Orlando, Florida The Triple Aim & Beyond- Partnering with Payers- Increasing Trust, Building Infrastructure, & Rethinking Partnerships Iva Tatum, RN CCM CLNC Manager of Case Management Community Care Managed Healthcare Plans of OK IHI Summit March 20 22, 2016 Session Objectives Understand the approaches taken by payers to successfully engage with providers and communities to improve delivery of care and patient outcomes and the keys to effective collaboration among the stakeholders Outline what payers can offer to provider practices to enable them to thrive in a value-based payment model, as well as the components of the Triple Aim that can be achieved in partnerships of payers with providers and their staff Provide data to support the momentum that fosters patientcentered care and effectively implement intervention bundles Identify innovative resources for population management and care coordination and tools to build community partnerships and relate success stories from providers engaged in valuebased programs 1
3 Provider owned health plan Tulsa, Oklahoma Serving over 400,000 lives, predominately in NE Oklahoma Owned by St. Francis Hospital and St. John Health System Each system with employed medical group Integrated System Where do you start? 4 For everything there is a beginning.. 2
Americans are Living Longer 6 Centers for Disease Control (CDC) www.cdc.gov 3
The 2014 State of the States Health Report reports the following statistics. Oklahoma ranks 44 th in overall health status compared to other states in the nation. Oklahoma has the 1. 12 th highest rate of death due to cancer in the nation. 2. 3rd highest rate of death due to heart disease in the nation. 3. 4th highest rate of death due to stroke in the nation. 4. Highest rate of death due to chronic lower respiratory disease in the nation. 5. 4th highest rate of death due to diabetes in the nation. PAYERS as PARTNERS 8 What are the puzzle pieces in utilizing cutting edge practices to execute optimal healthcare??? CPC TTH PAYERS Community Collaborative Patient ACO My Health Community Resources SNF FHP 4
Initiatives, Interventions & Outreaches 9 CPC Community Collaborative ACO TTH My Health SNF Community Resources PAM FHP 1. Individuals come to the hospital at the right time. (By way of prevention and education, members learn to come earlier in their symptoms before something becomes an acute emergency. It s much more expensive to treat acute cases in the ER.) Find the Right Door 2. Individuals come through the right door. (Members get information about how to access primary care facilities and doctors, avoiding the ER if possible to keep costs lower.) 3. Individuals come ready to be treated: Education reduces anxiety, they understand their benefits & financial options, & they understand their medications. 4. Individuals to understand the importance of a support system: As payers & providers empowering those we serve to identify their support system is an extremely important part of recovery especially support after the patient is released from an inpatient stay. 5
11 CPCI - Principles 12 Shared decision making Protocol driven evidence-based medicine Advanced access Integrated behavioral health Integrated pharmacy services Self management support Strong care management support Change in payment methodologies Build the airplane while we re flying it 6
SNF Focus areas for 2015 13 Communication and Coordination of Care Patient Engagement Smooth Transitions Skilled Nursing Care 14 Dedicated SNFist teams rounding 2X/week Dedicated nursing staff that rounds at facilities Quarterly joint meetings with all contracted facilities support, education & data sharing Sponsored symposia and webinars IHI webinar on eradication of C diff Yearly quality projects mimic 100K lives campaign 7
Communication Standardized Admission Packet Checklist RTA Return to Acute Audit Tool Quarterly SNF Collaborative meetings to provide data and education Weekly onsite rounding by SNF nurse and physician Availability of SW for unusual discharge needs Communication with HH agencies & DME providers at time of DC Communication with PCP office to transition back into the community & set up F/U office visits 15 Patient Education 16 Teach back technique Health Literacy Interpreters, when necessary Input from pts and caregivers Unified materials across the continuum of care Educate pt regarding diagnosis, self-care mgmt and importance of follow-up Listen before we teach ask open ended questions Goal for pt: Take action when you notice a change in your health 8
Do You Know What the Patient WANTS? Dr. Gawande s Four Questions? (1) What is the person s understanding of their health or condition? (2) What are their goals if their health worsens (3) What are their fears? (4) What are the trade-offs they are willing to make and not willing to make? 17 Is What you see What they see? Perception is Key.. Feedback provided to facilities through patient survey data to allow them to view their facility through the eyes of their patients. 18 9
Patient Activation Measure (PAM ) 19 The PAM survey reliably predicts future ER visits, hospital admissions and readmissions, medication adherence and more. PAM activation levels are mapped to hundreds of consumer health characteristics motivators, attitudes, behaviors and outcomes for dozens of health conditions. Take Individuals from Disengaged to Activated PAM identifies where an individual falls within four different levels of activation. This gives providers and health coaches insight to more effectively support each individual. http://www.insigniahealth.com/products/pam-survey Curative Medical Care Palliative Care What are the Patient s Goals? Palliative Palliative Care Care Life Prolonging Therapy H O S P I C E B E R E A V E M E N T Diagnosis of serious illness Death World Health Organization, 1990 10
Interventions to Reduce Readmissions 21 Patient education Discharge planning Medication reconciliation Appointment scheduled prior to discharge Timely follow-up Timely PCP communication Follow-up telephone call Patient hotline Home visit Transition coach Patient-centered discharge instructions Provider continuity Admission Packet Checklist 22 SNF Collaborative Admission Packet checklist. Both area hospitals management teams have been educated on the information needed to assess a member for admission to SNF level of care. The 5 items on the checklist below are key components on what is needed for a SNF facility to evaluate for a SNF level of care placement. 1. Face sheet with the patients demographics 2. Physicians order The order needs to indicate they are discharging to a SNF level of care. 3. Current Medication list preferably to include the last dose received 4. Current Physical Therapy notes. 5. H & P The information should be current for review. You should not be reviewing a patient on Monday to accept them on Friday, by Friday they may be able to go home with home health. When they arrive at your facility they should have hard scripts for all medications requiring them. Please notify me if this continues to be an issue. 11
RTA Audit Tool 23 Return to Acute Care Audit Tool Fax form to: Iva Tatum @ (918)877-9761 Name: Rm # Admit Date: Transfer to Acute Care Date: Admit DX: Source of Admission: Attending Dr. @ SNF: Transferring Nurse: Any Significant PMH or Surgical History: Reason For Transfer Anemic/Transfusion R/O DVT CHF Behaviors S/S Infection Electrolye Imbalance Cardiac/CP -URI Dehydration Change in LOC -UTI Planned Fall -GI --Reason Other -Sepsis Family Insistence Clinical Findings that may have contributed to transfer: Was the patient stay >72hrs? Yes No N/A Were abnormal labs addressed? Yes No N/A Did the patient receive all medications within the last 72 hrs? Yes No N/A If change in VS over last 72 hrs., were they addressed? Yes No N/A Was the patient treated in accordance to DNR status? Yes No N/A Was an appropriate assessment and intervention conducted? Yes No N/A Was medication reconciliation completed on admission? Yes No N/A Was SBAR utilized? Yes No N/A If any NO then essentially avoidable? Yes No N/A Initiation of Authorization of Transfer Attending MD On-Call MD Medical Director 911, Nursing Other Name of person authorizing transfer: ****Additional documentation If there was a NO to any above questions, provide the documentation: (ie: med errors, VS changes and how they were addressed, reason SBAR was not initiated, copy of abnormal labs when they were drawn, reported and interventions if any, was there a change in overall symptoms of member within the last 72 hrs prior to DC? 01/20/2016 Community Collaborative Meetings Goals To pilot and report on the use of standardized processes of care. To discuss best practices and review the feasibility of adapting community wide standards of care for the following high risk patient groups. CHF and atrial fibrillation Pneumonia COPD Strokes To share and evaluate effective interventions that have been piloted at area facilities and healthcare agencies. To education participants on area community services available as well as educational opportunities to benefit your staff. 24 12
Transition to Home TTH 25 Coleman model University of Colorado Focused on patient coaching encouraging active patient involvement in health care Focused diagnoses Atrial fibrillation, CHF, COPD, Pneumonia, AMI/CABG Decreased readmission rate 35% at one year Now have added TTH from SNF TTH Transition to Home 26 This is a FREE service to help patients: Recover. Understand and manage their medications better. Help prevent them from being readmitted to the hospital. Make a plan for their follow-up appointment with their primary care team. Maintain the good care they received in the hospital after they get home. 13
27 What s Included A home visit by a Transitional Care Nurse. A booklet to keep questions, logs, and any healthcare information they would like to share with their Dr. A Health information card designed to help them manage their health conditions. Three follow-up calls from a Transitional Care Nurse who provides support during the transition from the health care facility to home. 14
Medication selfmanagement Use of a patientcentered health record that helps guide patients through the care process Primary care provider and specialist follow-up Patient understanding of "red flag" indicators of worsening conditions and appropriate next steps Patient Centered Goals Faith Health Partners 15
31 Faith Health Partners Patterned after Congregational Health Network Memphis, TN Health systems working with local faith-based congregations to improve health awareness (education), empowering (training of embedded workers in the churches) and resources (programs from hospitals in the churches) Support from the church post-discharge In TN, decrease of readmissions by as much as 50% in vulnerable populations 16
How to enroll: Registration form Member Card Plans and Purposes of Faith-Health Partners Improve Health Outcomes Increase Satisfaction with Healthcare Services Decrease Admissions and Readmissions Decrease Healthcare Costs Health Education and Advocacy Voluntary Care-giving Congregational Liaison Increase communication with doctors to decrease need for emergency services Coordination of Volunteers Reconnect the Homebound or Homeless Health and Community Resource Assessments Faith leaders help design program for their congregation Training for specific disease processes Training on accessing appropriate levels of care, and navigating the healthcare systems Hospital Visitations Assisting members at discharge and after returning home 17
My Health Access Network 35 Tulsa, OK is a Beacon Community Received a $12M grant to start a health information exchange Data comes from all NE OK hospitals, most primary care groups, labs. ADT feed admission, discharge, transfers which allows embedded care managers to quickly provide telephonic follow-up and minimize risk of readmission Heavily involved in building and maintaining infrastructure our CEO is the immediate past chairman of the board myhealth@myhealthaccess.net Welcome to MyHealth. 36 MyHealth Access Network links more than 4,000 providers and their patients in a community-wide health information system that will help providers better monitor and improve care to: Reduce health care costs associated with redundant testing, hospital admissions,and emergency department visits Improve care coordination during transitions between health care settings Improve patients experience and ability to take control of their own health Improve quality care for the state of Oklahoma and its nearly 4 million patients Bring community leaders and organizations together to utilize health information in meaningful ways to improve community care 18
My Health Access--Who We Serve 37 Think of MyHealth as a health care public utility. MyHealth Access Network is a health information network that provides secure, online access to a comprehensive view of patients health care records for providers, including specialists, hospitals, ancillary care providers, etc. Members of MyHealth Access Network can share medical records, perform referrals, obtain lab and pharmacy data electronically, submit reportable data to the Oklahoma Health Department and share data between electronic medical records (EMR). By participating in the MyHealth network, a complete picture of patient medical care-from test results and allergies to X-rays-is available with the click of a mouse. This secure data also makes it possible fore MyHealth to generate snapshots of your community s, highlighting current statistics and possible trends. Data Quality Improvement Patient Centered ACO Participation 38 Oklahoma Health Initiatives Focused on support of owner ACO Data management and reporting (CPC-like) Care management Transition to Home Skilled nursing support Care transition support especially ER, which mimics CPC-like functions of embedded care managers 19
ACO participation 39 HICNO Last Name First Name DOB Address City State Zip Phone 1 Patient Type 123456789A Duck Donald 10/05/51 NAOR NAOR NAOR NAOR (918)-000-000 E 101112134D Duck Daisy 07/27/59 209 E Daffodil Lane DEWEY OK 71245 (918)-000-000 I 151617182A Wreck Ima 01/26/48 6703 W Storey AVE Tulsa OK 71245 (918)-000-000 E 162025169D Blessing Ura 07/18/45 1704 Crossover DR BARTLESVILLE OK 71245 (918)-000-000 E Date of Admission Date of Discharge Discharge Status Medical Center ACO Attributed Group ACO Attributed Provider Follow Up Provider Name Provider 1 1 Date 1 Follow Up Provider 2 F/U Phone Call Date Nurse Person Providing Informatio n Reason for hospitalization Medications New Medications Identified Need for Medication Management Identified Need in obtaining Medication Fall Risk Completed 1/5/2016 Caregiver ^SWELLING, LIP New Rx Added ABX No No No falls Completed 1/5/2016 Beneficiary R TKA New Rx Added PAIN MED, ABX No No No falls Wrong # 1/5/2016 Not Entered Yet Encounter for general adult medical exam Not Entered Yet Not Entered Yet Not Entered Yet Not Entered Yet Completed 1/5/2016 Beneficiary ^HEADACHE No Changes No No No falls Additional Notes Community Resources Seniors Services Adult, Senior, and Disability Services Infants, Children, Youth and Parent Services Questions Call Karie Graybill, SW 20
Community Resources 41 Community Resources 42 2-1-1 2-1-1 is a free, confidential call from any phone www.211oklahomahelpline.org/resources/findhelp.h tm Available 24 hours a day, every day Available for every county in Oklahoma For health and social services information, financial assistance, housing, counseling, health care and information on free and low-cost services offered by hundreds of agencies 21
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Food Pantries Clothing Furniture Utility Assistance Gasoline Car Repairs Household Supplies Personal Care Products Prescriptions Help with rent and mortgage Eviction notices Free Medical and Legal Clinics Shelters Tulsa Healthy Start Purpose: The purpose of Healthy Start is to reduce infant mortality by providing healthy messages and support for the entire family. It also seeks to ensure continuity of care for women and children. Case Management offers Assistance with prenatal care Access to well-baby visits Childhood immunizations Referrals to WIC services Family planning assistance Links to social services for jobs, child care, housing, and education 23
QUESTIONS???? 47 FOR ALL YOU DO FOR ALL THE PATIENTS YOU SERVE!!! 24