Hospital Readiness. Preparing For Care Transitions and Population Health Management. A Readiness Assessment Tool For Rural Hospitals

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1 Hospital Readiness Preparing For Care Transitions and Population Health Management THE SURVIVAL OR OF RF R E H PITALS HOS AL UR WORKING TO GE T A Readiness Assessment Tool For Rural Hospitals 245 Backbone Rd E., Princeton, IL

2 Team Members Assisting in Global Overview: ICAHN Hospital Readiness Form/org. 09/2017

3 Dear Hospital Administrator: Healthcare Transformation: Healthcare transformation involves assessing and continually improving the way patient care is delivered at all levels in a care delivery organization. It occurs when an organization rejects existing practice patterns that deliver inefficient or less effective results and embraces a common goal of patient safety, clinical outcomes and quality care through process redesign and information technology implementation. By effectively blending people, processes and technology, clinical transformation occurs across facilities, departments and clinical fields of expertise. Organizations seeking to adopt innovative care models often need to develop new systems and roles, while overcoming resistance to change. To successfully implement care transitions and population health, you will need to ensure that the conditions are right and that needed resources are readily available. This Readiness Assessment Tool is designed to help you and your team take a global view of your internal and external operations to facilitate the change in your hospital transformation journey. This is just the first step of your journey, and additional gap analysis tools and project management templates will follow the initial readiness assessment. As you will see, the tool is designed in six specific categories of: Governance and Leadership Operations Patient Care Management Population Health/Disease Management Quality IT Infrastructure This tool has been designed to use the stoplight approach to readiness by using the red/yellow/green view of preparedness within your hospital inpatient, outpatient and provider settings. There is no right or wrong answers when completing the tool. It is to serve as a guide for preparation and identification of areas requiring further education and organization change to achieve transformation. At the end of each section, there is a scoring line to total the number of red/yellow/green checks within the section for further evaluation and provide a look at the areas of focus. The final page of the Readiness Assessment Tool will allow you to populate the table for final view of your scoring numbers moving forward. We ask that you complete this page and submit scores to this link: by December 8. A population health webinar series will be presented at the March meeting. Thank you for using our Readiness Assessment Tool and we look forward to working with each of you on the journey. Regards, Executive Director Director of Quality and Educational Services This is a product of Illinois Critical Access Hospital Network (ICAHN) and the Illinois Rural Care Coordination Organization (IRCCO). Materials provided by ICAHN through the Iowa Small Hospital Improvement (SHIP) Program. Grant FY17, Iowa Contract #5888 SHO1.

4 Governance & Leadership Organization Not Yet Moderately Highly Comments Organization has aligned its mission and vision with population health Organization s culture positively embraces population health and change Organization has implemented its Community Health Needs Assessment plan Organization targets the needs of its community and those we serve. Examples: Palliative care Preventative care Wellness Curative Rehabilitative Health promotion activities Organization currently has a process to identify patients for population health management Claims data Patient registry Biometrics Organization s strategic plan includes initiatives to prepare for hospital transformation and population health management Board Governing board is involved and supports hospital transformation and organizational change Governing board is actively involved in the development of its strategic plan Governing board understands and supports quality and performance improvement principles (board priority) Governing board participates in ongoing education and training on care coordination and transformation principles Physicians and Advanced Practice Practitioners Medical providers are involved in hospital decisionmaking and are supportive of the hospital strategic plan Medical providers participate in ongoing education and training on clinical integration and population health management Medical providers are actively involved in quality improvement

5 Physicians and Advanced Practice Practitioners (continued) Medical providers are involved in hospital decisionmaking and are supportive of hospital s strategic plan Medical providers understand Patient Centered Medical Home and have implemented concept Score Medical providers support and incorporate evidencebased medicine in practice Financial Financial team is actively engaged in hospital transformation Hospital financially supports care navigation programs inpatient and outpatient Hospital has identified budget items required for care transitions and population health management for next fiscal year Hospital has tools to analyze service line value and return on investment Hospital financially supports population health management initiatives Leadership Leadership is actively engaged in change management as part of transformation Leadership understands hospital transformation and population health management principles Leadership supports and takes responsibility to implement the strategic plan Leadership is considering or interested in developing Clinically Integrated Networks (CIN) and advancing population health efforts in the community. Leadership has provided education on ACO concepts to governing board, physicians and others Leadership maintains both formal and informal means of communication and encourages new ideas and informal feedback Governance & Leadership Notes:

6 Operations Care Transitions/Population Health Not Yet Moderately Highly Comments Hospital has a centralized scheduling program Hospital has a system for patient reminders/appointment changes Hospital has dedicated staff to provide community education programs Hospital offers wellness programs. Examples: Our employees Our business partners Our community Hospital has a plan to shift more patient services to the outpatient setting, which includes retraining staff as needed Hospital has begun education to staff on care transitions and care management Hospital participates in readmissions and chronic disease management programs Hospital provides resources for clinical areas to incorporate evidence-based practice Hospital has a organization-wide customer service program Hospital has implemented Lean practices throughout the organization with staff engagement Hospital has incorporated performance/productivity based measures Hospital has initiated a chronic disease wellness program for employees and/or community Case managers and other have reviewed the Community Health Needs Assessment Score Operations Notes:

7 Operations Not Yet Patient Care Management - All Clinical Departments Moderately Highly Comments Hospital has an inpatient case management program Hospital case manager is on call for after-hours discharges and difficult patient care situations Hospital has an outpatient case management program Hospital has a discharge call-back program and includes the following, but not limited to: Emergency room visits D/C from nursing floors Outpatient visits Nursing staff utilizes a discharge assessment tool to determine patient readiness for discharge Nursing and other health professionals incorporate evidence-based practices into the clinical setting and hospital policies and procedures Nursing has established bedside reporting program Nursing/case management includes patient and family in the care planning process Medical providers are part of the care management team Discharge program includes making appointments for follow-up visit with medical providers and/or therapy services as needed Nursing/case management conducts at least weekly multidisciplinary care management meetings Hospital has established ongoing communications with area nursing homes, local health departments, referral centers, home health, hospice and other social services and behavioral health programs Hospital staff has established ongoing communication with primary care providers to ensure continuity of care and improvement in care and hospital services Hospital has a means to identify and monitor high-risk chronic disease patients and create a care plan based on needs and resources Hospital staff is engaged in care transition from one level of care to next Hospital has behavioral health resources readily available for inpatient and outpatient care needs Score Patient Care Management

8 Operations Population Health/Disease Management Not Yet Moderately Highly Comments Hospital has initiated a population health management plan for its employees Hospital has established at least one outpatient chronic disease management program (i.e. diabetes, congestive heart failure, obesity) If yes, please indicate in comments Hospital offers an annual wellness education and screening program for the community Hospital provides offsite education and screening in cooperation with local medical primary care providers Hospital has established a community health education program, providing at least one program quarterly, and based on population health needs Providers have a well-designed process in place for referral tracking and obtaining feedback from specialists Hospital is actively engaged with local health department programs and initiatives Medical providers actively support and refer to hospital s chronic disease management and community education programs Score Population Health/Disease Management Notes:

9 Quality Not Yet Moderately Highly Comments Hospital has an active hospital-wide quality improvement program and reports findings to the board Hospital has established a program to measure readmission rates and actively monitor trends/ improvement methods Medical providers report quality improvement measures, including practices and clinics Hospital participates in programs, such as Project RED, BOOST, Hospital Engagement Networks (HEN) or other programs Leadership rounds a minimum of once a week Score Hospital staff has embraced quality as part of the organization s culture and practice Hospital staff is aware of the quality measures and participates in data collection and improvement of care and service Hospital provides a transparent view of quality measures to the public reports required measures to Hospital Compare Providers are monitoring PQRS quality metrics for improvement Quality Notes:

10 Operations IT Infrastructure Not Yet Moderately Highly Comments Hospital has conducted a facility-wide analysis of internal improvements required for statistical data and informatics reporting through EMR Hospital has or will meet Meaningful Use Stage II by December 2017 Clinic will meet Meaningful Use Stage I by 2017 Hospital has IT connection to all departments, including physician practices, clinics and off-campus services, such as home health Hospital EMR connects to one or more physician practices or clinics for exchange of patient information Medical providers have the ability to share data electronically with other medical providers Hospital participates in a statewide, regional or system-wide health information exchange Hospital utilizes a clinical information specialist Hospital utilizes a discharge call management software program Hospital has initiated or plans to launch a patient portal within six months for its customers Hospital IT system provides for medical provider e-prescribing with pharmacies and others Hospital IT system has modules for population health management (trend and track data) Score IT Infrastructure Summary Recommendations:

11 Hospital Name: Contact Person: Contact Key: Moderately prepared organizations will have greater than 61 responses in yellow and green Highly prepared organizations will have greater than 76 responses in green CATEGORY Not Yet Moderately Highly Governance & Leadership (27) Operations (13) Patient Care Management (16) Population Health/Disease Management (8) Quality (9) IT Infrastructure (12) TOTALS (85) Areas identified that are not within the tool: Any specific areas of education identified when completing this tool? Please upload data to the following link by December 8,

12 WORKING TOGETHER FOR THE SURVIVAL OF RURAL HOSPITALS Take The Lead Hospital Readiness 245 Backbone Rd E., Princeton, IL