Care Transitions Collaborative Webinar May 15, 2014

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1 Care Transitions Collaborative Webinar May 15, 2014

2 Agenda

3 Measures progress update Feb and March,2014 Data Reporting Hunter Gatewood

4 » Inpatient measures: 5 teams (3 for April)» Non-hospital measures: 2 teams» March #s similar to Feb. #s for most» What will happen next? Improvement? Reliable improvement? 4

5 5

6 » Measurement for improvement, not judgment or research.» Goal: improve AND reduce process variation.» Use run charts and run chart rules. Don t declare victory/defeat too soon.» Process measures almost always show impact before outcomes measures.» Team-level goals used in charts for illustration only. 6

7 Percentage patients with d/c summary 100 Percentage discharged patients who received written discharge summary Value Median Goal Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 7

8 Percentage patients with d/c summary 100 % discharged patients with community provider contact in 7 days Value Median Goal Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 8

9 Percentage patients whose provider rec'd summary 60 % discharged patients whose follow-up provider rec'd summary within 7 days Value Median Goal Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 9

10 CLOSING THE GAP Improving Lives Through Innovative Personalized Care Transitions Presenter: Michelle Reed, LCSW, RC, ACM Director, Inpatient Case Management

11 JPS Health Network INNOVATIVE CARE TRANSITIONS Safety Net provider for Tarrant County (Population 1.88 million) Trauma Level I Facility Capacity: 502 Acute Medical Surgical and OB; 98 Acute Behavioral Health 50 Locations of care Largest hospital-based family residency program in the nation 6,000 teammates

12 Transition of Care & Care Coordination Care Giver Patient Patients Family Nurse Physician Pharmacist Case Manager Social Worker

13 Bridge Builders-Care Transitions

Care Coordination Development Patient Challenges Patient Centered Plan of Care Moving from one health care setting to another Medical Records are

the patient s multiple and complex needs Close the loop with post-acute providers Increase focus on readmission rates Emphasis on

14 Care Coordination Development Patient Challenges Patient Centered Plan of Care Moving from one health care setting to another Medical Records are accessible by all providers Timely follow-up for appointments Hospital Care/Plan accessible by the PCP Communication between providers regarding the patient s multiple and complex needs Close the loop with post-acute providers Increase focus on readmission rates Emphasis on interdisciplinary plan of care Engage patient in the discharge process Timely post-discharge appointments Integration of discharge hand-off to all patient providers

15 Care Transition Bridge Building Case Management Assessments at all points of entry, ED,OBS, Direct Admit DSRIP CARE TRANSITION REFERRALS Access Data Mechanism for identifying discharge needs Adequate Staffing Ratios Staffing based on acuity and patient ratios Transitioning Care

16 Where were we? Reactive Case Management Primary functions -Utilization review. The need to meet National standards by increasing staffing Improved baseline data Enhance communication with providers and other care team disciplines. Maximize IT systems to support CM functions. Need for consistent assessments for discharge needs and care planning. Need for enhanced Hand-off process. Expand knowledge of Community resources & DSRIP projects criteria's for referrals

17 Stakeholders Expectations: Care Management Referral Process DSRIP DSRIP DSRIP DSRIP non-dsrip non-dsrip non-dsrip DSRIP non-dsrip DSRIP DSRIP DSRIP DSRIP DSRIP DSRIP DSRIP DSRIP MedStar HUG Program MedStar Avoiding OBS Admission MedStar CHF CHF Clinic Hospice Outpatient Case Management Home Health HealthSource Rehab Transitions Diabetes Collaborative Community Connect Diabetes Chronic Care Mgmt Behavioral Health Discharge Mgmt (waiting on criteria) Integrated Behavioral Health (waiting on criteria) Care Connections for the Homeless (criteria not developed yet) Wound Care Specialty Care (waiting on criteria) Expanded Pain Mgmt Services (waiting on criteria) Palliative Care (waiting on criteria)

What we needed Healthy Sustainable Transformation Make gradual incremental changes Set reasonable targets Celebrate Wins no matter how small Learn new ways of doing things,

18 What we needed Healthy Sustainable Transformation Make gradual incremental changes Set reasonable targets Celebrate Wins no matter how small Learn new ways of doing things, through education Create accountability and new habits Implement process improvement Identify and remove non-value added activities Reimagine care transitions to transition of care.

What we ve done Best Practice Features Case Management Model Redesign Began ongoing education/orientation for staff Pro-Active Patient Advocacy Progression of Care Workflow activities that increase

19 What we ve done Best Practice Features Case Management Model Redesign Began ongoing education/orientation for staff Pro-Active Patient Advocacy Progression of Care Workflow activities that increase value Interdisciplinary Coordination Added additional staff Team Member Performance measures Instituted daily operational metrics Expanded Physician Advisor role EMR-Epic Design Adopted Outcome Measures

Case Management Pilot RN/Social Work/CM Unit Based Assessments With-in 24hr of admission

Identified SNF/LTACH Home Health/Hospice OP/CM Healthy At Home CHF Clinic Referral Diabetic

Rounds Case Management Discharge Hand-off Nationwide there is medication related problems in

understanding Taking wrong dose at wrong time Continuing a STOPPED medication Experiencing

20 Case Management Pilot RN/Social Work/CM Unit Based Assessments With-in 24hr of admission High Risk Stratification for readmission Discharge Risk Interventions- Discharge Needs Identified SNF/LTACH Home Health/Hospice OP/CM Healthy At Home CHF Clinic Referral Diabetic Referral Homelessness Referral DSRIP Project Referral (by criteria) Inter-disciplinary Rapid Rounds Case Management Discharge Hand-off Nationwide there is medication related problems in 60% of all patients discharged(cms) Did not start the new medication due to lack of understanding Taking wrong dose at wrong time Continuing a STOPPED medication Experiencing adverse medication effects INR monitoring needed Meds to the Bed Pre-discharge medication reconciliation/education

21 Where are we? Developing long lasting relationships with patients Collaborative and supportive relationships with multidisciplinary teams Increased referrals to DSRIP projects and out patient community resources Increased management of chronic conditions Improved follow-up post-discharge Making Progress to goals Reduction of avoidable ER visits, hospitalizations, and readmissions Reduced length of stay Decrease ancillary resource utilization

22 Creating A Healthy Environment Empowering and engaging the staff

23 Number of Patients Number of Patients Results-Measured Outcomes Inpatient Length of Stay 0-30 days Inpatient Length of Stay days /1-12/31/2012 1/1-11/30/ /1/13-5/15/14 0 5/1-12/31/2012 1/1-11/30/ /1/13-5/15/ days days days days days 90+ days 60% 50% 40% 30% 20% 10% 0% % Discharged with follow-up appointment 38% 38% 41% 44% 44% 46% 47% 49% 48% 3/2-3/8 3/9-3/15 3/16-3/22 3/23-3/29 3/30-4/5 4/6-4/12 4/13-4/19 4/20-4/26 4/27-5/3 % DC'd with follow-up appointment

24 Case Management s Role in the ED

25 Closing the Gap

A Final Note Improving Care Transitions The hospital case manager is the hub for patient care. He/she engages with the care team, the patient, the family and others beyond the team.

26 A Final Note Improving Care Transitions The hospital case manager is the hub for patient care. He/she engages with the care team, the patient, the family and others beyond the team. In an increasingly complex health care system, the case manager links patients and families with appropriate resources across the care setting. The case manager also links the various providers and resources with the patient. Case Managers are uniquely positioned to coordinate care and improve transitions, to serve as the hub to which all parties are connected. Case Managers strengthen healthcare s weakest link: The Transition of Care

What are your methods for evaluating the effectiveness of your process

27 Discussion/ Questions Ideas/Thoughts How would you describe the state of transitions of care at your organization? What are your methods for evaluating the effectiveness of your process for transitions of care? Ultimately, who in your organization is accountable for safe transitions of care?

28 Region 10 Learning Collaborative Care Transitions Monthly Webinar May 15, 2014 Provider Participant MCA Kathleen Sweeney Cook Children s - TCPH - MHMRTC Mahie Ghoraishi, Elewechi Ndukwe, Kathryn Brown, Camille Patterson, Delia Luna, Luke Reynard, Karyssa Bowers, Michael Parker, Shantelle Collins NHH Kathleen Sweeney Lake Granbury Medical Center - PMC Kathleen Sweeney Huguley Jamie Hixson, Kristen Drake, Kim Trull, Carol Johnson, Charisse Huey, Lori Dachroeden, Vicki Galati THFW Jamie Hixson, Kristen Drake, Kim Trull, Carol Johnson, Charisse Huey, Lori Dachroeden, Vicki Galati THSW Jamie Hixson, Kristen Drake, Kim Trull, Carol Johnson, Charisse Huey, Lori Dachroeden, Vicki Galati THS Jamie Hixson, Kristen Drake, Kim Trull, Carol Johnson, Charisse Huey, Lori Dachroeden, Vicki Galati Ennis Regional Edwina Miner Lakes Regional Ian Smith JPS Hospital Heather Beal, Erica Hilliard, Aubrie Augustus, Gillian Franklin, Vincent Do, Robert Hernandez, Rachel Bryant, Rama Koganti, Michelle Reed, Lynette Blackwood, Brenda Gomez, Connie Garcia, Dawn Zieger, Shelly Corporon, Rehana Karjeker, Jillian Elliott, Yvonne Kyle, Brenda Gomez, Robert Hernandez, Amy Mwaura, Gwen Darby, Victor Henderson UT Southwestern Moncrief Cancer Institute Paula Anderson THAZ Jamie Hixson, Kristen Drake, Kim Trull, Carol Johnson, Charisse Huey, Lori Dachroeden, Vicki Galati Helen Farabee Andrew Martin Wise Regional Shane Jones, Wanda Villard THAM Jamie Hixson, Kristen Drake, Kim Trull, Carol Johnson, Charisse Huey, Lori Dachroeden, Vicki Galati Pecan Valley Romie Foreman THC Jamie Hixson, Kristen Drake, Kim Trull, Carol

29 Region 10 Learning Collaborative Care Transitions Monthly Webinar May 15, 2014 Johnson, Charisse Huey, Lori Dachroeden, Vicki Galati Baylor Jennifer Anderson, Tonya Selman, Lister Robinson THHEB Jamie Hixson, Kristen Drake, Kim Trull, Carol Johnson, Charisse Huey, Lori Dachroeden, Vicki Galati Dallas Children s Ashley Sadlon, Hilda Sallack UNTHSC Jeanie Foster, John Allen JPS PG - Methodist Mansfield Gail Serralta Wise PG Shane Jones Glen Rose - Texas Health Alliance Jamie Hixson, Kristen Drake, Kim Trull, Carol Johnson, Charisse Huey, Lori Dachroeden, Vicki Galati Other Stakeholders Provider ECHD LRCC Parkland NTSP Border Region Participant Diana Ruiz Natalie Wilkins Alda Rendo

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