Measuring Family Experience of Care Integration to Improve Care Delivery
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1 Measuring Family Experience of Care Integration to Improve Care Delivery Thursday, June 15, :30 a.m. PT, 1-1:30 p.m. ET Sponsored by Lucile Packard Foundation for Children's Health Catalyst Center Family Voices
2 INTRODUCTION Edward Schor, MD Senior Vice President Lucile Packard Foundation for Children's Health
3 HOUSEKEEPING Please enter questions into the GoToWebinar chat box. All attendees will be muted for the duration of the webinar. Webinar recording and slides will be posted on the Foundation website and shared with all registrants.
4 PANELISTS Hannah Rosenberg, MSc Project Manager, Integrated Care Program, Boston Children's Hospital, and Manager, National Center for Care Coordination Technical Assistance Rebecca Baum, MD Division Chief, Developmental and Behavioral Pediatrics, Nationwide Children's Hospital, and Clinical Associate Professor of Pediatrics, The Ohio State University
5 Pediatric Integrated Care Survey: A New Tool to Measure Family Experience of Care Integration to Improve Care Delivery Richard C. Antonelli, MD, MS, FAAP Primary Care Pediatrician Medical Director of Integrated Care Director, National Center for Care Coordination Technical Assistance Hannah Rosenberg, MSc. Project Manager, Integrated Care Program Boston Children s Hospital Manager, National Center for Care Coordination Technical Assistance Neha Safaya Technical Assistance Coordinator, National Center for Care Coordination Technical Assistance Webinar sponsored by Lucile Packard Foundation for Children's Health, the Catalyst Center, and Family Voices
6 Family Experience Measures Triple Aim Outcomes 1 o Patient/Family Experience o Patient Outcomes o Cost Patient/Family Experience Measures o Identify gaps in care and care coordination services o Data used to drive improvement/intervention 1.
7 Pediatric Integrated Care Survey (PICS) Development of survey funded by Lucile Packard Foundation for Children s Health The PICS is: o 19 validated experience questions + health care status/utilization & demographic questions o Supplementary and topic specific modules o Spanish Version is available
8 Integrated PICS Domains Ziniel SI, Rosenberg HN, Bach AM, Antonelli RA. Validation of a Parent- Reported Experience Measure of Integrated Care. Pediatrics
9 PICS Example Measures In the past 12 months, how often did your child s care team members: Explain things in a way that you could understand? Know about the advice you got from your child s other care team members? Follow through with their responsibilities related to your child s care? Explain to you who was responsible for different parts of your child s care? Treat you as a full partner in the care of your child?
10 Implementing PICS PICS can be adapted to reflect the experience of different populations, including children with o medical needs o behavioral needs o significant social determinant of health risk factors PICS currently deployed: o o o o o State/ Community/Family Partner organizations Community-based and academic primary care clinics Subspecialty clinics Liver Transplant Ketogenic Diet Clinic Rett Syndrome Clinic Spina Bifida Clinic Complex Care services Academic medical centers, including research institutions Clinics/State Programs with focus on behavioral health integration PICS results help to set priorities
11 How to get started Identify population to work with Start Small! Choose target area to prioritize question selection Discuss plan for processing data We can help!
12 Navigate My Care Rebecca Baum, MD Chief, Developmental Behavioral Pediatrics June 15,
13 What Is Navigate My Care? Our goal Reduce avoidable care Improve the patient/family experience across our health care system Informed by Organizational successes and challenges Family feedback....
14 One department will say we re done with you, and another will say I don t think so. Communication Transitions and Integration The providers aren t talking to each other. I was never told about support groups. Selfmanagement and activation Monitoring, follow up and response It would be nice to have a social worker call to make sure we got it right. 14
15 The Global Care Coordination Algorithm is a retrospective model where NCH charges, visits, and specialty clinic utilization are used to stratify patients into levels of care coordination. NMC Cohort Level 4: IP + ED Charges=$1M; IP + ED Visits=>12; # of OP Specialty Services= 7+ Level 3: IP + ED Charges=$500,000- $999,999.99; IP + ED Visits=6-12; # of OP Specialty Services=4-6 Level 2: IP + ED Charges= $250,000- $499,999.99; IP + ED Visits=3-5 Level 1: Everyone Else n = ~500 n = ~2,500 All utilization is based on the last 12 rolling months
16 Navigate My Care Project Champions: Becky Baum, MD; Kimberly Conkol, RN By December 31, 2017, achieve the following amongst medically complex patients*: ED visits: 145 (2014) to 125 visits/1000 pts/mo Inpatient admissions: 205 (2014) to 175 admits/1000 pts/mo Hospital days: 750 ( ) to 650 days/1000 pts/mo 7-day readmissions: 16 (2015) to 14 /1000 pts/mo 30-day readmissions: 35 (2015) to 30/1000 pts/mo % in PICS scores Improve integration and coordination of care for medically complex patients Fully implemented Implementation in process Planned for a later date Specific Aim Strategic Goal Key Drivers Communication Interpersonal Information transfer Transitions & Integrated Care Specialty specialty Inpatient outpatient Pediatrics adult NCH non-nch Primary specialty Follow-Up, Monitoring, & Response Post-discharge follow-up Troubleshooting Help at home Self-Management & Activation Education resources Support systems * Patients achieving Level 3 or Level 4 on the NCH Global Care Coordination pyramid Projects/Interventions Develop burning platform (patient stories) to highlight need for NMC interventions Collaborate with Treat Me With Respect, Diversity & Inclusion and related groups to optimize interpersonal communication for coordination of care Develop interventions to proactively plan for new CMS Conditions of Participation standard related to discharge planning Optimize existing care coordination programs Implement care coord programs in new areas Optimize physician referral form in Epic Implement CRG risk stratification Implement goal-driven, patient-centered (rather than service-centered) Epic care plans Implement Transitions of Care project & leverage technology resources for post-discharge followup (ie automated phone calls and telemedicine) Develop strategies to coordinate appointment scheduling for complex patients Expand availability of parent mentors Develop funding plan to continue Complex Care notebook Implement Daily Goals (whiteboards) for inpatients
17 Expanding Care Coordination CC Models with Existing Resources (NAS, Neurology, Complex Care, Fostering Connections, Healthy Weight and Nutrition) Resources More Service Lines on Board Culture Change Learning from PDSAs All Care Coordination- Eligible Patients Full Program Implementation PDSA Cycles 17
18 Improving the Patient Experience PICS questions selected (19 core questions + 6 supplementary questions) Sampling strategy ¼ of patients each quarter with no duplications Marketing to assist with mailing (cover letter and survey)....
19 Nationwide Children s Hospital Patient/Family Centered Quality Strategic Plan Keep Us Well Navigate My Care Do Not Harm Me Heal Me Cure Me Treat Me w Respect Population health Throughput Access Care Coordination Preventable Harm Outcomes Patient experience Interprofessional Communication....
20 Questions? Today s webinar slides and recording will be posted online. Hannah Rosenberg, MSc Project Manager, Integrated Care Program, Boston Children's Hospital Manager, National Center for Care Coordination Technical Assistance Hannah.Rosenberg@childrens.harvard.edu Rebecca Baum, MD Chief, Developmental Behavioral Pediatrics, Nationwide Children's Hospital Clinical Associate Professor of Pediatrics, Department of Pediatrics, The Ohio State University Rebecca.Baum@Nationwidechildrens.org Edward Schor, MD Senior Vice President, Lucile Packard Foundation for Children's Health Edward.Schor@lpfch.org
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