Boulder County Care Transitions Collaborative 2016 Age Well Conference
What is BCCTC Boulder County Care Transitions Collaborative started March 2012 CMS Grant Goal to reduce Readmission in Boulder County Partnership between Area Agency on Aging and Quality Improvement Organization (QIO)/Colorado Foundation for Medical Care (CFMC) with community involvement
Foundation Small Think Tank March, 2012 Quickly realized all stakeholders needed to be at the table to make real change Community Coalition June, 2012 Expanded into a community coalition primarily identifying struggles to readmissions and discussing solutions in an ideal world Collaboration August, 2014 CMS Grant ended Community run group with leadership team guiding direction and helping to ensure progress
Quantitative Accomplishments 30 Day Readmission Rate (All Cause) 2014 Boulder County Colorado Medicare Only 6.68% 10.15% Private Insurance Only 5.76% 5.28% Medicaid Only 7.81% 10.10% All Current Payers 6.75% 8.51% 2012 17.6% of Medicare beneficiaries nationwide were re-hospitalized.
Qualitative Accomplishments Improved partnerships between providers Understanding each other s businesses Providers (who) Organizational structure Regulations Clinical/provider capabilities Sharing of best practices Local Resources: involve over 75 organizations throughout Boulder County Similar struggles/systems developed within providers Development of county wide templates/expectations Teamwork Less of a competitive mentality Focus on the right thing for the patients/people of Boulder County, no longer about the individual organization
Establishing Peaks Formation of leadership team Community Lead Representing a variety of types of organizations Hospital, SNF, ALF, Home Health, Home Care, PCP Creation of mountain top goals Established timeline
Mountain Top Goal 2011-2017 2011
Peak 1 Goal: Reduce hospitalization between hospital to skilled nursing facility Local Involvement/ Resources First time the hospitals and SNF s sat down together 4 meetings between Fall 2013 and Fall 2014 Identified barriers and discovery of capabilities of both sides of the patients care SNF Regulations: Acceptable discharge plans, restraints, psychotropic medications, labs, medication delivery Best Practices: Re-evaluated necessary information on transfer forms and report call Improved partnership between providers Organizational contacts Sharing of best practices Peak 1 Hospital-SNF protocol/set of information has been established and implemented Transitional care nurses follow patients closely
Peak 2 Goal: Reduce hospitalization between hospital to skilled nursing facility by involving/educating the PCP and educating hospitalists Local Involvement/ Resources Transitional care nurses, PCPs, Specialist and Hospitalist involvement Identified barriers and discovery of capabilities of more sides of the patients care Educated PCP s, specialists and hospitalist on SNF clinical capabilities Misconceptions identified, i.e. stat labs, ability to do certain procedures Assumptions addressed, relationships built, respect established Best Practices: Expectation of improved communication and collaboration between all providers involved Improved partnership between providers Organizational contacts Peak 2 Hospital-PCP & specialists & hospitalists protocol/set of information has been established and implemented Hospital informed PCP of discharge from hospital to SNF SNF provided discharge information to PCP upon leaving SNF Specialty education within SNF s Transitional care staff follow patient closely while at SNF and schedule specialty appointments during SNF stay and PCP appointments within 1 week of discharge
Peak 2 Trial and Best Practices--discharge information being sent to all parties involved when leaving a SNF Your Patient is being discharged from our facility on. A follow up appointment will be made prior to discharge with the Primary Care Physician, and a copy of the discharge orders will be faxed to all following physicians for review. Primary Care Physician Follow up appointment Orthopedic physician Nephrologist Cardiologist Other Home Health
Peak 3 Goal: Reduce hospitalizations. By this point we have hospital to skilled nursing facility by involving/educating the PCP and educating hospitalists and bringing in Home Health and Home Care agencies. Local Involvement/ Resources-over 10 local Home Health s and a handful of non-medical agenesis joined our collaboration Identified barriers and discovery of capabilities of more sides of the patients care: Who orders what and when do they arrive: Wound Care Supplies, DME Peak 3 Hospital- Home Health protocol/set of information has been established and implemented O2 orders, Medications, INRs Medication Management getting Rx s to patients home, setting up pill boxes, watching for side affects, reporting errors to who and when? Psyc- Social Issues and Support Family Dynamics
Nurse-to-Nurse Handover Pilot Program Goal: determine if Nurse to Nurse Handovers were valuable in the communication piece of reducing rehospitalziations for complex/ at risk patients 3 SNF s participated and 3 Hospitals and 5 Home Health agencies 76 patients were tracked in a 60 day window. Feedback: average Quality of Call -4, most were LC, comments included- Very valuable! From paperwork, I would never had know what the nurse was able to share in the phone call.
Peak 3 Best Practices: Expectations- time frame for SOC, supplies and communication Communication points-nurse to Nurse Hand-Over Education
Peak 4 Peak 4 Hospital-ALF protocol/set of information has been established and implemented Over 55 licensed ALF s in Boulder County
Peak 4 Goal: Reduce hospitalization between hospital to skilled nursing facility by involving/educating the PCP and educating hospitalists and bringing in Home Health and Home Care agencies for individuals living in Assisted Livings Local Involvement/ Resources-over currently have over 15 active assisted livings in our collaboration Identified barriers and discovery of capabilities of more sides of the patients care: When a resident can return to home: regulations, each community is different, time frames How can a resident get home? Family involvement Local Involvement COMMUNICATION between ALF, EMT, ER
Peak 4 Area Agency on Aging developing a quick reference on their website. Trial currently in progress, through end of 2016: TRANSFER SUMMARY TEMPLATE Goal of having better communication as to why resident is being sent out by ALF and how fast can they get back home and stay. Alz Slums 15, Alert and oriented Very confused last 2 hrs
Mountaintop Goal 65 days until 2017 Our mission will never be fully completed It is an ever changing industry Needs are ever changing Rules and Regulations are ever changing But our goals remain the same Improved partnerships between providers Sharing of best practices Utilize and work successfully with Local Resources, Teamwork Development of county wide templates/expectations Best Practices Reduce Rehospitalzations in Boulder County
If you want to get involved: Please contact a member of the BCCTC Leadership Team Julie Nash303-440-9100, Julie.Nash@hcr-manorcare.com Sherri Klotz 720-639-2200, Sherri.Klotz@genesishcc.com Next Meeting will be November 2 nd at 3:00 PM PowerBack in Lafayette 329 Exempla Circle, Lafayette Meeting are the 1 st Wednesday of each month from 3:00 5:00 PM Questions?