A Boston Pioneer ACO’s “Shared Expectations: Building ... · A Boston Pioneer ACO’s “Shared Expectations: Building from the Ground Up” Laurie Herndon, MSN, ... • Staying

A Boston Pioneer ACO’s “Shared Expectations: Building

from the Ground Up”

Laurie Herndon, MSN, GNP-BC Director of Clinical Quality

Mass Senior Care Foundation [email protected]

May 12, 2015

Leadership Summit Lifespan Network

Maryland Hospital Association

Goals for This Afternoon

Share Focus Inspire

The

Ground in

2009-2010

Fertile Soil: State Leadership and Vision

http://www.patientcarelink.org/uploadDocs/1/Strategic-Plan-for-Care-Transitions_2-11-2010-(2).pdf

The Foundation:

State Vision/Local Execution

The cornerstone (or foundation stone) concept is derived from the first stone set in the construction of a masonry foundation, important since all other stones will be set in reference to this stone, thus determining the position of the entire structure.

Why This Mattered

•  Scale matters

•  Language changed

•  Key stakeholders involved

“It is not about the forms, it is

about the relationship”

MA INTERACT Champion

What About The Forms Though?

Provided platform for: • Organizing our

work as a group • New language of

collaboration

Why the SNF focus?

•  Priority relationship driven by data and number of readmissions from SNFs

•  Not the only focus •  SNF

•  SNF provider teams

•  Hospitals

•  ACOs

•  ……

Building Progress Update

Key Stakeholders

•  Pioneer ACO representatives

•  Mass Senior Care •  1-3 Members

•  Leading Age •  1-2 Members

•  Monthly meeting

•  Convener role

•  Meeting space

•  Agenda

•  Document version control

Key Stakeholders: Clinical Leaders

March 2013

•  Mass Senior Care Spring Meeting

•  Leading Age to occur in April

2013 Mass Senior Care Spring Meeting

Standards

•  Staffing

•  System Continuity

•  QI Efforts

•  Screening/Admission

•  Medical Coverage

•  Care Transition

•  Facility Environment

•  Care System

•  Care planning and Coordination

•  Medication Reconciliation and Education

•  Advance Directive Documentation

•  Communication of Discharge Paperwork to the Group

•  Standard Discharge Checklist and Planning

•  Selection of Transfer Facility

Good News/Bad News

Reporting

Contractual Obligations

Readmissions Consumer Satisfaction

Getting To Standard Readmissions Measure

David Gifford, MD, MPH SVP for Quality & Regulatory Affairs

American Health Care Association [email protected]

Getting To Standard Consumer Satisfaction Measure

Nicholas G. Castle, Ph.D.

Department of Health Policy and Management,

Graduate School of Public Health, University of

Pittsburgh [email protected]

Remember this?

•  Why the SNF focus?

•  Priority relationship driven by data and number of readmissions from SNFs

•  Not the only focus (right?) •  ✔SNF

•  ✔SNF provider teams

•  Hospitals

•  ACOs

•  ……

Early Stages

Lessons Learned

•  Large scale/key stakeholder collaboration sets the foundation

•  Local/grassroots collaboration and innovation is required to actually get the job done

•  Language matters •  Trust, respect at highest levels

•  “Standards” at grassroots and frontline

The Challenge

•  Maintaining momentum and “bandwidth”

•  Staying out of the silo •  What else is going on?

•  CMS 5 star change

•  QIO data/SOW

Think About

•  What is status of your “ground” right now?

•  What should the foundation be?

•  Where are the conditions right to begin building right away?

•  Who are your key stakeholders?

•  Who is your “coalition of the willing”?

Most Important

“It is not about the forms, it is about the relationship”

Thank You!