Transformation Metamorphosis
Building Healthiest Communities By Aligning Forces For Quality (AF4Q) A Humboldt County Community Collaboration
Goal Building Healthiest Communities: AF4Q Develop and Implement a High-quality Integrated Patient-centered system of care that is Accessible to all North Coast residents.
Building Healthiest Communities: AF4Q The ALLIANCE ROBERT WOOD JOHNSON FOUNDATION AF4Q ALIGNING FORCES FOR QUALITY IPA PERFORMANCE MEASUREMENT QUALITY IMPROVEMENT DISEASE REGISTRY PUBLIC REPORTING ST. JOSEPH S CARE TRANSITIONS CORE MEASURES CHA CONSUMER ENGAGEMENT OUR PATHWAYS TO HEALTH TAKING CHARGE (POET) HOW TO HAVE A GOOD VISIT
Building Healthiest Communities: AF4Q APPROACH Regional Quality Improvement via Transitions in Care Consumer Engagement via Promoting Self Skills Consumer Awareness via Physician Measurement & Reporting
Building Healthier Communities: AF4Q
Humboldt County Us The Redwood Curtain Civilization
California County Health Rankings 42
Building Healthier Communities: Care Transition PERFORMANCE IMPROVEMENT WILL IDEAS EXECUTION
Building Healthiest Communities: Aligning Forces For Quality (AF4Q) Our Contribution The Care Transition Us Civilization Program
Building Healthier Communities: Care Transition TRANSITIONS To integrate care systems between the hospitals and community providers as the client transitions through the continuum.
Building Healthier Communities: Care Transition QUALITY IMPROVEMENT Hand offs Problems occur most often in the between service providers. Challenge Primary Care Providers don t see their own clients in the hospital = need for transition management.
Medicare Cost Per Beneficiary and 30-Day Readmission Rates HIGH C O S T S LOW DAYS HIGH
Building Healthier Communities: Care Transition QUALITY IMPROVEMENT Main reasons for hospital readmission: 1. Lack of connection with PCP 2. Medication management 3. Not knowing when to seek help 4. Lack of follow up on tests and treatments.
Building Healthier Communities: Care Transition The Case Continuum Disease management Touch Works centralized scheduling Virtual access PCP appointments Referral system; risk assessment Shared Call center Community partnership Healing hospital (green) Multidisciplinary assessment Discharge transition team Evidence-based pathways Community Patient Client Care Network Care Navigator Electronic care plan Care Wellness center Mobile clinics Care Plan Clinics-heart failure, wound care, pulmonary Key Drivers of Readmission Connectivity with Primary Care Provider Medication Lack of Follow- Up on Tests & Treatments Lack of Knowledge Regarding Disease Self- Keys Intensity of Community Care Low Health/Wellness Needs Continuum High
Building Healthier Communities: Care Transition TRANSITIONS Operationalizing the Case Continuum 1. Know your population 2. Know your goals 3. Target the intervention
Building Healthier Communities: Care Transition FOUNDATION Partner with the community and other care providers Fill in the gaps of service: don t duplicate Tailor interventions to the client s needs. Empower the client to be a co-manager in their health Focus on effectiveness & efficiency
PARTNERSHIPS
Client Needs Building Healthier Communities: Care Transition STRUCTURE Upstream Prevention Core Services Intensive Transitional Services SNF Case Fill the gaps, build on success
Building Healthier Communities: Care Transition STRUCTURE Core Services Senior level RN Coaches. Pt focus: Core Measure & Chronic Disease with limited resources Intensive Transitional Services RN/ MSW Team Complex pts w/ high risk of poor outcomes Automatic screens & visits for CMSP clients Hospital and Community based referrals Skilled Nursing Case RN Case Manager w/ psychiatrist & internist MD assist Complex pts w/ high risk of poor outcomes Focus on rehabilitation & DC to community w/ CTP support
Building Healthier Communities: Care Transition HISTORY Seeds to Trees Year 1: Core Services, Partnership with HSU, CHCF Funding Year 2: Expansion to RMH, RWJ Funding Year 3: Student Interns, Inpatient Discharge Phone Calls Year 4: Intensive Transitional Services, CMSP Funding Year 5: SNF Case Services, Community Heart Failure Collaborative, Core Services Expansion to MRCH
Building Healthier Communities: Care Transition TRANSITIONS Operationalizing the Case Continuum 1. Know your population 2. Know your goals 3. Target the intervention: the PAM
The Patient Activation Measure (PAM ) assessment gauges the knowledge, skills and confidence essential to managing one s own health and healthcare. Level 1 Level 2 Level 3 Level 4 Starting to take a role. Building knowledge and confidence Taking action Maintaining behaviors Increasing Level of Activation
Building Healthier Communities: Care Transition CORE SERVICES: What Is It? Free service Addresses the primary reasons for readmission Facilitates development of client co-managers Sustainable platform for: Patient Empowerment Health Care Self- management Self-advocacy skills
Building Healthier Communities: Care Transition FOCUS: CORE SERVICES Service learning partnership Clients served : 829 Average Daily Census: 82 Total Number of Students : 67 Paid Interns: 32 Average time in the CTT program: 120 days Medication Discrepancies at time of Discharge: 2.2 Post Discharge Phone Calls: SJE: 420 calls per month RMH: 112 calls per month
Building Healthier Communities: Care Transition RESULTS: CORE SERVICES 30 Day Readmission Rate: 11% All hospitalized patients contacted post discharge Improved coordination between the hospitals and the Primary Care Provider (PCP) network. HCAPFS Score on Preparation for Discharge:83 Higher than state & national average
PAM Level Scores: Admission & 60 Day Desired trend: moving from low to high LOW HIGH LOW HIGH
The Million Dollar People: Matthew & Reggie
HUMBOLDT COUNTY S HOT SPOTS What We Can Do To Alleviate Them: Managing Transitions
The Evolving Population Landscape
The Evolving Financial Landscape PIC financial Armageddon or making lemonade
Current State Fragmented Multidisciplinary Suboptimal Clinical Outcomes Pt Experience Workplace Satisfaction Financial Performance
Medicare Cost Per Beneficiary and 30-Day Readmission Rates HIGH C O S T S LOW DAYS HIGH
Future State PIC REGU BEAST (Balrog)
Building Healthier Communities: Care Transition FOCUS: INTENSIVE TRANSITIONAL SERVICES MSW and RN Case Team Focused on high utilizers of services Care planning addresses determinants of health Integrated with Community Benefits Program Purchase needed resources (housing, transportation, food, medications, communication)
The Healing Ring House
Building Healthier Communities: Care Transition RESULTS: INTENSIVE TRANSITIONAL SERVICES Readmission rate: 9% Decreased resource utilization: ACF: 69% ED: 64% UC: 88% Savings avoidable hospital days: $1.43 million Savings decreased resource utilization: $891,000 Community savings d/t resource utilization: $2.97 million Community savings to d/t homelessness: $2.3 million
Building Healthier Communities: Care Transition NEXT STEPS Collaboration on Population The Humboldt County Community Heart Failure Collaborative Flow chart
Inputs/ Demands 1 Assessment/ Admission Phase Patient Flow Diagram Admission Decision 2 Acute Care Phase Transition Decision 3 Transition Phase 4 Community Care Phase Trauma Emergency Entrance Door UNSCHEDULED ADMISSION + Handoff Admission Status: Compliance Coordination Reimbursement Interdisciplinary Care Exit Door Acute Long Term: SNF Rehab + Handoff Care Transition Team + Service Primary Care SNF/Rehab Dialysis Primary Care Visit Discharge Planning Failures SCHEDULED ADMISSION Hot Spotters = (High Risk + High Consumption) Home Skilled: Home Health Hospice Home Health PAC (Population Health ) Hot Spotters = (High Risk + High Consumption) Home Health Hospice/ Palliative Care Substance Abuse Treatment Specialty Care Out Patient Services Total Cost of Care = Clinical Practice & LOS Reimbursement Case Mental Health Treatment Patient Population & Payer Mix Impacts
Care Redesign Coordination across the Continuum of Care Right Level of Care at the Right Time Interdisciplinary Care Coordination
ACMC Patient Flow & Care Transition Related Initiatives 1. Care System Redesign 2. Project RED (DC Planning) 3. Care Transitions Team 4. Care System 5. ED Flow 6. Physician Discharge Toolkit 7. Discharge Medications 8. Improve Interdisciplinary Communication 9. Financial Planning on Admission
Building Healthier Communities: Care Transition CONCLUSIONS 1. Quality of care is improved by facilitated transitions. 2. Readmissions & unnecessary utilization of resources are decreased with tailored case management and client coaching. 3. Strengthening linkages between PCP network & hospitals prevents adverse outcomes & improves client experience.
Our Future Is Only Limited By Our Imagination FLYING COW PIC HERE