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2/1/2016
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IHI ExpeditionImproving Care Transitions To Reduce Readmissions
Session 1: Building the Will, Ideas and Execution for Successful Transitions
February 4, 2016
These presenters have
nothing to disclose
Peg Bradke, RN, MA Jill Duncan, RN, MS, MPH
Today’s Host2
Colby Champagne, Project Assistant, Institute
for Healthcare Improvement (IHI), is a co-op
student from Northeastern University. She is a
health science major with a minor in business
administration and hopes to pursue a career in
healthcare management. She is working on the
Passport, Expeditions, and Leadership Alliance
teams.
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Today’s Agenda
• Welcome & Introductions
• Expedition Overview
• Building the Will, Ideas and Execution for
Successful Transitions
• Action Period Assignment
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Where are you joining from?
2/1/2016
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What is an Expedition?
ex•pe•di•tion (noun)
1. an excursion, journey, or voyage made for some
specific purpose
2. the group of persons engaged in such an activity
3. promptness or speed in accomplishing something
Ground Rules12
We learn from one another – “All teach, all learn”
Why reinvent the wheel? – Steal shamelessly
This is a transparent learning environment
All ideas/feedback are welcome and encouraged!
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Expedition Director13
Jill Duncan, RN, Executive Director, IHI, provides
strategic development and programming leadership
for IHI's Quality, Cost, and Value Focus Area;
leadership of IHI's Joint Replacement Learning
Community; program coordination and faculty
leadership for IHI's Leading Quality Improvement:
Essentials for Managers program; and program
development and facilitation for many of IHI's
workforce development initiatives. Her previous IHI
responsibilities include daily operations and
strategic planning for the IHI Open School, and
development and leadership of Impacting Cost +
Quality. Ms. Duncan draws from her learning as a
Clinical Nurse Specialist, quality leader, pediatric
nurse educator, and front-line nurse.
Expedition Sessions
Session 1 Building the Will, Ideas and Execution for Successful Transitions
Session 2 Establish and Implement a Person Centered Transition Plan to meet the
Identified Post-Acute Care Needs
Session 3 Working with Community Partners for Successful Transitions
Session 4 From Prehospital to In-Hospital: The Continuum for Time-Sensitive Care
Session 5 Executing on an Ideal Outcome in the Transition: Right time, Right Place, Right
level of care at the Right Cost
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Faculty15
Peg M. Bradke, RN, MA, has held various administrative
positions in her 25-year career in heart care services. Currently
she is Vice President of Post-Acute Care at St. Luke's Hospital
in Cedar Rapids, Iowa, where she oversees a long-term acute
care hospital and two skilled nursing and intermediate care
facilities, with responsibility for home care, hospice, palliative
care, and home medical equipment. In her previous role as
Director of Heart Care Services at St. Luke's, she managed two
intensive care units, two step-down telemetry units, several
cardiac-related labs, and heart failure and Coumadin clinics.
Ms. Bradke also serves as faculty for the Institute for
Healthcare Improvement on the Transforming Care at the
Bedside (TCAB) initiative and the STAAR (STate Action on
Avoidable Rehospitalizations) initiative.
Expedition Objectives16
At the conclusion of this Expedition, participants will be able to:
• Assess current challenges in reducing care coordination and identify opportunities for improvement in care transitions.
• Build an effective improvement team including patients and families as well as acute, post-acute and community care partners
• Identify successful approaches to engaging staff in all clinical settings to make an ideal individualized person centered transition of care plan.
• Engage participants in sharing strategies and innovative thinking to explore real life issues related to transitions.
• Develop processes with post-acute care providers and community partners to ensure the timely transfer of critical information during transitions.
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Chat
In 5-words or less, describe one of your
current priorities specific to Improving Care
Transitions To Reduce Readmissions
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Expedition Sessions
Session 1 Building the Will, Ideas and Execution for Successful Transitions
Session 2 Establish and Implement a Person Centered Transition Plan to meet the
Identified Post-Acute Care Needs
Session 3 Working with Community Partners for Successful Transitions
Session 4 From Prehospital to In-Hospital: The Continuum for Time-Sensitive Care
Session 5 Executing on an Ideal Outcome in the Transition: Right time, Right Place, Right
level of care at the Right Cost
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Building the Will, Ideas and Execution for Successful TransitionsSession 1
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Achieving Desired Results
“Results”
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The Major Challenges
Potentially preventable rehospitalizations are prevalent,
costly, burdensome for patients and families and
frustrating for providers
No one provider or patient can “just work harder” to
address the idea smooth transition
Our delivery system is highly fragmented - providers
often act in isolation and patients are usually responsible
for their own care coordination
Most payment systems reward maximizing units of care
delivered rather than quality care over time
Changing Paradigms
Traditional Focus Transformational Focus
Immediate clinical needs Whole person needs
Patients Patient & family members
LOS & timely discharge Post-acute care plan for
comprehensive needs
Handoffs Co-design of “handovers”
Clinician teaching Patient & family learning
Location teams Cross-continuum team
“We can’t solve problems by using the same kind of thinking
we used when we created them.” Albert Einstein
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Opportunities
Many re-hospitalizations are avoidable
Nationally we are making progress
Keys to reducing re-admissions include:
– Not focusing on the hospital alone
– Aligning financial incentives
– Addressing systematic barriers
– Fostering leadership at the multiple levels
What Can Be Done and How?
A growing number of approaches to reduce 30-day readmissions and improving transitions have been successful locally
Which are high leverage?
Which are scalable?
Success requires engaging clinicians, providers across organizational and service delivery types, patients, payers, and policy makers
How to align incentives?
How to catalyze coordinated effort?
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CMS Incentives for Reducing Readmissions
1. Risk Adjusted 30 day all cause
Readmission Rate
2. Readmission Penalty in the Quality
measures of VBP
3. Bundling payment across continuum of
care
Hospital Readmission Program
2016 Readmission penalties are estimated at $420 million –average 0.61%
2592 Hospitals received lower Medicare payments for all Medicare patients
Just slightly less than last year
6 million more that FY 2015 – 22% -- no penalties
– 63% -- 1% or below
– 11% -- 2% or below
– 4% -- 3% or below (38 hospitals got max. 3%)
FY 2016 penalties were just announced, but 2017 penalties are already set
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Selected Index Admission Diagnoses
Medicare Focused Diagnoses –affects payment
adjusted for Age, Sex, Acuity and recent diagnosis
Acute MI
COPD
Heart Failure
Pneumonia
Stroke
Total Hip Replacement
Total Knee Replacement
– Coming CAB will be factored in during 2017
Other penalties coming
SNF – Oct. 2018: 2% payment withhold to fund incentive
pool to reward SNF based on preventable readmissions
– Lower readmissions rates can recoup the 2%+
Home Care – Value Based Purchasing in 9 states
related to measurable performance
– Metrics: Pt. function, ED visits, Hospitalizations during episode
of care, Pt. Satisfaction, Advanced Care Planning
– Payment adjustment begins at 3% increases to 8% in 2022
– MA, MD, NC, FL, WA, AZ, IA, NE, TN
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The Bad News:
There are No “Silver or Magic Bullets”!
….no straightforward solution perceived to
have extreme effectiveness
Conclusion: “No single intervention implemented
alone was regularly associated with reduced risk
for 30-day rehospitalization.”
Hansen, Lo, Young, RS, Keiki, h, Leung, A and William, MV, Interventions to Reduce 30-Day
Rehospitalizations: A Systematic Review, Ann Int Medicine 2011; 155:520-528.
The Good News: There Are Promising
Approaches to Reduce Rehospitalizations
Improved transitions out of the hospital
– Project Red, BOOST,
– IHI’s Transforming Care at the Bedside and STAAR Initiative
Reliable, evidence-based care in all care settings
– PCMH, INTERACT, VNSNY Home Care Model
Supplemental transitional care after discharge from the
hospital
– Care Transitions Intervention (Coleman)
– Transitional Care Intervention (Naylor)
Alternative or intensive care management for high risk patients
– Proactive palliative care for patients with advanced illness
– High Risk clinics
– PACE Program; programs for dual eligibles
– Intensive care management from primary care or health plan
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Determinants of Preventable Readmissions
Preventable readmissions have hallmark characteristics of
healthcare events prime for intervention and reform
Patients with generally worse health and greater frailty are
more likely to be readmitted
Identification of determinants does not provide a single
intervention or clear direction for how to reduce their
occurrence
There is a need to:
– Address the tremendous complexity of contributing variables
– Identify modifiable risk factors (patient characteristics and health care
system opportunities)
Determinants of preventable readmissions in United States: a systematic review.
Implementation Science 2010, 5:88
Patient and Family Engagement
Cross-Continuum Team Collaboration
Health Information Exchange and Shared Care Plans
Transition from Hospital to Home or other Care Setting
Transition to Community Care Settings
Alternative or Supplemental Care for High-Risk Patients
The Transitional Care Model (TCM)
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Target Populations: Each Have Challenges
1. Medicare
2. Medicaid
3. Dual-eligibles
4. Commercial
5. Uninsured
40% of Medicare Discharges Admit to PAC Hospital
≤ Continuing Care Hospital (2%)
≤ 17%
Inpatient Rehabilitation (30%)
≤ 12%
Skilled Nursing Facility (43%)
≤ 22%
Home Health (37%)
≤ 28%
Outpatient Therapies (9%)
≤ 20%
HIGH
LOW
Severity of Illness
PalliativeCare
Source: RTI/Cain Brothers Analysis, Integrating Acute and Post-Acute Care” 2012
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Loehrer S, McCarthy D, Coleman, EA Population Health Management DOI: 10.1089/pop.2015.0005
Cross-Continuum Teams
Comprised of acute and post-acute care partnerships to
co-design care transitions processes
Emphasize that readmissions are not solely a hospital
problem and require a community solution
Have built the foundation for many care settings
participating in ACO development, Patient Centered
Medical homes and the Community-based Care
Transitions Program
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Poll Question
Do you have a Cross-Continuum Team (CCT)?
If so, please chat:
– The people
– The roles
– The organizations engaged in your CCT
Cross-Continuum Team Membership
Recommendations
• Executive Sponsor
• Day-to-Day Leader
• Patients and family caregivers
• Hospital clinicians and staff
• Supporting staff (QI, IT, Finance, etc.)
• Clinical and administrative staff and/or leaders from the community
– Skilled nursing facilities
– Office practice settings
– Home health care agencies
– Community or Public health services
– Outpatient Clinic Centers (Dialysis, Diabetes, Rehabilitation)
• Public and private payers
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Effective collaboration among health
care providers requires:
Trusted convener (individual or organization)
Cultivation of trust (common goals)
Shared understanding of the challenges faced by each
participant (site visits and shadowing)
Starting small and building on early progress
Expand type of participants as needs arise
Data to identify opportunities for improvement
Focusing on patients’ needs and experiences
Loehrer S, McCarthy D, Coleman, EA Population Health Management DOI: 10.1089/pop.2015.0005
Fostering Cross-Continuum Collaborations
Start your meetings with a patient story
Before all else, build trust
Convene meetings in various care settings
Do a “deep-dive” into a series of recently readmitted
patients to identify opportunities for improvement across
care settings
Use the power of observation- have members of various
care setting shadow critical processes such as
admission, discharge and patient education
Members from the CCT hear first-hand about the
transitional care problems “through the patients’ eyes
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Hospital
Skilled Nursing Care Centers
Primary & Specialty Care
Home Health Care
Home (Patient & Family
Caregivers)
Improving Transitions Processes
Cross-continuum Teams are Core to the
Work
Core
Processes
IHI Four Key Changes
1. Perform an Enhanced Assessment of Post-
Hospital Needs
2. Provide Effective Teaching and Facilitate
Enhanced Learning
3. Ensure Post-Hospital Care Follow-up
4. Provide Real-Time Handover Communications
Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for Healthcare
Improvement; June 2013. Available at www.IHI.org.
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Lessons Learned
Cross-continuum team partnerships transform
care processes together
“Senders” and “receivers” partnerships agree upon
and design the needed local changes
– Vital few critical elements of patient information that
should be available at the time of discharge to
community providers
– Written handover communication for high risk patients is
insufficient; direct verbal communication allows for
inquiry and clarification
Reducing readmissions is dependent on highly
functional cross-continuum teams and a focus on
the patient’s journey over time
Providing intensive care management services for
targeted high risk patients is critical
Lessons Learned
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Lessons Learned
There are no universally agreed upon risk
assessment tools
– We need a much deeper understanding of how best
to meet the needs of high-risk patients
– Use practical methods to identify modifiable risks
Written handover communication for high-risk
patients is insufficient
Diagnostic Case Reviews
Provide opportunities for learning from reviewing a small sampling of patient experiences
Engage the “hearts and minds” of clinicians and catalyze action toward problem-solving:
– Teams complete a formal review of the last five readmissions every 6 months (chart review and interviews)
– Members from the cross-continuum team hear first-hand about the transitional care problems “through the patients’ eyes”
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Four Guides on Transitions
Senders:
– From Hospital to SNF or Home
Receivers:
– Office Practice
– Home Care
– Skilled Nursing Care Facilities
How-to Methods
http://www.ihi.org/resources/Pages/Tools/HowtoGuideImprovingTransitionstoReduceAvoidableRehospitalizations.aspx
Summary
Rehospitalizations are frequent, costly, and actionable for
improvement
The IHI approach acts on multiple levels – engaging hospitals and
community providers, communities, and state leaders in pursuit of a
common aim to reduce avoidable rehospitalizations
Working to reduce rehospitalizations focuses on improved
communication and coordination over time and across settings
– With patients and family caregivers;
– Between clinical providers;
– Between the medical and social services (e.g. aging services,
etc.)
Working to reduce rehospitalizations is one part of a comprehensive
strategy to promote patient-centered care and appropriate utilization
of health care resources
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How Might We….
“….gain a deeper understanding of the
comprehensive post-hospital needs of
the patient through an ongoing
dialogue with the patient, family
caregivers, and community providers?”
Key Changes for Enhanced Assessment
Partner with patient and family to determine post-hospital needs:
• Involve the patient, their family, family caregiver(s) and community providers as full partners in completing a needs assessment of the patient’s home-going needs.
• Involve the full care team and be respectful of all that have interactions with the patient/family
Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. How-to Guide: Improving Transitions from the Hospital to Community Settings to Reduce Avoidable Rehospitalizations. Cambridge, MA: Institute for
Healthcare Improvement; June 2013. Available at www.IHI.org.
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Barriers to a Good Ongoing Assessment
Not addressing the whole patient (e.g., focusing on one condition, missing underlying depression or social needs, etc.)
Looking at only current admission missing the need to look at previous admissions in 30 - 90 days, 12 month
Delayed or absent goals of care discussion
Medication errors, polypharmacy, and incomplete medication reconciliation
Labeling the patient as ‘noncompliant’
Lack of probing around unrealistic patient and family caregivers optimism to manage at home
Partner with Patient and Family to
Determine Post Hospital Needs
‘Enhanced assessment’ goes beyond the nursing
admission assessment
Start on Admission
Establish a relationship – Sit down- be attentive-
LISTEN
Continue ongoing assessments throughout the
hospital stay to reveal new need-to-know details
Share what you learn with the care team
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Open Ended Questions
What are your concerns as you transition?
What matters most to you during these
transitions?
Who do you want involved in your
transitions?
Involve Patient and Family Caregivers
“Family caregivers” are those individuals who
are directly involved in the patient’s care at
home
“Visitors” are not necessarily the persons who
best understand the home environment
limitations/issues and the patient’s home-going
needs
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Assessments are Conversations
Ask open ended questions:
– What do you think may have caused you to come to the hospital?
– Did you call your health care provider( HCP) when you became
concerned?
– What prompted you to call or What kept you from calling?
– When was your last appointment with your HCP?
– Were you able to keep the appointment, if not, why not?
– How do you take your medications at home?
– Describe kind of foods you eat at home
– Do you think there is anything that could have prevented coming
to the hospital?
Assessments > Improving Discharge
Communicate. Communicate. Communicate what is learned in the conversation
Include useful information that might be beneficial but not found on a form, e.g.:– Useful medication lists
– Ability and motivation to provide self care
– Advance directives; Goals of Care conversation was started
– Patient likes to take pills with ice cream
– Patient very concerned about her dog, etc.
– Patient aware that he is getting forgetful and concerned for future
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Questions?
Comments?
Discussion?
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Next Steps
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What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make that
will result in improvement?
Model for Improvement
Act Plan
Study Do
Aim of Improvement
Measurement of
Improvement
Developing a Change
Testing a Change
Adapted from Langley, G. J., Nolan, K. M., Nolan, T. W.,
Norman, C. L., & Provost, L. P. The Improvement Guide:
A Practical Approach to Enhancing Organizational
Performance. San Francisco, CA: Jossey-Bass, 1996.
Why Test?
Increase the belief that the change will result in
improvement
Predict how much improvement can be expected from
the change
Learn how to adapt the change to conditions in the local
environment
Evaluate costs and side-effects of the change
Minimize resistance upon implementation
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Repeated Use of the PDSA Cycle61
Hunches
Theories
Ideas
Changes that Result
in Improvement
A P
S D
A P
S D
Very Small
Scale Test
Follow-up
Tests
Wide-Scale Tests
of Change
Implementation of
Change
Sequential building of knowledge under a wide range
of conditions
Spread
Multiple PDSA Cycle Ramps
Transfusion
Administration
Safety
Communication
and Awareness
Strategies
Engaging with
Leadership
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Implementing
Transfusion
Guidelines
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Action Period Assignment
Action Period Assignment
• Between now and the next session, please
select one of the following activities:
• 1-2 chart reviews using the form, or
• 1-2 patient interviews using the tool, or
• 1 chart review along with a patient interview
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1-2 Volunteers to report back at the start of the next session?
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What did you learn?
Did you have any “a-ha” moments?
What surprised you?
Did you identify any opportunities for
improvement?
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Expedition Communications
• All sessions are recorded
• Materials are sent one day in advance
• Listserv address for session communications:
expeditiontransitions@ls.ihi.org
• To add colleagues, email us at info@ihi.org
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Session 273
Establish & Implement a Person-Centered
Transition Plan to Meet the Identified Post-
Acute Care Needs
Thursday, February 18th
1:00-2:00 PM ET
Thank You!74
Jill Duncan
jduncan@ihi.org
Colby Champagne
cchampagne@ihi.org
Please let us know if you have any questions or
feedback following today’s Expedition webinar.
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