Quarterly Community Meeting. Barb Averyt, BSHA Director, Care Coordination and Nursing Homes Health Services Advisory Group (HSAG) July 14, 2016

Transcription

1 Quarterly Community Meeting Barb Averyt, BSHA Director, Care Coordination and Nursing Homes Health Services Advisory Group (HSAG) July 14, 2016

2 Today s Agenda Welcome and Introduction Community Updates Workgroup Updates We Hear You! Evaluation Debrief Best Practice Intervention Package CMS * Updates Meeting Feedback and Evaluations 2 *Centers for Medicare & Medicaid Services (CMS)

3 Who Is at Our Table? 3

4 Community Updates Barb Averyt, BSHA Director, Care Coordination, HSAG Jenna Burke, BS, CHES Quality Improvement Specialist, HSAG

5 Your Meeting Feedback Is Important! Please help us exceed the 85% target! Evaluation Completion Rate 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 90% 91% Feb Kickoff April July 5

6 Membership April Organizations to Date 1. Archstone Care Center 2. Arizona Care Network 3. Arizona Health-e Connection 4. Arizona Home Care 5. Arizona Orthopedic & Surgical Specialty Hospital 6. Arizona Spine and Joint Hospital 7. Arizona Living Well Institute 8. Assisted Home Health 9. Assisted Living Locators 10. Brookdale North Chandler 11. Chandler Fire, Health & Medical Department 12. Chandler Post Acute & Rehabilitation 13. Chronic Care Community Partners 14. Citadel Post Acute Care Center 15. City of Mesa Fire and Medical Department 16. ComForCare 17. Crisis Preparation and Recovery, Inc. 18. Desert Blossom Health & Rehabilitation Center 19. Dignity Health Mercy Gilbert Medical Center 20. Dignity Health Chandler Regional Medical Center 21. Foundation for Senior Living 22. Gentiva Home Health 23. Gilbert Fire & Rescue 24. Golden Heart Senior Care 25. Healthsouth South East Valley Rehabilitation Hospital 26. Home Instead Senior Care East Valley 27. Hospice of the Valley 28. Mikell Christian, Patient Representative 29. IPC Healthcare, Inc 30. KC's Home Health Care LLC 31. La Estancia Nursing and Rehabilitation Center 32. Montecito Post Acute Care and Rehabilitation 33. Mountain Vista Medical Center 34. Neighbors Who Care, Inc. 35. Oasis Behavioral Health 36. Plaza Healthcare 37. Serenity Hospice and Palliative Care 38. Team Select Home Care 39. Universal Care Management 40. Valley Transitional Care 41. Vitalyst Health Foundation 42. Wellsprings of Gilbert 6

7 Membership June Organizations to Date 1. Archstone Care Center 2. Arizona Care Network 3. Arizona Health-e Connection 4. Arizona Home Care 5. Arizona Orthopedic & Surgical Specialty Hospital 6. Arizona Spine and Joint Hospital 7. Arizona Living Well Institute 8. Assisted Home Health 9. Assisted Living Locators 10. Brookdale North Chandler 11. Chandler Fire, Health & Medical Department 12. Chandler Post Acute & Rehabilitation 13. Chronic Care Community Partners 14. Citadel Post Acute Care Center 15. City of Mesa Fire and Medical Department 16. ComForCare 17. Crisis Preparation and Recovery, Inc. 18. Desert Blossom Health & Rehabilitation Center 19. Dignity Health Mercy Gilbert Medical Center 20. Dignity Health Chandler Regional Medical Center 21. Foundation for Senior Living 22. Gentiva Home Health 23. Gilbert Fire & Rescue 24. Golden Heart Senior Care 25. Healthsouth South East Valley Rehabilitation Hospital 26. Home Instead Senior Care East Valley 27. Hospice of the Valley 28. Mikell Christian, Patient Representative 29. IPC Healthcare, Inc. 30. KC's Home Health Care LLC 31. La Estancia Nursing and Rehabilitation Center 32. Montecito Post Acute Care and Rehabilitation 33. Mountain Vista Medical Center 34. Neighbors Who Care, Inc. 35. Oasis Behavioral Health 36. Plaza Healthcare 37. Serenity Hospice and Palliative Care 38. Team Select Home Care 39. Universal Care Management 40. Valley Transitional Care 41. Vitalyst Health Foundation 42. Wellsprings of Gilbert 43. Visiting Angels 44. Homewatch CareGivers of Tempe 45. Arizona in Home Care Association (AZNHA) 46. Gap Care Solutions 47. Stepwell 48. Vanguard Mobile Physicians 49. Centrix Health Resources 50. Reflections Hospice 51. Sunrise Health Services 52. Doves Senior Care 53. The Center at Val Vista 7

8 Where Can You Find Materials for Past and/or Today s Meeting? Go to: 8

9 Find the Date of the Event and Click on the Title 9

10 Choose the Download 10

11 Workgroup Updates Roxanne Dudish, BA, RN Director of Care Coordination, Dignity Health Chandler Regional and Mercy Gilbert Medical Centers

12 Root-Cause Analysis (RCA) Topics That Drive Workgroup(s) Development RCA Topic 1. Care Coordination Workgroup 2. Medication Management/Medication Reconciliation Workgroup 3. Health literacy and teach-back 4. Hand-off transitional communication 5. Community Resource Guide, including behavioral health resources 6. Hospice palliative care and education regarding palliative/hospice 7. Behavioral health Workgroup Status 12

13 Workgroup Updates What When Who 1. Care Coordination Workgroups A. Hospital Nursing Home (See meeting detail on next slide) Launched February 2016 and meets monthly Roxanne Dudish, BA, RN, Director of Care Coordination, Dignity Health, Chandler Regional and Mercy Gilbert Medical Centers HSAG Staff B. Hospital Home Health (See meeting detail on next slide) C. Community Transitions Hand-Off (See meeting detail on next slide) 2. Teach-Back Workgroup To impact all providers and first responders in community Launched June 2016 and meets monthly Brainstorming session at the November 9 Quarterly Meeting Pended until 2017 Roxanne Dudish, BA, RN, Dignity Health HSAG Staff Community Paramedicine and EMS Transitional Care Services Palliative Care AzHealthE Connection Non-medical Home Care Arizona Care Network ACO TBD 13

14 Dignity Nursing Home Care Coordination Committee Six Months At-A-Glance What Nursing Home Care Coordination Committee kick-off event Dignity Town Hall meeting Dignity Updates: Emergency department program update Internal readmissions team: structure and goals ACN (Dignity s Accountable Care Organization) update Discussion with nursing homes regarding upcoming changes in 5 Star Ratings When February 29, 2016 March 22, 2016 April 5, 9:30 11:00 a.m. HSAG s Composite Score and Nursing Home Readmission Reports (Quarterly) Impact of composite score and Star Rating May 17, 9:30 11:00 a.m. Introducing and training on the HSAG Medication Reconciliation Tracking Tool Open discussion Dignity Town Hall meeting June 21, 9:30 11:00 a.m. July 6, 8:00 10:00 a.m. Heart failure (HF) educator and creating protocols for nursing homes Open discussion August 16, 9:30 11:00 a.m. 14

15 Dignity Home Health Care Coordination Committee Six Month At-A-Glance What Home Health Care Coordination Committee kick-off Event Shared the Dignity Emergency department program update Internal readmissions team: structure and goals Future Plans for Transitional Care Clinic Dignity Town Hall meeting for all post-acute providers June 6, 2016 When July 6, 2016, 8:00 10:00 a.m. HSAG presents Home Health Readmission Data August 4, 9:30 11:00 a.m. Agenda TBD Dignity Town Hall meeting Agenda TBD Agenda TBD September 1, 9:30 11:00 a.m. October 4, 8:00 10:00 a.m November 3, 9:30 11:00 a.m. December 1, 9:30 11:00 a.m. 15

16 Community Transitions Hand-Off Workgroup November 9 Quarterly Meeting presentations: Transitional care management services Arizona Health-E Connection case study HSAG data of super users in the community Brainstorming session to develop the next steps for this workgroup 16

17 In Summary RCA Topic Workgroup Status 1. Care Coordination Workgroup Managed through three workgroups (Nursing Home, Home Health, and Community Hand-Offs) 2.Medication Management/Medication Reconciliation Workgroup Managed through Nursing Home Workgroup 3. Health literacy and teach-back Pended until Hand-off transitional communication Merged into Care Coordination Workgroup 5. Community Resource Guide, including behavioral health resources 6. Hospice palliative care and education regarding palliative/hospice Remains on list but no capacity at this time Remains on list but no capacity at this time 7. Behavioral health Remains on list but no capacity at this time 17

18 20-Minute Break 18

19 We Hear You! Evaluation Debrief Joan Bowman, MPA, BSN, RN, CCM Nurse Case Manager Arizona Orthopedic and Surgical Specialty Hospital

20 We Hear You! Evaluation Debrief Steering Committee reviewed the evaluations from the 4/21/16 Quarterly Meeting. Highlights: 91% completion rate Evaluation Results (Scale of 1-4 with 4 = Strongly Agree and 1 = Strongly Disagree) Evaluation Completion Rate of 60 = 91% Overall = 3.5 or 88 % Q1. The data were presented in a way that helped me 3.6 or understand readmissions in the. 90% Q2. I have a clear understanding of the current community 3.5 or paramedicine programs in the. 88% Q3. I have a clear understanding of the current workgroups in 3.4 or the. 85% 20

21 We Hear You! Evaluation Debrief (cont.) Comments Most Useful Overwhelming appreciated the Community Paramedicine information and learning about the resource they provide. Many comments about: Sharing information Learning about other resources available in the community Data presentation so the community understands the status of readmissions in the. 21

22 We Hear You! Evaluation Debrief (cont.) Comments How to Improve More opportunity for discussion Learn about other community providers and what they do Use fewer acronyms and more words so all understand what is being said Not completely clear about the goal of the workgroups Learn about community resources More brainstorming Provide ice tea in addition to coffee and water 22

23 We Hear You! Evaluation Debrief (cont.) How to improve What we are doing about it Not completely clear about the goal of the workgroups More opportunity for discussion Allowed more time for work-group discussion and moved it to the front the agenda so it is not rushed More brainstorming Structuring the November Quarterly meeting to be a brainstorming session Learn about other community providers and what they do Will profile community providers and the services they can provide, hopefully one at each meeting Learn about community resources Sharing community resources starting today Use fewer acronyms and more words so all understand what is being said Provide ice tea in addition to coffee and water Facilitator will keep an ear tuned for acronyms and ask for definitions when used 23

24 Best Practice Intervention Package (BPIP) Heart Failure Barb Averyt, HSAG Debra Buehler, MA Executive Project Manager, HSAG

25 Welcome to the HHQI National Campaign Since 2007, the Home Health Quality Improvement (HHQI) National Campaign has been dedicated to improving the quality of care provided to America s home health patients. Whether you are a home health practitioner directly providing patient care, or an allied partner with a stake in improving the quality of care that home health patients receive, we are here to help you with evidence-based tools and a wealth of ongoing educational opportunities. Most of the information can be utilized by other provider settings and all of the resources are absolutely free and available to everyone. 25

26 Educational Resources Best-Practice Intervention Packages (BPIPs) Evidence-based resources Adaptable to all settings Contain useful information for home health nurses, medical social workers, therapists, and aides Interactive with videos Resources are often translated and available in Chinese, Russian, Spanish, Vietnamese 26

27 BPIP Topics Cardiovascular Health (Part 1 and 2 and At-Risk Populations) Blood Pressure Control and Smoking Cessation Disease Management: Heart failure Disease Management: Diabetes Underserved Populations Focused: Patient Self- Management Fundamentals of Reducing Acute Care Hospitalizations Improving Management of Oral Medications Fall Prevention Cross Settings I, II, and III Medication Management Immunization/Infection Control Disease Management: Part 1 and 2 27

28 Make it Your Own Customize many of these materials with your organization s logo or make changes to meet your individual needs. There are no copyrights on any of the HHQI Campaign s original material. Resources are free, but you have to sign up for the HHQI Campaign to access them. 28

29 Scavenger Hunt Goals 1. Select a spokesperson for your table. 2. Each table will review a specific section of the BPIP. 3. As a team, conduct a scavenger hunt of the BPIP and web sources from the BPIP. 4. Prepare a 5-minute presentation for the group that informs us about your section and answers the following questions. 29

30 As a Group, Discuss Your Thoughts Regarding These Questions 1. What new information about Heart Failure did you learn from reviewing your section? 2. What two resources do you think everyone in this meeting needs to know about? (Be prepared to mention the page number) 3. What resources or ideas in this BPIP could be acted on next week and for what health care setting? 30

31 HSAG and the HHQI National Cardiovascular Campaign Benefits: Participation has allowed HHAs to achieve measurable improvements in the cardiovascular health of their patient populations Aligned with the Million Hearts National Campaign Data-driven and evidence-based resources Staff can earn continuing education credits at no cost Use of HHQI s educational tools and resources Attend quarterly Learning and Action Network webinars Participate in the monthly Live Chat sessions and learn best practices Obtain no-cost technical assistance 31

32 HSAG and the HHQI National Cardiovascular Campaign (cont.) Next Steps: Join HHQI at Assign a staff member to register for data access and perform monthly data abstraction into the Home Health Cardiovascular Data Registry (HHCDR) Select focus areas: Aspirin, Blood Pressure Control, Cholesterol Management, and Smoking Assessment and Cessation (ABCS) Review HHQI data monthly and share with staff 32

33 Immunization Initiative Aligns with Healthy People 2020 Goals 70% national absolute rate for influenza by % national absolute rate for pneumonia by 2019 Individuals with heart disease are at a higher risk for pneumonia Pneumococcal immunizations should be monitored all year Always verify immunization status, never assume Always document immunization status, refer or offer Immunizations tied to Five Star Ratings HHQI immunization data reports include influenza and pneumococcal Join initiative to receive no-cost technical assistance and educational resources 33

34 Questions? Regarding HHQI: Debra Buehler, MA Executive Project Manager, HSAG

35 CMS Updates Ettie Lande, RN, BSN, MS Associate Director Care Coordination, HSAG

36 Shifting Medicare Healthcare Payments from Volume to Value Alternative Payment Models (Categories 3 4) FFS linked to quality (Categories 2 4) All Medicare FFS (Categories 1 4) % 22% 30% 50% 68% 85% 85% 90% Historical Performance Goals 36 Source: The Centers for Medicare & Medicaid Services

37 Hospital Readmission Reduction Program (HRRP): Saves Medicare $100 Million More in FY * ,603 $532 million Number of hospitals CMS estimates will have their DRG ** payments reduced by their FY 2017 hospital-specific readmission payment adjustment factor Amount CMS estimates the HRRP will save the Medicare program in FY 2017, ~$100 million over the estimated FY 2016 savings Savings primarily due to Refinement of the pneumonia readmissions measure in FY 2016 Addition of the coronary artery bypass graft surgery (CABG) readmission measure in FY *Fiscal Year (FY) **Diagnosis-related group (DRG) Source:

38 Medicare s Hospital Compare Website 38

39 Medicare s Hospital Compare Website (cont.) Select area of interest: Compares the hospital s rates to national rates For example, included in readmissions and deaths: Measures of 30-day unplanned readmissions Measures of 30-day deaths (mortality) For these medical conditions: heart failure, heart attack, chronic obstructive pulmonary disease, pneumonia, and stroke For this surgical procedure: coronary artery bypass graft 39

40 Nursing Homes

41 Medicare s Nursing Home Compare Website 41

42 Nursing Home Compare: Six New Quality Measures Posted April 2016 New short stay quality measures: Discharge to the community (claims based) Emergency room use/observation stays (claims based) Re-hospitalization (claims based) Improvement in function since admission (Minimum Data Set [MDS] based) New long stay quality measures: Decline in mobility (MDS based) Use of hypnotics/anxiolytics* (MDS based) *All new quality measures will be added to five star except Use of hypnotics/anxiolytics 42 Press-releases-items/ html

43 Home Health

44 Home Health Value-Based Performance: Pay-for-Performance Demonstration Model A new Home Health Value-Based Purchasing Mandatory Program (HHVBP) implemented January 1, 2016, for all home health agencies in nine states: Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee Chosen randomly and participation is mandatory Payment adjustments annually (based on performance) can either go up or down by up to 3% beginning in 2018 and as high as 8% in 2022 CMS projects about 43% of home health agencies will have negative margins by Sources: CMS.gov - Home Health Value-Based Purchasing Model and

45 Medicare s Home Health Compare Website 45

46 Medicare s Home Health Compare Website (cont.) The information on Home Health Compare helps consumers learn: How well home health agencies care for their patients How often each agency used best practices when caring for its patients and whether patients improved in certain important areas of care What other patients said about their recent home health care experience 46

47 Final Discussion and Next Steps Jenna Burke

48 Your Meeting Feedback Is Important! Please help us exceed the 85% target! Evaluation Completion Rate 100% 95% 90% 85% 80% 75% 70% 65% 60% 55% 50% 90% 93% Feb Kickoff April July 48

49 Quarterly Community 2016 Meetings Meeting Date and Time Where Registration Required Kick Off Monday February 8, 2016 Thursday April 21, :30 11:30 a.m. Thursday July 14, :30 11:30 a.m. Tuesday September 20, 2016 Statewide Fall 2016 Care Coordination Conference 8:00 a.m. 3:30 p.m. Wednesday November 9, :30 11:30 a.m. Mercy Gilbert Medical Center McAuley Auditorium 3420 S. Mercy Drive Gilbert, AZ Mercy Gilbert Medical Center McAuley Auditorium 3420 S. Mercy Drive Gilbert, AZ Mercy Gilbert Medical Center McAuley Auditorium 3420 S. Mercy Drive Gilbert, AZ Desert Willow Conference Center 4340 E. Cotton Center Blvd. Phoenix, AZ $15.00 per attendee cost solely for food/beverage Mercy Gilbert Medical Center McAuley Auditorium 3420 S. Mercy Drive Gilbert, AZ

50 Thank you!

51 This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, 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. Publication No. AZ-11SOW-C