Care Coordination in a no discharge system

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1 Care Coordination in a no discharge system Barry Bittman, MD Estes Park Institute Let s begin with a basic question. Who should be responsible? How can we align physicians with our hospital?

2 Can we continue to operate independently? Recalibrating Our Work For better or worse, I have come to believe that we patients, families, clinicians, and the health care system as a whole would all be far better off if we professionals recalibrated our work such that we behaved with patients and families not as hosts in the care system, but as guests in their lives. I suggest that we should without equivocation make patient-centeredness a primary quality dimension all its own, even when it does not contribute to the technical safety and effectiveness of care. Donald Berwick, MD

3 Care Coordination How does it work? Patient Identification Hospital Admission/ Discharge Practitioner Workplace Screening Needs Assessment Screening Appointment Adherence Review Medication Usage/Errors Behavioral/Emotional Functioning Cognitive Functioning Nutrition Evaluation Preventive Health Evaluation Activities of Daily Living/Challenges Community Resources Identification Interdisciplinary Team Evaluation PCP Coordinated Care Plan Specialists Care Coordination Health Coaching & Support Adherence Enhancement Medication Reconciliation Early Symptom Detection Readmission Prevention Education Interval and Longitudinal Assessment and Feedback

4 Screening SEMAPS socioeconomic educational medical-mental health adherence potential psychosocial risk factors support CCN Strategies ongoing caregiver relationships that foster trust in-home coaching aligned with the patient s goals real medication reconciliation early detection and timely appropriate care healthy lifestyle and prevention strategies meaningful use communications outcomes-based metrics an overarching system-wide commitment Early Insights Discharge summaries often appear nebulous. Medication reconciliation errors are ubiquitous. Symptoms are frequently poorly understood. Limited access to care often results in significant delays. Adherence can progressively be modified by developing meaningful caregiver relationships. Physician to physician communication challenges interfere with best practice strategies.

5 HEALTH COACHES: Who benefits? patients community physicians hospital educational institutions insurers Action Plan Begin with the end in mind.

6 Perhaps the most important lesson I have learned from the health-coaching program with the Community Care Network thus far is to realize ways in which I can become a better healthcare professional in the future. Everything we have learned in the past two semesters is important to providing the best care for patients. Actively listening to concerns is invaluable. It is impossible to know a person s full lifestyle and stressors during a short doctor s appointment or speaking with them in a hospital. However, keeping an open mind to what a patient may be experiencing, and remembering their barriers, can help ensure they are getting the best care. Good health may not always be defined by tests showing if a patient is free of disease, but by the methods in which the community is meeting the overall needs of a patient. - SM Thank You

7 TringaleHealthStrategiesLLC Care Coordination as Core Business CARE COORDINATION, IT'S CORE BUSINESS NOW Steven J. Tringale, President & CEO Tringale Health Strategies, LLC November 6, 2012 Quality and Outcome Requirements Medicare Readmission Penalties Readiness Assessment for Population Health Management/Risk Care Coordination as a product Care Coordination as a benefit/insurance Product Design Business Advantages of Care Coordination Care Coordination and Payer Strategy Improved relationship and alignment with physician organization Higher patient satisfaction scores Higher productivity of professional staff Better outcomes, higher quality scores All of these factors can translate into significant income opportunities for hospital and physicians Payer movement toward quality and efficiency in contract models requires care coordination Opportunities for ROI from care coordination Improved performance against budget targets Improved performance against quality targets (hospital & physicians) Direct Infrastructure Payments (ppm or lump sum) Direct to Employer/Payer Joint Venture Revenues (admin $'s) Care Coordination and Payer Strategy - Product Options Care Coordination is a Core Competence Requirement for Hospitals / Systems Payers will soon incorporate care coordination in product design Hospitals/Systems given preferred status or "tier" (volume) Access to payers complete product portfolio (volume) Medicare Advantage/Managed Medicaid/National Account Preferred status on Exchanges (1/1/2014) for products with care coordination (volume) Improved hospital/physician alignment Improved payer strategy and leverage Improved volume opportunities Improved status/diminished risk in age of data transparencies Medicare read mission data, payer and exchange public data CARE COORDINATION IS CORE AND STRATEGIC

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