Today s Host 2/18/2016

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1 February 18, 2016 These presenters have nothing to disclose IHI Expedition Improving Care Transitions To Reduce Readmissions Session 2: Establish and Implement a Person Centered Transition Plan to meet the Identified Post-Acute Care Needs Peg Bradke, RN, MA Jill Duncan, RN, MS, MPH Today s Host 2 Colby Champagne, Project Assistant, Institute for Healthcare Improvement (IHI), is a co-op student from Northeastern University. She is a health science major with a minor in business administration and hopes to pursue a career in healthcare management. She is working on the Passport, Expeditions, and Leadership Alliance teams. 1

2 Phone Connection (Preferred) 3 To join by phone: 1) Click on the Participants and Chat icon in the top, right hand side of your screen to open the necessary panels 2) Click the button on the right hand side of the screen. 3) A pop-up box will appear with the option I will call in. Click that option. 4) Please dial the phone number, the event number and your attendee ID to connect correctly. WebEx Quick Reference 4 Please use chat to All Participants for questions For technology issues only, please chat to Host Raise your hand Select Chat recipient Enter Text 2

3 Chat 5 Name and the Organization you represent Example: Sam Jones, Midwest Health 5 Please send your message to All Participants Expedition Director 6 Jill Duncan, RN, Executive Director, IHI, provides strategic development and programming leadership for IHI's Quality, Cost, and Value Focus Area; leadership of IHI's Joint Replacement Learning Community; program coordination and faculty leadership for IHI's Leading Quality Improvement: Essentials for Managers program; and program development and facilitation for many of IHI's workforce development initiatives. Her previous IHI responsibilities include daily operations and strategic planning for the IHI Open School, and development and leadership of Impacting Cost + Quality. Ms. Duncan draws from her learning as a Clinical Nurse Specialist, quality leader, pediatric nurse educator, and front-line nurse. 3

4 Expedition Objectives At the conclusion of this Expedition, participants will be able to: Assess current challenges in reducing care coordination and identify opportunities for improvement in care transitions. Build an effective improvement team including patients and families as well as acute, post-acute and community care partners Identify successful approaches to engaging staff in all clinical settings to make an ideal individualized person centered transition of care plan. Engage participants in sharing strategies and innovative thinking to explore real life issues related to transitions. Develop processes with post-acute care providers and community partners to ensure the timely transfer of critical information during transitions. 7 Expedition Sessions 8 Session 1 Building the Will, Ideas and Execution for Successful Transitions Session 2 Establish and Implement a Person Centered Transition Plan to meet the Identified Post-Acute Care Needs Session 3 Working with Community Partners for Successful Transitions Session 4 From Prehospital to In-Hospital: The Continuum for Time-Sensitive Care Session 5 Executing on an Ideal Outcome in the Transition: Right time, Right Place, Right level of care at the Right Cost 4

5 Faculty 9 Peg M. Bradke, RN, MA, has held various administrative positions in her 25-year career in heart care services. Currently she is Vice President of Post-Acute Care at St. Luke's Hospital in Cedar Rapids, Iowa, where she oversees a long-term acute care hospital and two skilled nursing and intermediate care facilities, with responsibility for home care, hospice, palliative care, and home medical equipment. In her previous role as Director of Heart Care Services at St. Luke's, she managed two intensive care units, two step-down telemetry units, several cardiac-related labs, and heart failure and Coumadin clinics. Ms. Bradke also serves as faculty for the Institute for Healthcare Improvement on the Transforming Care at the Bedside (TCAB) initiative and the STAAR (STate Action on Avoidable Rehospitalizations) initiative. Session Agenda 10 Action period review Patient-Centered Approach to Transitions Peg Bradke Guest Presenters Mark Green, Ochsner Health Systems Julie L. Mirkin & Patricia Peretz, New York Presbyterian Hospital Action period assignment and closing 5

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8 16 Establish & Implement a Person Centered Transition Plan to Meet the Identified Post Acute Needs Session 2 8

9 How Might We. 17.effectively communicate the plan of care (based on the assessed needs and capabilities) to the patient/caregiver and community-based providers of care? Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June Available at Simply 18 What do we know about the patient/caregiver that will help the next level provide the needed care in the transitions? How will we communicate that? Sender Role vs Receiver Role 9

10 Patient Centered Approach 19 Doing to me: Probing, sticking, shaking, pushing Turning me into a nurse without training Having a test with only a thin gown on Nurse also saying you are doing fine Doing for me: Physical Therapy Making me move/repositioning me in bed Hygienic measures Asking if there was anything they could do for me Do with me and my family Keeping whiteboard up to date Bedside report Asking patient what they need, but asking family members as well. Sharing facts - being transparent Always giving and updating the plan 20 Prompts frequent monitoring In the post acute continuum Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June Available at 10

11 Recommendations 21 Risk Level: Review daily the patient s medical and social risk and/or barriers that would contribute to a readmission. Customized plan of care: with real-time critical information to the patient and next clinical care provider(s). Timely follow-up care: initiate clinical and social services as indicated from identified post-hospital needs Determine capabilities of the patient/caregiver and the post acute services to meet the identified needs Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June Available at Risk 22 High Risk 11

12 Eric Coleman, MD: Identification of Patients at Risk for Admission Ideally a risk tool would not only identify those at highrisk for readmission but more precisely those who have modifiable risk. In other words, risk tools should be aligned with what we understand about how our interventions work and for which patients our interventions work best In the case of heart failure, we should be careful to not assume that the primary readmission for heart failure is after all the heart Low health literacy, cognitive impairment, change in health status for a family caregiver, and more may be greater contributors than left ventricular ejection fraction 23 Eric Coleman, MD: Identification of Patients at Risk for Admission (cont.) Asking the patient to describe, in her or his own words, the factors that led to the hospitalization and where they need our support may provide greater insight into risk for return- What is the real story from patients perspective? Non-patient factors may have a larger role in readmission rates, such as the health care system and access 24 12

13 Include the Patient s Perspective Ask patient/caregiver: What matter most to you during this transition? What are your concerns or worries about going home or to the next care setting? Who do you want involved in your transition (your Support person) 25 Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June Available at Customized Plan of Care 26 Develop one comprehensive assessment and plan of patients post-acute care needs that integrates input from all members of the care team Make sure each member of the care team is clear about what information they must bring to the assessment and plan Consider: Patients Preferences Patient Capabilities Activation Level Change the focus on daily patient care rounds to include a discussion on current site but anticipating needs for next site Develop Bidirectional dialogue and collaboration between sender and receivers 13

14 Key elements in Transitions of Care 27 Ensure that the patient and caregivers are present for discharge instructions Provide both the patient and caregiver a copy of the written discharge instructions; in user-friendly formats Use Teach Back in your discharge instructions Highlight important points in the patient s d/c instructions Provide instructions that give them actions of what to do Follow-up care, list of reasons to call for help and phone numbers for emergent and non-emergent questions. What to expect when they return home and medication instructions Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June Available at Timely Follow Up Care 28 If the patient is transitioning home and will be receiving care in primary care office or specialty practice: Ensure timely and action oriented discharge summary that arrives prior to the patient s visit Final reason for Hospitalization Recommendation for f/u Pending studies needing attention Arrange for access to patient discharge instructions in the office practice 14

15 Warm Handover to Community Partners 29 Written handover communication for the patient at risk is insufficient : direct verbal communication allows for inquiry and clarification Transition to Home Health Care, Long-term Care, Skilled Nursing Facility or Other Community Settings Co-design handover communication processes (i.e. preferred formats for information and Senders and receivers agree upon the format) There are a vital few critical elements of patient information that should be available at the time of discharge for the community providers Create processes for bidirectional communication for care coordination, continual learning and ongoing improvement efforts 30 15

16 Handovers to Home Health Care, Skilled Nursing Facilities or Community Services Share patient education materials and educational processes across care settings Offer education for the staff in HHC, SNF, LTC and community services 31 How much coordination do you have? 32 How many services are wrapped around the patient/ caregiver? Are all the services communicating? Do they all understand the Plan of Care? If there are multiple services involved is a lead person identified and communicated to the patient/caregiver and the care team? How many phone calls is that patient/caregiver receiving after they get home? What are each of the calls purposes? 16

17 Case Studies Mark Green, MBA, PMP, LSSBB Ochsner, System AVP Transition Management, discussing their telephonic f/u program 33 Julie Mirkin, MA, RN, Wharton Fellow & Patricia Peretz, MPH New York Presbyterian, reviewing their Community Health Worker grassroots follow-up program. Guest Presenter 34 Mark Green MBA, PMP, LSSBB is currently Ochsner Health Systems Assistant Vise President of Transition of Care Initiatives and their Post-acute Network. This includes the Ochsner Care Coordination Center (C3). Mark is seen as industry expert in new and emerging care coordination efforts, and in developing leading edge transition models in our changing healthcare settings. In his previous roles Mark has held positions in the industry as a Credentialed healthcare Project Manager, and a practicing Lean Six Sigma Black Belt. Mark also has 18+ years of hospital leadership experience running Diagnostic Divisions and Cardiology Centers for several national health systems prior to working with Ochsner. Mark holds an undergraduate degree in Radiology Sciences (BSRT) from Adventist Healthcare, and an MBA from Marylhust University, as well as holding national certifications in both Project Management (PMP) and a Black Belt in Lean Six Sigma (LSSBB). Mark presents nationally on a variety of relevant Healthcare topics including, building and scaling readmission reduction programs, optimizing care coordination / transition management efforts, defining social determinants role in care management efforts, and project management and lean six sigma in the Healthcare industry 17

18 Ochsner Health System 35 Starting With the Answer **Collaborative Model** 36 18

19 The Challenge (Breaking the Readmit Cycle) 37 Triage Integration with Post Discharge Management Program 38 LPN Post Discharge Calls LPN LPN During Post-Discharge Calls any Symptom based complaint is forwarded to a triage RN s in order to manage them with standardized protocols. 87% of all call sent to the triage RN s are managed outside of the ED setting LPN LPN RN RN RN LPN LPN Triage / Advice 19

20 After-Hours Triage Integration with Discharge Clinic 39 After-hours calls to the Discharge Clinic are auto-routed through the Triage Call Center for care management. On average 200 calls a month are triaged and 85% of those calls result in an intervention other than the ED RN RN RN Triage / Advice Normal LACE Distribution Modeling 40 Risk Score 0 Risk Score 1 Risk Score 2 Risk Score 3 Risk Score 4 Risk Score 5 Risk Score 6 Risk Score 7 Risk Score 8 Risk Score 9 Risk Score 10 Risk Score 11 Risk Score 12 Risk Score 13 Risk Score 14 Risk Score 15 Risk Score 16 Risk Score 17 Risk Score 18 Risk Score 19 Validated Distribution 13,000 74,000 46,000 58, , , , , ,000 62,000 50,000 30,000 20,000 15,000 4,000 6,000 2,000 1,000 1,000 1,000 1,008,000 Model 1.29% 7.34% 4.56% 5.75% 15.08% 12.90% 10.12% 12.90% 11.01% 6.15% 4.96% 2.98% 1.98% 1.49% 0.40% 0.60% 0.20% 0.10% 0.10% 0.10% % 2014 OHS Low Risk High Risk Super High Risk Complex Case Discharges Risk Score 0 Risk Score 1 Risk Score 2 Risk Score 3 Risk Score 4 Risk Score 5 Risk Score 6 Risk Score 7 Risk Score 8 Risk Score 9 Risk Score 10 Risk Score 11 Risk Score 12 Risk Score 13 Risk Score 14 Risk Score 15 Risk Score 16 Risk Score 17 Risk Score 18 Risk Score 19 Total Projected Readmit rate 2.00% 2.50% 3.00% 3.50% 4.30% 5.10% 6.10% 7.30% 8.70% 10.30% 12.20% 14.40% 17.00% 19.80% 23.00% 26.50% 30.40% 34.60% 39.10% 43.70% Projected Readmits LPN Management Total RN Management Low Risk Rising Risk High Risk Total Risk Score 0 Risk Score 1 Risk Score 2 Risk Score 3 Risk Score 4 Risk Score 5 Risk Score 6 Risk Score 7 Risk Score 8 Risk Score 9 Risk Score 10 Risk Score 11 Risk Score 12 Risk Score 13 Risk Score 14 Risk Score 15 Risk Score 16 Risk Score 17 Risk Score 18 Risk Score 19 20

21 Triage / LACE Relationship Modeling 41 LACE Score % Needing Triage Ochsner Post Discharge Transitional Care Program 2.00% 2.25% 2.50% 2.75% 3.00% 3.25% 3.50% 3.75% 4.00% 4.25% 4.50% 4.75% 5.00% Post Discharge Calls Needing Triage Interventions Post Discharge Outreach Workflow 42 RN RN RN Triage / Advice ED / IP Care Setting Clinic / Urgent Care Setting 21

22 Post Discharge Outreach Workflow Acute to Home Discharges Day one Acute To Home Discharge Day Two Outreach Call By Day Seven High Risk Follow Up Visit By Day Fourteen Low Risk Follow Up Visit Day Thirty Readmission Reduction RN 43 Segmented Reason For Triage Need 44 Socioeconomic Segmentation Challenges Medication Adherence and Education Transportation Issues Exacerbation of Condition Health Literacy Complications Care Giver Support 44 22

23 Results of C3 Transitional Care Program 45 December 2015 Outreach Volumes # Discharges 2,197 # Calls Attempted in 48 Hours 2,381 # of 48 Hour Calls Attempted-Distinct MRN 2,051 % Called within 48 Hrs of Discharge 93% # of 48 Hour Calls Contacted 1,120 % 48 Hour Calls Contacted 50% # of Follow-up Calls Attempted in 3-7 Days 208 # of Calls Attempted in 3-7 Days-Distinct MRN 132 # of Calls Contacted in 3-7 Days 92 Ochsner C3 Questions? 46 23

24 Guest Presenter 47 Julie L. Mirkin, MA RN, Wharton Fellow is the Vice President for Care Coordination New York- Presbyterian Hospital. In this role, she leads strategic planning, development, and implementation for the Hospital s care coordination program across all six campuses, to ensure the delivery of safe, efficient, and cost-effective inpatient and ambulatory care. Ms. Mirkin, a nationally-recognized expert in care coordination with broad experience in clinical and hospital operations, joined New York- Presbyterian from IMA Consulting, where she served as Senior Consulting Manager. In this position, she was responsible for providing consultative and interim leadership services to health care organizations nationwide. Earlier in her career, she held Senior Vice President/Chief Nurse Executive positions at a number of health care organizations and hospitals in New York. Mrs. Mirkin received her Bachelor of Science in Nursing from State University of New York at Stony Brook, Master of Arts in Nursing Administration, summa cum laude, from Columbia University Teacher s College, and a Wharton Fellowship in the Nursing Executive Program from Wharton School of Business. She is currently pursuing her Doctorate at Case Western Reserve University. Guest Presenter 48 Patricia Peretz, MPH is the Manager of Community Health and Evaluation at New York Presbyterian Hospital where, for the last 8 years, she has worked alongside health care providers, program staff, and community partners to design, implement, and evaluate community health initiatives aimed at reducing the burden of illness in the local community. In this capacity, Patricia co-leads the Center for Community Health Navigation at New York Presbyterian Hospital that encompasses the peerbased community health worker and emergency department patient navigator programs based in 4 campuses of New York Presbyterian Hospital and in the surrounding communities. Prior to this role, Patricia worked at the New York City Department of Health and Mental Hygiene where she refined and evaluated strategies to improve the delivery of care for children with special needs and where she conducted research on the prevalence of overweight and obesity amongst low-income, preschool aged children in New York City. Patricia is a graduate of the Mailman School of Public Health at Columbia University. 24

25 49 Definitions: 50 Patient: able to remain calm and not become annoyed when waiting for a long time or when dealing with problems or difficult people. 25

26 Definitions: 51 Discharge: to relieve of a charge, load, or burden: to release from an obligation. tell (someone) officially that they can or must leave, in particular. The Challenge Never Discharge a Patient 52 Seamless Transition of Care is the Goal 26

27 53 Care Coordination: Key Guiding Principles Patient Experience Patient Advocacy Quality and Safety Effective Communication Efficient and Effective Utilization of Resources Transitions of Care Compliance with Accreditation and Regulatory Care Coordination: Inpatient Model 54 Physicians Patient Nurses Care Coordinators/Social Workers Quality supports the team and drives improvement 27

28 Care Coordination: Team Roles 55 Care Coordinators (RNs) Social Workers Discharge Planning Assistants Clinical Assessments, Patient advocate and navigator Psychosocial Assessments and interventions Supports Care Coordination Team Discharges to home with or without Home Care Services Complex discharges to facilities, Social Service Agencies and home Arranges Transport, Administrative tasks Care Coordination: Transition of Care Team Roles 56 Transition of Care RN Community Health Worker Clinical Assessments, Patient advocate and navigator Develops relationship and trust and visits patients post discharge Manages high risk Patients for 30 days post discharge Assists with health coaching, medication management, followup appointments 28

29 Discharge Planning Workflow 57 *Adapted from infographic 'NYPCC_ModelOverview_ ' Health Care s Changing Landscape: DSRIP NY State Delivery System Reform Incentive Program Ten NYP DSRIP Projects: 80,000 Attributed Lives Integrated delivery System Ambulatory ICU ED Care Triage Care Transitions: Prevent 30 Day re-admissions Behavioral Health and Primary Care Integration Behavioral Health Crisis Stabilization HIV Center of Excellence Palliative Care Tobacco Cessation Reduce HIV Morbidity 58 29

30 NYP Transitional Care Program Admission Discharge 30 days post discharge 59 Care Coordinator /Social Worker Transitional Care Managers Community Health Workers Ambulatory Care Network Care Manager Physician Organization Care Manager Manage Manage Manage Phone follow-up visits Education Disease monitoring Medication management Collaboration with, and/or referrals to: Community pharmacy Clinics (PCPs, Specialists) Home Care SNFs FQHCs NYS Medicaid Health Homes Behavioral health providers Supportive housing Other community agencies Center For Community Health Navigation At NewYork Presbyterian Hospital 30

31 Key Milestones WIN for Asthma CHW Program 2011 CHWs in the PCMH 2014 DSRIP 2008 ED Patient Navigator Program 2012 WIN for Diabetes CHW Program 2015 Center for Community Health Navigation CHW Definition A Community Health Worker (CHW) is a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served. This trusting relationship enables the CHW to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery. A CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support and advocacy. Source: Community Health Worker Section of the American Public Health Association

32 CHW Model 63 Hospital-Community Partnership Community Health Workers Bilingual Community-based Peer support & education reinforcement Members of health care teams Peretz P, Matiz LA, et al. Community Health Workers as Drivers of a Successful Community-Based Disease Management Initiative. American Journal of Public Health: August 2012, Vol. 102, No. 8, pp Program Stages: Pediatric Asthma 64 Stage 1 Months 1-3 Stage 2 Months 4-6 Stages 3 Months 7-12 Comprehensive Education Monthly Check-In Bi-Monthly Check-In Home Visit/Home Environmental Assessment Home Visit Home Visit Goal Setting & Service Referrals Goals Check-in Service Referrals Provider-Led Workshops Service Referrals 12 Month Follow-up Intake Survey 6 Month Follow-up Graduation *Frequency of check-ins and intensity of services determined by participant needs 32

33 PCMH-Based Support and Education 65 Community Health Workers: Work as members of the team and participate in multidisciplinary meetings and rounding Apply non-clinical, peer-based approach to reinforce key health messages Help patients understand diagnoses and uncover disease management obstacles Impact: 6004 patients have received practicebased support & education since February Core Training Curriculum 66 NYP Credentialing Shadowing Senior Workers CHW Core Competencies Asthma 101 Home Visiting Nutrition 101 Case Management Diabetes 101 Goal Setting Behavioral Health 101 Motivational Interviewing Cultural Competency Integrated Pest Management Health Literacy Home Remedies HIPAA Time Management/Case Management Mental Health/Wellness 33

34 Highlights 67 Asthma 1319 patients enrolled in year-long program ED visits and hospitalizations decreased by more than 65% among graduates Nearly 100% of graduates stated that they feel in control of child s asthma Diabetes 531 patients enrolled in year-long program Nearly 60% of graduates improved their A1C levels Nearly 100% of graduates stated that they are able to cope and reduce their risk Next Steps 1. Launch the Center for Community Health Navigation 2. Expand models to Cornell & Lower Manhattan 3. Expand support to new populations 4. Expand and enhance training curriculum 68 34

35 Lessons Learned CHWs from the local community are uniquely positioned to build trusting partnerships with patients and colleagues CHWs can move fluidly between community and health care settings CHWs can be the voice of the community in clinical settings and bridge gaps in care Community partner involvement in the development, implementation, and evaluation of programs is critical to success CHW models can be transferable to other areas and populations Questions? Comments? Discussion? 35

36 Action Period Assignment 71 Observe a discharge encounter and/or plan of care processes using the observation guide Or Utilize your Cross Continuum Team to review cases and determine if there was a clear actionable discharge plan develop communication protocols and tools to be used in transition across sites Observe Current Discharge Processes 72 Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare Improvement; June Available at 36

37 Expedition Communications All sessions are recorded Materials are sent one day in advance Listserv address for session communications: To add colleagues, us at 73 Session 3 74 Working with Community Partners for Successful Transitions Thursday, March 3 rd 1:00-2:00 PM ET 37

38 Thank You! 75 Please let us know if you have any questions or feedback following today s Expedition webinar. Jill Duncan jduncan@ihi.org Colby Champagne cchampagne@ihi.org 38