and Tools Dean Neumann, APR Community Relations Director HealthEast Care System St. Joseph s Hospital Mental Health and Substance Use Services 23 Post-Acute Care Mental Health Training Series Stratis Health East Metro Coordination of Care Quarterly Meeting January 17,

13 Presenter and Objectives Dean Neumann, Community Relations Director St. Joseph s Hospital Mental Health and Substance Use Services Objectives: Understand why the series was developed Understand how best to use the videos and written teaching aids Understand the timing and sequence of the information Background Lake Superior East Metro Coordination of Care Committee presentation September 2017 Providers voice concern about caring for persons with intense mental illness symptoms Workgroup Formed Identify training needs, experts, content and format Video Series Stratis Health Grant 13

14 Target Audiences For care providers and caregivers especially those without formal clinical training programs Assisted living direct care staff Family caregivers Home care nursing staff Home care chore staff Nursing facility nursing assistants Residential care staff Training Goals Boost understanding of older adult mental health Equip providers and caregivers with techniques to prevent and de-escalate behavioral crises that may lead to unnecessary hospitalization Improve behavioral / mental health outcomes for older adults Encourage more education and training CARE PROVIDERS OF MINNESOTA Leading Members to Excellence #CPMEducates 14

15 Advisory Group Michelle Wincell O Leary Touchstone Mental Health Patti Cullen Care Providers of Minnesota Peter Thelen Andrew Residence Dean Neumann St. Joseph s Hospital Kay King NAMI Minnesota Aira Wandamacher CareChoice Cooperative Janelle Shearer Stratis Health Nancy Miller Stratis Health Jane Gendron Stratis Health Teresa Lewis MN DHS Julie Apold Leading Age Minnesota Barb Jeroski - HealthStar Home Health Leslie Brown Tealwood Senior Living CARE PROVIDERS OF MINNESOTA Leading Members to Excellence #CPMEducates Older Adult Mental Health Basics Video #1 in a series 15

16 Prevention & De-escalation Video #2 in a series Person-centered care and collaboration Video #3 in a series 16

17 Facilitator Guide Video Quiz Two Methods Fill-in during viewing open book test Provide quiz after viewing Answer Checking Self-score after taking the quiz Facilitator scores Time codes listed in answer sheet for each quiz question 17

18 Fact Sheet Handout separately or Post on bulletin boards / provider common areas Action Checklist Pocket-size reminder card Carry and apply during daily work 18

19 Sample Plans and Templates Geriatric Depression Screening Tool Sample Crisis Prevention Plan Person-centered Care Plan Template Overview of Three Videos Older Adult Mental Health Basics Explain common mental illness disorder categories share the compelling statistics - address the fear and inadequacy many providers and caregivers feel confront stigma and derogatory labels express hope and treatment can be effective convey how you as a care provider or family caregiver - can support provide resources for more help. Crisis Prevention & De-escalation Describe common behaviors and triggers likely to cause behavioral events Suggest prevention tips to reduce behaviors - Demonstrate right way / wrong way de-escalation scenarios - how to apply new learning after an event offer additional resources. Person-centered care & collaboration Importance of individual behavioral care plan - creative solutions to diminish / redirect behaviors - when to consult with outside professionals for behavioral assessments / evaluations offer additional resources 19

20 Video Training Series Locations Video Highlights 20

21 What Worked? Sponsoring organization Phenomenal workgroup Longer planning period yielded better content Excellent video production company On-camera talent and location shooting Unforeseen Challenges Longer planning period than anticipated Search for funding Prioritizing topics, content and experts Balancing clinical focus with audience health literacy Cost constraints 21

22 Advice For Similar Projects Find a good project manager Timeline takes longer when you re doing something new Be over-inclusive to insure key stakeholder buy-in Volunteers have limited time trade-off between time and budget Everyone brings strengths to the table Some will be disappointed Be willing to be a long-term champion Some may do more work than others Don t get paralyzed - Just Do It Contact Dean Neumann St. Joseph s Hospital Director of Community Relations deneumann@healtheast.org Phone:

23 Discussion How can the videos and training be used in various health care settings? 45 Contact Information Nancy R. Miller or Janelle Shearer

24 This material was prepared by the Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MN-C