Care Coordination as a Team Sport. Sharon Quinlan MS, MBA, RN, NEA-BC November 3, 2017
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1 Care Coordination as a Team Sport Sharon Quinlan MS, MBA, RN, NEA-BC November 3, 2017
2 Objectives Explain critical elements of coordination and teamwork and their relationship to quality outcomes Describe local and industry care coordination best practices Identify inter-professional care models and key ingredients for success
3 Case Study #1 76 year old male with COPD Retired pharmacist; stable family unit Lifetime smoker Problem list: s/p prostate cancer; hernia repair Hypertension Emphysema/COPD Eczema; Foot pain Involved: PCP; pulmonology; urologist; surgeon Clinical course: smoked until oxygen dependent; poly-pharmacy; recurrent pneumonias with frequent hospitalizations; expired after 2 week ICU stay
4 Case Study #1 Care Coordination Story No follow up to positive prostatectomy bx No aggressive smoking cessation efforts No end of life planning Quality of life issues related to medication side effects, skin discomfort and foot pain unaddressed Lack of medical continuity extended endof-life decision making and hospital stay
5 Case Study #2 72 year old female AMI, renal failure Widow, retired government employee Two children living out of state Problem list S/p nephrectomy at age 52 Mild cognitive impairment Adult onset diabetes controlled orally S/p AMI Renal failure on dialysis Involved: PCP; cardiologist; nephrology, PT, OT, nursing, SW, Case Manager; neurology, infectious disease Clinical Course: AMI at age 72; renal failure secondary to coronary catheterization; expired after 3 month hospital stay
6 Case Study #2 Care Coordination Story Treated for depression; no screening for cognitive impairment Missed communication r/t nephrectomy Multiple transfers between ICU, med-surg and rehab units led to poor continuity of care plan, discharge planning No medical captain of the ship; no overall plan for care; goals of care discussed only after family request Family involvement in decision making not optimized
7 Outcomes of Care Coordination Patient & family satisfaction Reduced over/under utilization Lowered lengths of stay Decreased readmissions Patient safety, fewer errors Duplication and care gaps eliminated G. Lamb 2015
8 Poor Coordination Costing Us Billions Nationally Difference Between Loosely-Managed and Well-Managed PMPM 1 Spending 2 Medicaid Commercial Medicare $ $ $ Loosely Well Managed Managed Loosely Well Managed Managed Loosely Well Managed Managed $12B $25B-$45B Estimated annual cost of preventable Estimated annual amount of wasteful spending 30-day hospital readmissions resulting from inadequate coordination 2 1. Per member per month The Advisory Board Company advisory.com 29760D Source: Milliman; Health Affairs, Health Policy Brief: Care Transitions, 2012, healthpolicybriefs/brief.php?brief_id=76; Nursing Executive Center interviews and analysis.
9 Financial burden Health care growth as a percent of GDP
10 Care Coordination is essential to achievement of the Triple Aim
11 Key Findings 1 of 5 out Responsibility Importance Coordinate with doctor/care team 49% Least comfortable with navigating the healthcare system compared to other common consumer activities Navigate system Knowledge / advice Transition assistance 36% 36% 36% Title Information Prioritization top of mind suggested title #1 Patient Advocate Word Preference coordinator 2:1 navigator Consumer Insights Health Share Nursing Care Coordination Role Alignment - Naming Study 11 patient 10:7 care
12 National Dialogue: Care Coordination & Quality National Priorities Partnership: IOM, IHI, NCQA.. And 25 more Emphasis on outcomes rather than care processes More direct measures of the patients voice in relation to their experiences Priorities involving the continuum of care
13 National quality priorities National Quality Forum National Priorities Partnership Safety Patient Engagement End-of-Life Planning Care Coordination Overuse Population Health
14 Care Coordination Defined National Quality Forum 2014 Care Coordination is the deliberate synchronization of activities and information to improve health outcomes by ensuring that care recipients and families needs and preferences for healthcare and community services are met over time.
15 Advocacy AAACN Education and engagement of patients and families Coaching and counseling Patient-centered care planning Support for self-management Nursing process Teamwork and collaboration Cross-setting communication Population Health Management Commonwealth Fund Specific care coordination outside visit Manages continuous communication Completes/analyzes assessments Develops care plans with families Tracking tests, referrals and outcomes Coaches patients and families Integrates critical care information Supports/facilitates care transitions Team meetings Uses health information technology
16 Key Principles Patient/family-centered Engagement, collaboration Continuum of Care-focused Communication Deliberate planning around hand-offs Teamwork Need for HIT/EMR development
17 Target Interventions Transitions in care Care coordination for high risk groups Community-based programming Care Planning and goal setting Create a system that never discharges a patient
18 Enter Title Text Here November 27, We must create and support a coordinated TEAM approach to delivering health care The increased complexity of health care makes it no longer possible for one individual or discipline to manage all aspects of patient care. Preventive Med Intervention Chronic Disease Monitoring Medication Refill New Acute Complaint Test Results Medication Refill Chronic Disease Monitoring Test Results New Acute Complaint Preventive Med Intervention Point of Care Testing Acute Mental Health Complaint Chronic Disease Compliance Barriers Provider VS Healthcare Support Team Case Manager Mental Health Provider Referral to Specialist after Assessment Certified Medical Assistant Healthcare Support Team Case Manager Provider Certified Medical Assistant Behavioral Health Consultant All work funnels through physician Integrated team approach
19 Principles of Team-based Healthcare
20 Inter-professional Models
21 Coverage to Care Program Overview Purpose To provide a comprehensive approach to care management for patients atrisk for high ED utilization due to the impact of social determinants Objectives To reduce non-emergent use of emergency services To help patients establish care with a primary medical home To help patients achieve greater stability at home and in the community Target Population ED High utilizers (3+ visits in 30 days; 5+ visits in 90 days; 11+ visits in 12 months) significantly impacted by social determinants Scope of Services Intensive social work case management and care coordination Follow-up in-home and incommunity as needed Duration of Services Usual care = 4 6 months Highest need = 6 12 months Referral Sources ED Care Team EPIC
22 6 Month Outcomes for Aurora Sinai and St. Luke s Medical Centers Coverage to Care Charges Visits Net Change 0-6 Months 6 mo Pre 6 mo Post6 mo Pre 6 mo Post Charges Visits ASMC Cohort #1 (47 patients) 3,453,368 1,469, % -50% ASMC Cohort #2 (55 patients) 3,759,606 2,005, % -30% ASMC Cohort #3 (28 patients) 1,410, , % -34% ASMC Cohort #4 (23 patients) 1,372,721 1,565, % -23% ASLMC Cohort #1 (64 patients) 4,373, , % -68% ASLMC Cohort #2 (38 patients) 1,363, , % -58% 255 Total Patients Measured ED charges were reduced by 44% ($8,565,335) Patients reduced the number of ED visits by 46% (1585 visits)
23 Coverage to Care Key Partners Aurora Health Care ED Care Team Hospital Social Services RN Case Management Behavioral Health/ Intake; Community-Based Case Management Aurora at Home Primary and Specialty Care Providers Population Health Government Affairs EPIC Team Project Management Aurora Senior Leadership
24 Coverage to Care Contact Information AFS Integrated Family Support Services Robert W. Marrs, MS, LMFT - Manager 3200 W. Highland Blvd. Milwaukee, WI Phone: robert.marrs@aurora.org
25 Primary Care Traditional Model Patient sees primary care provider in office Patient is scheduled to see PCP Treatment Regimen Patient is discharged from hospital Patient has an episode Patient is admitted as Inpatient Patient goes to ER
26 Team-based Primary Care Health Coach RN performs outreach call Health Coach RN coordinates team members for the patient (Pharmacy, Home Care etc.) Patient arrives for primary care visit Health Coach RN continues to follow schedule and work with pt. daily or weekly Patient sees Health Coach RN & Provider (co-visit) Team develops the tx plan and visit schedule
27 Primary Care Team High Risk Care Coordination All Patients: Change in utilization Readmissions Period n Sum of Total Percent Period start /finish Readmits Utilization 8/13 through 7/14 65/ % 8/14 through 7/15 Inpatient Admissions 484/ % Sum of Total IP Percent Period Admits Utilization 8/13 through 7/ % 8/14 through 7/ % ED Visits Period Sum of Total ED Visits Percent Utilization 8/13 through 7/ % 8/14 through 7/ % IP Change Readmit Change Readmit Utilization Change -1.54% -48.8% Percent IP Utilization Change -2.44% -22.5% ED Change Percent ED Utilization Change 0.01% 0.2% All Patients August 2013 through July 2014 & August 2014 through July 2015
28 Community-Based Case Management Naylor Model 1 Yr. Before Start Date ED Visits Inpatient Admissions Inpatient Days Day Readmits After Start Date Change 20% decrease 35% decrease 24% decrease 48% decrease Medicare Impact 2014 n = 105
29 Community Paramedic Program Objective Reduce 30 day readmission of defined program patients 65 and older in service market area Improving transitional patient care Building a community network Demonstrate ROI on cost of program Demonstrate reduction in 30 day readmission
30 Community Paramedic Program PRELIMINARY OUTCOME: Transition in Care Community Paramedic Program 86% did not readmit during enrollment Potential cost savings per preventable readmission: Source: Weighted national estimates from a readmissions analysis file derived from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID), 2009, Agency for Healthcare Research and Quality (AHRQ).
31 Other strategies: EMR Development Kaiser Permanente LPOC
32 34
33 PATIENT S CARE TEAM 35 Established relationships both inside and outside of KP Relationship with the patient, i.e. Main Point of Contact, will let the patient, family and other members of the team know your role. Specialty, i.e. Medical Oncology, will let everyone know how you may be involved. Comments with phone number and pool number.
34 The human and societal costs of inadequate care coordination are high Systems change must be planned and deliberately focused on coordinated care Designs necessary for coordinated care are complex Teamwork is fundamental
35
36 References Priority Setting for Healthcare Performance Measurement: Addressing Performance Measure Gaps in Care Coordination NQF August 2014; _Measurement Addressing_Performance_Measure_Gaps_in_Care_Coordination.aspx Making care coordination a critical component of the Pediatric health system: a multidisciplinary framework. Richard C. Antonelli, Jeanne W. McAllister, and Jill Popp. May Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; (Available on National Priorities Partnership Setting a National Agenda for Healthcare Quality and Safety Karen Adams, PhD Institute of Medicine February 10, n.pdf AHRQ Team STEPPS The value proposition for investing in RN Care Coordination and transition management in ambulatory care settings. Haas,S, Swan,B.A., Haynes,T. American Academy of Ambulatory Care Nursing (AAACN) 40 th Annual Conference 2015.
37 References, cont. Mangus, M., Presentation: EPIC UGM Coordinating Care & Managing Transitions through a Longitudinal Plan of Care Navigating the C s: Collaborative Care Coordination. Lamb.G. Keynote: Steering the Future of Care Coordination. Wisconsin Center for Nursing 5 th Annual conference. June 12, American Association of Ambulatory Care Nurses Curriculum: Care Coordination and Transition Management (CCTM) 2014 Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach, and I. Van Kohorn Core Principles & Values of effective team-based health care. Discussion paper, Institute of Medicine. Washington, DC. Lamb, G. Presentation: Steering the Future of Care Coordination. Wisconsin Center for Nursing Annual Conference. Navigating the C;s: Collaborative Care Coordination.. June, 2015.
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