Session #8: Strengthening Community Partnerships: Post-Discharge Firefighter Visits
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1 Session #8: Strengthening Community Partnerships: Post-Discharge Firefighter Visits Presenters: Steve Koering and Linda Bauermeister Hennepin 3 Saturday, Jan. 7, :15 a.m. 12:15 p.m.
2 Steve Koering Chief Koering is a 28-year veteran of the fire service and currently holds the position of fire chief for the City of St Louis Park. The department responds to in excess of 5,000 calls annually with approximately 78% of those calls being emergency medical services. The department is widely engaged throughout the community on issues of wellness and improved health, community risk reduction and resiliency. Chief Koering, in partnership with Park Nicollet, recognized the challenges of health care cost controls and opportunities to partner fire departments and health care providers with the goal of minimizing post discharge risks. Their solutions have provided smoother transitions for patients through improved safety and reduced readmissions. Linda Bauermeister BSN, RN MAL Linda Bauermeister is the senior director for home care and hospice across Park Nicollet and HealthPartners and also the director of nursing and population health at Park Nicollet. Linda has worked at Park Nicollet since 1992 and has served in many diverse roles in the following areas: nursing operations, process improvement, project management, information technology and population health. In her current population health role, she is responsible for creating, implementing and evaluating a system-wide strategic population health plan for Park Nicollet and is the operational lead for the Next Generation accountable care organization. Linda served as the co-lead on the Firefighter Visit Project since it started and continues to support this work.
3 Strengthening Community Partnerships: The Post Discharge Firefighter Visit Partnership of Park Nicollet and Fire Departments in St. Louis Park, Minneapolis, Minnetonka, Hopkins, and Eden Prairie Post Discharge Firefighter Visit Program Background and methodology of how the Post Discharge Firefighter visit got developed Processes and content of the visit: a focus on enhancing patient safety in the home Data and outcomes from the visits How the firefighter visit addresses the triple aim and enhances patient and community resilience 1
4 Background of the Firefighter Visit January 6, 2014: first meeting between SLP FD and PN to discuss possible partnership Current State: Fire Department SLP Fire Department: 70%of their calls are now medical with many of those calls involving patients that are recently discharged Background of the Firefighter Visit The Changing Role of the Fire Department Continued increased demand of fire resources for medical response Calls could be preventable many times Mandates of the Patient Protection Affordable Care Act on the roles of the fire department Aligning the correct resource for the call type (both vehicle and staff) Need to create a revenue stream to sustain service levels 2
5 Background of the Firefighter Visit Current State: Methodist Hospital Average of 49 patients go home every day. Of these patients, 26 go home with no services (53%) Readmission Interventions Risk Stratification Tool to identify high risk for readmission patients Medication safety MTM Pharmacists Hospitalist, RN, SW team Standard work for care integration team Warm hand offs to next level of care Post acute care partners Improved discharge instructions (After Visit Summary) Post discharge phone calls 3
6 Measuring Readmissions (a proxy for effective care coordination/transition to next level of care) CMS Adjusts for Out of the hospital s Align Appropriately control: Patient level factors Community level factors No Adjustment the vault TRANSITIONS CONNECTING TOGETHER Post Discharge Firefighter Visit 4
7 Process Improvement Methodology Used: Kaizen Project form: Defined targets and deliverables Agreeing to a future state process Process flow or Value Stream Map: Understanding the current state process PDSA Cycles: Trying something and making Changes as needed: Fail forward quickly OUR GOAL: More expansive follow up (ID areas of concern) Connect patient with available resources Promote safe transition in home 5
8 Post Discharge Firefighter Visit Kaizen Event Deliverables Process Visit Components Tools Patient ID and consent process Dispatch process Fire Department receipt of information process Fire Department scheduling/previsit/visit process Test Visits Medications Red flags Who to call Follow up visit PEAT Pilot Planning Patient flyer Patient consent form Fax forms FF visit documentation form Patient survey And others Three visits Made process and other changes Three Departments Measures Training Our Process Patient Admitted to Methodist Firefighter Visit the day after discharge ensures safe transition PN Care Team is notified of patients eligibility in program Patient transitions to home Firefighter Coordinator visits patient to seek consent Patient engages and consent is received 6
9 Our Patient Flyer We also have a patient education video Our Patient Consent form- we must obtain consent as we share the patient s AVS (After Visit Summary) with the Fire Department 7
10 Post Discharge Firefighter Visit Componentsbased on the elements known to ensure a safe transition Medications-does the patient understand what medications to take? 14 Site s Follow up visit-does the patient have a follow up visit scheduled with her doctor? 14 Sit es Symptoms-does the patient know what symptoms to be aware of and who to call if she experiences the symptom? 14 Site s Food-does the patient have enough food in the house to get through the next few days? 14 Site s Home safety-are there hazards in the house? Is the smoke/co2 alarm working? (PEAT Assessment) 14 Site s The Visit Form 8
11 Current Program Components Departments: St. Louis Park Minneapolis Minnetonka Hopkins Eden Prairie Visits: Tuesday-Saturday Same day if needed Weekly conference call with Core team DataCollected from Start of pilot Part Time Project Coordinator Who are the patients? Age Youngest: 3 months Oldest: 101 Gender 39% males Totals HRR patients: 165 Average: 67 Mode: 73 61% females TOTAL VISITS: 827 9
12 Firefighter Visit Data Averages Number of calls to schedule= 1.3 Cycle time of visit= 23 Minutes Time of Day Range: Average time= 12:16 PEAT Score Range: Average: 34 Patient Engagement 70% % 59% % 40% 30% % % 45% 39% 36% 36% 32% 50% 39% % 36% % 34% 77 27% % 22% % % AVG 2014 AVG 2015 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun # Approached % consented % completed 10
13 Visit Outcomes Not Home 26 Contacted PN Care Team Initiated 911 Referred to Social/Community Resource Contacted Adult Protection Contacted Homecare 3 Medication Follow-up 26 Installed Smoke Alarms/Batteries 144 Referred to a food shelf 26 High Risk Follow-up MH staff informed me about the firefighter visit in a way that I could understand: 99% agree/strongly agree What our patients are saying about the visits: Most important aspect of visit: Safety Assessment I would recommend a firefighter visit to my family and friends : 99% agree/strongly agree 11
14 Patients feel safer at home I feel safer in my home after having a firefighter visit. 95% of patients Agree or Strongly Agree Strongly agree Agree Disagree Firefighter Visit Program Impact on Readmissions 12.00% Readmission Rates Before and After FF Program 10.62% 10.58% 10.00% 9.55% 9.63% 9.35% 8.99% 8.95% 9.60% 9.48% 9.15% 8.00% 7.71% 7.74% 6.00% 4.00% 2.00% 0.00% EDEN PRAIRIE HOPKINS MINNEAPOLIS MINNETONKA ST LOUIS PARK ALL 5 CITIES Before (Jan12-Apr14) After (May14-Jun16) 12
15 Successes Highlighted in The Advisory Board Community Paramedicine Best Practices Research and Case Study for Project ManagementCourse on improvements MHA Innovation of the Year Award Patient Story 13
16 Post Discharge Firefighter Visit Health Patients have what they need to care for themselves at home and understand what community resources to use if something changes Experience Safe and successful integration back into their home/community Consistent and repeated key messages from PN team and fire fighter colleagues Affordability Decrease readmissions Appropriate use of healthcare resources and decrease unnecessary 911 calls Community Integration in Patient Transition Processes Require New Drivers for Success Relationship Management- Fire Department and HC Provider Expectation Management- City Management/Elected Officials/HC Provider/Community Resource Management for Visits- Recommend resource increases or realignment Financial Management- Responsible for viability and sustainability of program to tax payers 14
17 Questions? Thank You! 15
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