Achieving Population Health One Patient at a Time

Transcription

1 Achieving Population Health One Patient at a Time 11/7/16 Jane Russell, RN, MSN, Director of Continuum of Care Karen Haak RN, MSN, NE-BC, CNO Good Samaritan Vincennes, Indiana

2 Learning Objectives Describe how the use of nurse navigators in a Patient Centered Medical Home model can reduce readmissions and decrease unnecessary ED visits. Discuss the effectiveness of multidisciplinary daily huddles, led by nurse navigators, as a tool to achieve the coordination of patient care. 2

3 11/7/16

4 Indiana s First County Hospital 232- Bed Acute Care Hospital Service area includes 9 rural Indiana counties and 4 rural Illinois counties Opened in February 1908 with 25 beds 4

5 Comprehensive Services Along A Continuum of Care 29 Medical and Surgical Sub-Specialties Community Screenings Emergency Medicine Inpatient and Outpatient Services Ambulatory Care Transitional Care Palliative Care Hospice 5

6 Robust Community Outreach Programs Free Screenings Wellness Offerings Clinics for Migrant Workers Who Transition Through the Years 6

7 Mission / Vision / Values Mission: Provide excellent health care and promote healing through trusting relationships. Vision: To be recognized as the regional center of excellence for health care. Values: Pride / Respect / Dignity / Excellece 7

8 11/7/16 Patient-Centered Medical Home

9 Purpose Our team approach provides a health care option with better outcomes and higher patient and employee satisfaction. 9

10 The Model Assertive Community Treatment (ACT) Model Safety Net Medical Home Initiative National Committee for Quality Assurance NCQA) Model 10

11 Benefits Delivers accessible services Shorter waiting times for urgent needs Enhanced in-person hours Around-the-clock telephone or electronic access to a member of the care team Alternative methods of communication if desired 11

12 Accessible Services Considers both physical and social needs of the patient Nurse is available 27/7 when issues arise Open five days a week with late hours on Monday, Wednesday and Thursday After office hours nurse can facilitate access to emergency housing and food by utilizing local resources 12

13 Quality and Safety Medication reconciliation is performed at discharge from hospital and at every visit Education is provided at every visit Environmental assessment for safety is done at admission and when patient circumstances change 13

14 How Does It Work? The patient is seen by a Nurse Practitioner (NP) and may then be referred to a Nurse Navigator for care coordination services Patients who do not receive a navigation referral are monitored at every visit to determine any change in status The nurse navigator completes a thorough assessment in the patient s home (so the patient s environment and social situation can be assessed) and brings it back to the PCMH team The patient s assessment is reviewed at the morning clinic meeting or huddle The entire team reviews the assessment and makes changes to the treatment plan as needed 14

15 How Does It Work? (continued) The patient is followed by the NP, RN, and CM and his/her care is communicated in the daily huddles For patients who have no money to pay for medications, the Good Samaritan Pharmacy has developed a formulary that can be used by the PCMH at hospital cost which ensures patients are able to acquire medication as prescribed Case Managers utilize community resources to help with food, housing and transportation A nurse is available to PCMH patients 24 hours a day, seven days a week which helps build a relationship with the staff and decreases visits to the ER 15

16 Nurse Navigators Advocate for and assist the patients in navigating the health care system Provide care coordination Provide health literacy education Obtain medication and medical supplies Provide nutritional counseling 16

17 Case Manager Provide Self-Managing Skill Development Provide Education on Budgeting Assist with Benefits and Resources Teach Problem Solving Skills Assist with Social Needs (Food, Housing, Employment, etc.) 17

18 Team Approach The Daily Huddle occurs every morning before the clinic opens The first part of the huddle focuses on patients to be seen that day or patients who are in need of assistance that day The second part of the huddle reviews patients discussed the previous day, reports from the office visit or any other patient contact that was made 18

19 11/7/16 Results

20 Financial In the third quarter 2015, ER visits for PCMH patients were reduced by an average of 39 per month Inpatient admissions were reduced by 11 a month Using an average ER charge of $2,082.86, and an average inpatient charge of $9, the Medical Home cost avoidance is now $974,778 for the year The cost avoidance saved in the ER more than covers the cost of running and staffing the medical home 20

21 Patient Satisfaction 93% of patients surveyed in Q4 of 2015 rated the care they received in the PCMH as very good and felt the staff worked very well together to provide very good care 96% reported the likelihood of recommending the clinic to someone else as very high 21

22 11/7/16 Questions?

23 Refrences EBP-KIT/SMA (accessed December 30, 2014) Berwick, D., Nolan, T, & Whittington, J. The Triple Aim: Care, Health, and Cost. Health Affairs 27, No. 3 (2014): centered. (Accessed December 29, 2014) Carver, M. C., Jessie, A., (May 31, 2011) "Patient-Centered Care in a Medical Home" OJIN: The Online Journal of Issues in Nursing Vol. 16, No. 2, Manuscript 4. (accessed December 15, 2014) 23

24 Jane Russell, RN, MSN, Director of Continuum of Care Karen Haak, RN, MSN, NE-BC, CNO 11/7/16