Quarterly Community Meeting Barb Averyt, BSHA Director, Care Coordination and Nursing Homes Health Services Advisory Group (HSAG) April 21, 2016
Today s Agenda 8:30 a.m. Welcome and Opening Remarks 8:45 a.m. East Valley Care Coordination Coalition () Community Update 9:00 a.m. Knowing your Community Partners: Paramedicine Presentations 1. An Introduction to Community Paramedicine 2. Mesa Fire/CMS * Grant: Community Care Response Initiative 3. Chandler Fire: Complex Patient Management Program 10:00 a.m. Break 10:20 a.m. Community Discussion 11:00 a.m. Workgroup Updates 11:20 a.m. Evaluations and Adjourn 2 *Centers for Medicare & Medicaid Services
Evaluations Feedback 2016 Evaluation Completion Rate 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Goal = 85% Feb Kickoff April July Sept Nov. 3
2014 Medicare Fee-For Service (FFS) Beneficiary Activity 30% of all admissions 33% of all ED visits Source: HSAG Analysis of Medicare FFS Part-A Claims Data Q2 2014 Q1 2015
2014 30-Day, All-Cause Readmissions 5 Source: HSAG HSAG Calendar Analysis Year of Medicare 2014 Medicare FFS Part-A Fee-For-Service Claims Data Q2 claims 2014 Q1 data. 2015
National and State Picture: Readmissions by High-Risk Medication Class HRM significantly increases the risk for readmission! 6 Source: Calendar Year 2013 Medicare FFS Part-D Claims Data
Community Update Kick-off February 4, 2016 58 community providers attended 42 signed Charters Evaluation completion rate: 90 percent Overall evaluation score: 3.6 On a scale of 1 4, with 4=Strongly Agree 7
Membership April 2016 42 Organizations to Date 1. Archstone Care Center 2. Arizona Care Network 3. Arizona Health-e Connection 4. Arizona Home Care 5. Arizona Orthopedic & Surgical Specialty Hospital 6. Arizona Spine and Joint Hospital 7. Arizona Living Well Institute 8. Assisted Home Health 9. Assisted Living Locators 10. Brookdale North Chandler 11. Chandler Fire, Health & Medical Department 12. Chandler Post Acute & Rehabilitation 13. Chronic Care Community Partners 14. Citadel Post Acute Care Center 15. City of Mesa Fire and Medical Department 16. ComForCare 17. Crisis Preparation and Recovery, Inc. 18. Desert Blossom Health & Rehabilitation Center 19. Dignity Health Mercy Gilbert Medical Center 20. Dignity Health Chandler Regional Medical Center 21. Foundation for Senior Living 22. Gentiva Home Health 23. Gilbert Fire & Rescue 24. Golden Heart Senior Care 25. Healthsouth South East Valley Rehabilitation Hospital 26. Home Instead Senior Care East Valley 27. Hospice of the Valley 28. Mikell Christian, Patient Representative 29. IPC Healthcare, Inc 30. KC's Home Health Care LLC 31. La Estancia Nursing and Rehabilitation Center 32. Montecito Post Acute Care and Rehabilitation 33. Mountain Vista Medical Center 34. Neighbors Who Care, Inc. 35. Oasis Behavioral Health 36. Plaza Healthcare 37. Serenity Hospice and Palliative Care 38. Team Select Home Care 39. Universal Care Management 40. Valley Transitional Care 41. Vitalyst Health Foundation 42. Wellsprings of Gilbert 8
Root Cause Analysis (RCA) Topics 1. Care Coordination Workgroup 2. Medication Management/Medication Reconciliation Workgroup 3. Health literacy and teach-back 4. Hand off transitional communication (does this belong in #1 or could they merge?) 5. Community Resource Guide, including behavioral health resources 6. Hospice palliative care and education regarding palliative/hospice 7. Behavioral health 9
Who is at Our Table? 10
Community Structure: Three Month At-A-Glance Workplan/Next Steps What When Who Kick-off Event February 4, 2016 providers sign Charters February March 2016 and ongoing Hospital CEOs or designee Establish Steering Committee A. Identify co-chairs B. Identify community members C. Define/develop work statement Establish three workgroups based on RCA and Steering Committee discussion First meeting March 28, 2016 Meet quarterly thereafter and one month prior to Quarterly Community Meeting June Date TBD October Date TBD Workgroup #1 March 2016 Workgroup #2 May 2016 Workgroup #3 July 2016 HSAG support Co-Chairs Community Members HSAG support Team co-lead(s) pending Team members Hold Next Quarterly Community Meeting April 21, 2016 Community 11
Steering Committee Members Melanie Mitros, PhD Director, Strategic Community Partnerships Vitalyst Health Foundation Joan Bowman, Case Management Arizona Orthopedic & Surgical Specialty Hospital Darryl Lerner, Community Liaison Assisted Home Health Mikell Christian, Patient Representative Forest Peterson, Executive Director Montecito Post Acute and Rehabilitation Shawn McAffee, CEO Serenity Hospice and Palliative Care Barb Averyt, Director HASG Roxanne Dudish, BA, RN Director of Care Coordination Dignity Health Chandler Regional & Mercy Gilbert Medical Centers Val Gale, Battalion Chief Chandler Fire, Health & Medical Department Nicole Owens, Community Outreach and Marketing Manager, ComForCare Rey Graf, Director Community Relations Home Instead Senior Care East Valley Robert Webb, Director Business Development Oasis Behavioral Health Center Bill Daniell, Deputy Chief EMS, Mesa Fire and Medical Department Ettie Lande, Associate Director HASG 12
We Are Right On Track With Our Timeline 13
An Introduction to Community Paramedicine Melanie Mitros, PhD Strategic Community Partnerships Vitalyst Health Foundation
Mesa Fire: CMS Grant Crisis Care/Behavioral Health Tony LoGiudice Mesa Fire and Medical Department CMS Innovation Grant Administrator Dennette Janus, MA, LPC Crisis Preparation and Recovery (CPR)
Chandler Fire: Complex Patient Management Program Val H. Gale, Jr. City of Chandler Fire, Health, and Medical Department
Community Paramedicine Discussion Questions for After Break Using a Likert Scale 1 5: Based on your knowledge, how involved is your local fire department or district in the health of your community (e.g., through immunizations, car seat installation checks, etc.)? Community paramedicine has many opportunities to meet the needs of the community. What opportunities do you see that could impact your organization directly? Emergency medical services (EMS)/community paramedicine want to provide feedback to the organizations they serve; how would you suggest that be accomplished? 17
Root Cause Analysis (RCA) Topics 1. Care Coordination Workgroup 2. Medication Management/Medication Reconciliation Workgroup 3. Health literacy and teach-back 4. Hand off transitional communication (does this belong in #1 or could they merge?) 5. Community Resource Guide, including behavioral health resources 6. Hospice palliative care and education regarding palliative/hospice 7. Behavioral health 18
RCA Topic Workgroups Three Month At-A-Glance Workplan/Next Steps What When Who 1. Care Coordination Workgroup A. Hospital Nursing Home Care Coordination Committee (See detail on next slide) B. Hospital Home Health Care Coordination Committee C. Community organizations? (To be discussed) Initial meeting occurred Feb. 29. Will have ongoing monthly meetings on the third Tuesday of each month Will start home health care meeting in late spring/early summer Roxanne Dudish, BA, RN Director of Care Coordination, Dignity Health, Chandler Regional and Mercy Gilbert Medical Centers HSAG Staff Roxanne Dudish, BA, RN, Dignity HSAG support 2. Teach-back Workgroup To impact all providers and first responders in community Time not determined, perhaps Spring 2017 19
Dignity Nursing Home Care Coordination Committee Six Month At-A-Glance What When Nursing Home Care Coordination Committee kick-off event February 29, 2016 Dignity Town Hall meeting March 22, 2016 Dignity Updates: Emergency department program update Internal readmissions team: structure and goals ACN (Dignity s Accountable Care Organization) update Discussion with nursing homes regarding upcoming changes in 5 Star Ratings HSAG s Composite Score and Nursing Home Readmission Reports (Quarterly) Impact of composite score and Star Rating Advancing Excellence Readmission Tracking Tool Introducing and training on the HSAG Medication Reconciliation Tracking Tool Open discussion Congestive heart failure (CHF) educator and creating protocols for nursing homes Open discussion April 5, 9:30 11 a.m. May 17, 9:30 11 a.m. June 21, 9:30 11 a.m. July 19, 9:30 11 a.m. Policy brief: Transfers of the elderly from nursing facilities August 16, 9:30 11 a.m. 20
Quarterly Community 2016 Meetings Meeting Date and Time Where Registration Required Kick Off Monday February 8, 2016 Mercy Gilbert Medical Center McAuley Auditorium 3420 S. Mercy Drive Gilbert, AZ 85297 Thursday April 21, 2016 8:30 11:30 a.m. Mercy Gilbert Medical Center McAuley Auditorium 3420 S. Mercy Drive Gilbert, AZ 85297 Thursday July 14, 2016 8:30 11:30 a.m. Mercy Gilbert Medical Center McAuley Auditorium 3420 S. Mercy Drive Gilbert, AZ 85297 http://www.cvent.com/d/yfqppp NEW Statewide Fall 2016 Care Coordination Conference 8 a.m. 3:30 p.m. Desert Willow Conference Center 4340 E. Cotton Center Blvd. Phoenix, AZ 85040 $15.00 per attendee cost solely for food/beverage SAVE THE DATE! Registration coming soon! UPDATE Thursday October 13, 2016 November 10, 2016 8:30 11:30 a.m. Mercy Gilbert Medical Center McAuley Auditorium 3420 S. Mercy Drive Gilbert, AZ 85297 http://www.cvent.com/d/tfqpp1 21
Evaluations Feedback 2016 Evaluation Completion Rate 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Goal = 85% Feb Kickoff April July Sept Nov. 22
Final Discussion and Next Steps
Thank you! Barb Averyt, BSHA baveryt@hsag.com Ettie Lande, MS, BSN, RN elande@hsag.com
This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, 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. AZ-11SOW-C.3-04142016-04