Orange County Care Transitions Collaborative

Transcription

1 Orange County Ettie Lande, BSN, MS, ACM-RN (HSAG) Thank You! For hosting today s meeting Saddleback Memorial Medical Center 2 1

2 Thank You! For sponsoring today s breakfast 24Hr Home Care and Blake Naudin If you can sponsor breakfast at a future meeting, contact JWingelman@hsag.com or Community Introductions Who Is At Your Table? 4 2

3 Today s Agenda Welcome and Introductions Findings From the Field Community Readmission Performance Immunizations and Avoidable Readmissions Resources for Success: You and Your Patients Meeting Summary Evaluation Feedback 5 Your Meeting Feedback Is Important! Please help us exceed the 85% target! 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 73% 2018 Orange County Collaborative Evaluation Completion Rate 85% 85% 85% 85% 55% Jan Apr Jul Oct

4 Road Map to Action Note the important takeaways from today s meeting on this Roadmap to Action to share with staff members and colleagues when you return to work. 8 Findings from the Field A Solutions-Based Talk Show Hosted by Ettie Lande 4

5 How Can We Fix These Transition Gaps? 9 Guests on Today s Show Laura Garcia Fountain Valley Regional Hospital Lisa Forsythe Memorial Care Saddleback Medical Center Claudia Skinner St. Jude Medical Center Sally Gaspar St. Joseph Health John Mastrocola Generations Healthcare, Southern Region 10 5

6 What We Will Learn From Each Guest Today 1. What gap opportunity related to care transitions was identified by your organization? 2. What was the biggest challenge you experienced in moving the strategy along to its next steps? 3. What advice would you give to someone trying to implement this strategy in their own organization? 11 Network and Break: 15 Minutes

7 Orange County Community Performance: Readmission Reduction Orange County Community 240,893 Medicare Fee-for- Service (FFS) Beneficiaries 23 Acute-Care Hospitals 69 Skilled Nursing Facility (SNFs) 57 Home Health Agency (HHAs) 14 7

8 Orange County Community How far is this collaborative from reaching the CMS 1 readmission improvement target? Target RIR 2 = 8% RIR Goal is to reach or exceed this target by September Centers for Medicare & Medicaid Services (CMS) 2. Relative Improvement Rate (RIR) Orange County Community RIR July 2015 December % 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 2.05% 2.78% 2.49% Jul Jun 2016 Oct Sep 2016 Jan Dec % Apr Mar 2017 Desired Direction: Goal: 8.0% RIR by Sept 30, % Jul Jun % Oct Sep % Jan2017- Dec 2017 Target RIR 8.0% 8.0% 8.0% 8.0% 8.0% 8.0% 8.0% Actual RIR 2.05% 2.78% 2.49% 1.83% 0.05% 2.18% 1.71% 16 Source: Medicare FFS Claims Data for beneficiaries residing within the ZIP codes of this community. The number of beneficiaries for this is 240,893. *The RIR is calculated based on the readmission rates per 1,000 beneficiaries and this formula: (Baseline Current)/Baseline. 8

9 90-Day Sprint to the Finish! 17 Turn in Your Meeting Evaluation and Receive a Copy of Your Community s Report Data Source for this Report: Medicare FFS Claims Data for beneficiaries residing within the ZIP codes of this community 18 9

10 Using Teach-Back to Improve Immunizations and Readmissions in HHAs Maria Gallegos Project Coordinator, HSAG So Let s Start With Readmission Rates Methodology: Derived from FFS, Part-A hospital claims. The rates represent readmissions from January 1, 2017 December 30, 2017 (mature data). Excludes planned readmissions. Excludes any beneficiary who dies in the hospital or is transferred to another hospital on the same day. Inclusive of all Medicare beneficiaries, regardless of age

11 All-Cause 30-Day Readmission Rates and Volume by Hospital Discharge Setting Q Q Orange County Community Setting Hospital Discharged To Hospital Discharge Volume 30-Day Readmission Rate Home 19, % 2,961 SNF 12, % 2,664 HHA 12, % 2,215 Hospice 1, % 42 Other* 3, % 682 Total 50, % 8, Day Readmission Volume *Other: based on hospital discharge disposition codes and include, for example, include psychiatric hospital, long-term acute care hospital, acute rehab, intermediate-care, left against medical advice, and correctional facility. 21 Data files provided to HSAG by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare FFS beneficiaries. All-Cause 0 7-Day Readmission Rates and Volume by Hospital Discharge Setting Q Q Setting Discharged To 0-7 Day Readmission Volumes 0-7 Days Readmission Rates Home 1, % SNF % Orange County Community HHA % Hospice % Other* % Total 3, % *Other: psychiatric hospital, long-term acute care hospital, acute rehab, intermediate-care, left against medical advise, based on hospital discharge disposition codes. 22 Source: Data files provided to HSAG by the Centers for Medicare & Medicaid Services (CMS) were used for analysis in this report. The data files include Part-A claims for Medicare FFS beneficiaries. 11

12 Why Teach-Back? Numerous studies have shown that patients remember as little as 50% of what they are told by their doctors. 1 Common causes for readmission 50% Lack of patient/family involvement and accountability in their own healthcare Patients/families do not fully understand how to care for themselves at home A. Boutwell and S. Hwu, Effective Interventions to Reduce Rehospitalizations: A Survey of the Published Evidence (Cambridge, Mass.: Institute for Healthcare Improvement, 2009), p. 14. And, S, Silow-Carroll, J. Edwards, and A. Lashbrook, Reducing Hospital Readmissions: Lessons from Top-Performing Hospitals (Commonwealth Fund Synthesis Report, April 2011) p Day and 7-Day Readmission Rates and Volume from HHA by Condition: Changes the Priority Condition 30-Day Readmission Volume 30-Day Readmission Rate 0-7 Day Readmission Rate AMI % 48.1% HF % 38.3% Orange County Community PNE % 40.7% COPD % 28.2% CABG % 53.3 % THA/TKA % 46.3% Data files provided to HSAG by the CMS were used for analysis in this report. The data files include Part-A claims for Medicare FFS beneficiaries Acute Myocardial Infarction=AMI 2. Heart Failure=HF 3. Pneumonia=PNE 4. Chronic Obstructive Pulmonary Disease=COPD 5. Coronary Artery Bypass Graft=CABG 6. Total Hip/Total Knee Arthroplasty=THA/TKA 12

13 The Flu Season in California CA Alameda, Contra Costa, and San Francisco Counties The seasonal baseline was calculated using a regression model applied to data from the previous five years. Two standard deviations above the seasonal baseline is the point at which the observed percentage of ILI is significantly higher than would be expected at that time of year %20Library/Immunization/Week _FINALReport.pdf Older Adults Are Hit Harder by the Flu Incidence of Influenza Hospitalizations in California Emerging Infections Program (CEIP) Counties, nt%20library/immunization/week _finalreport.pdf 13

14 Heart Attack Risk and the Flu The NEW ENGLAND January 25, 2018 JOURNAL of MEDICINE Acute Myocardial Infarction after Laboratory-Confirmed Influenza Infection Jeffrey C. Kwong, MD., Kevin L. Schwartz, MD, Michael A. Campitelli, MPH, et. al. Risk of heart attack is six times greater than normal while people are ill with the flu Pneumonia Risk for Older Adults 16,000 adults 65 years and older die annually due to pneumococcal disease

15 One Possible Issue: Low Immunization Rates Type Total White Black Hispanic Asian Seasonal Flu (> 18 years) % 45.4% 35.6% 33.1% 43.6% Season Flu (Medicare Claims) % 71.7% 55.3% 33.9% 56.1% Pneumococcal (> 65 years) % 64.0% 46.1% 43.4% 41.3% 1. Centers for Disease Control and Prevention. (2014). Flu vaccination coverage United States, influenza season. Retrieved from estimates.htm#by-race-adults 2. Centers for Disease Control and Prevention. (2014). Interactive mapping tool: Live-tracking flu vaccinations of Medicare beneficiaries. Retrieved from 3. Williams, W. W., Lu, P-J., O Halloran, A., Bridges, C. B., Pilishvili, T., Hales, C. M., & Markowitz, L. E. (2014). Noninfluenza vaccination coverage among adults United States, Morbidity and Mortality Weekly Report, 63(5), Goal: Increase Immunizations Rates Current HSAG Progress Time Period Flu Rate PNE Rate Oct. 17 Jan % 81.26% 30 Source: CMS Claims Data 15

16 Our Strategy: Teach-Back Health literacy is the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. Teach-back is a way to confirm that you have explained to the patient what they need to know in a manner that the patient understands. Motivational interviewing is a scientific, patientcentered approach for fostering motivation and assisting patients to resolve ambivalence about change. 31 Our Strategy: Teach-Back (cont.) Teach-back is asking patients to repeat in their own words what they need to know or do. It is not a test of the patient, but of how well you explained the concept. It is a chance to check for understanding and, if necessary, re-teach the information

17 Our Strategy: Teach-Back (cont.) 10% of what they read 20% of what they hear 30% of what they see 50% of what they hear and see 70% of what they say or write 90% of what they do 33 Sources: Dale, Edgar. Cone of Experience Treichler, DG. Film and Audio-Visual Communications Glaser, R. (1983, June). Education and Thinking: The Role of Knowledge. Technical Report No. PDS-6. Pittsburgh, PA: University of Pittsburgh, Learning and Development Center. Thalheimer, Will. Will at Work Learning. May 1, Our Strategy: Teach-Back (cont.) Engage those that have the highest impact in each community based on volume and return to hospital rates. Schedule and provide teach-back trainings to HHA nurses and other staff members. Goal: Improve patient understanding of immunizations to help prevent avoidable hospital readmissions

18 Thank you! Maria Gallegos Resources for Success: HSAG Website and YouTube Channel Ettie Lande 18

19 Where Can You Find Resources and Tools on HSAG s Website? You will always start with the path below: For Medicare Providers > California > Care Coordination > California Tools & Worksheets 37 Tools and Resources for California

20 ADEs and HRMs Tabs Orange County Tools/resources include: Quick tips for prescribers HRM resources Anticoagulants Opioids Diabetic agents ADE tools And more Provider Tools: Organization and Patient Assessment Resources Tab Tools/Resources include: Organizational Assessment Summary 7-day Readmission Checklist Strategy Tree Admission Observation Tool Discharge Observation Tool And more

21 Behavioral Health Resources Tab Alcohol Misuse Screening Tools Depression Screening Tools Reference Guide for Medicare Preventive Services Patient Education Treatment Quality Payment Program Behavioral Health Readmission Audit Tool Top Ten Intervention Series practices critical to reducing readmissions Webinars NEXT Changing the Stigma and Images of ECT (Electroconvulsive Therapy) 41 What Influences Readmissions? Jane s Experience is Now on HSAG s YouTube Channel Pre-Hospital/Pre-Admission Inpatient Post-Discharge/Community

22 Patient Tools Tab Orange County Red Flag Zone Tools: English/Spanish Asthma COPD Diabetes Heart Disease Heart Failure Medications Mood and Health Urinary System Teach-Back and Health Literacy Tab Tools/Resources include: Teach-back Starter Sentences Generic For Heart Failure Plain Language Generic For Heart Failure Health Literacy Tool Kit And more

23 Nursing Home Reducing Readmissions Preparation Program 45 Why You Should Join: Improve your staff members knowledge on readmission interventions Create and strengthen your internal readmission prevention program Help you to become, and stay, a preferred provider to your local hospitals Improve your readmission rates to receive maximum reimbursement Reducing Readmissions Preparation Program 2018 Webinar Series Fourth Wednesday of every month, 11 a.m. PT July 25 Listening to Your Residents: Teach Back and Motivational Interviewing August 22 Chronic Obstructive Pulmonary Disease (COPD) September 26 Ready, Set, Go! Sharing Success Stories Past event slides and recordings available

24 Home Health Best Practice Intervention Package (BPIP) 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 no cost, but you have to sign up for the HHQI Campaign to access them BPIP Topics Cardiovascular Health (Part 1 revised 2017 and Part 2) Blood Pressure Control and Smoking Cessation Cross Settings I, II, and III Depression Management (revised 2017) Disease Management: Part 1 and 2 Disease Management: Diabetes Disease Management: Heart Failure Fall Prevention Fundamentals of Reducing Hospitalizations Immunization/Infection Control (revised 2017) Improving Management of Oral Medications Medication Management Patient Self-Management Underserved Populations New! Wound Management 48 24

25 Home Health Services What a Patient Should Know Now on HSAG s YouTube Channel Video link: 49 Meeting Summary: What Will You Share When You Get Back to Work? 25

26 Your Meeting Evaluation Feedback Is Needed Target: At least 85% of you will complete a meeting evaluation form. Please complete the evaluation before you leave today (fold in half and leave on the center of the table). Your feedback is very important to us and highly valued. 51 Questions? 52 26

27 Thank You All for Your Participation Today! 53 Thank You! Ettie Lande 27

28 Disclaimer This material was prepared by, the Medicare Quality Improvement Organization for California, 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. CA-11SOW-C