Welcome to the HOMETOWN HEALTH...Hospitals and others accepting bundled payments are at risk. Requires a network of HHAs/SNFs available to patients that has adequate capacity, high

HTH Iowa SHIP IQTC Webinar 2‐16‐2017

For more Information, please contact: [email protected] 1

Welcome to the HOMETOWN HEALTH

A PORTION OF THESE MATERIALS WERE PRODUCED PURSUANT TO THE2016-2017 IOWA SHIP GRANT number 5887SH01.

Quality: Improving the Transitions of Care &

HCAHPS: Discharge Information (Q19, Q20) & Care Transition (Q23, Q24, Q25)

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Therapy (NBCOT)

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Webinar Agenda

HTH Welcome & Upcoming Events Jennie Price - HTH

Quality: Improving the Transitions of Care

Suzanne Mitchell - HMA

HCAHPS: Discharge Information (Q19, Q20)Care Transition (Q23, Q24, Q25)

Jeanine Davis- HMA

Next Steps & Questions Jennie Price - HTH

Upcoming Event for IQTC

Calendar & Online Education Access

Live ITC MeetingMarch 15‐16, 2017Courtyard in Des Moines Ankeny

• A live 2‐day workshop with other participating hospitals will provide education in the area of Quality

• Grant will provide for one attendee registration from each hospital, plus hotel for 2 nights

• Additional attendees can attend for $295 (+ hotel)

• REGISTRATION & HOTEL INFORMATION IS NOW LIVE!

Hotel reservations must be made by February 20th!



Live ITC Meeting

Conference Quality Sessions:

• Transforming Your Hospital: Lessons Learned from IQTC Year One & Consultations

• Transforming Our Focus: The Future of Quality & Compliance (A Legal Update)

• Transforming Results: Best Practice Panel ‐Thinking outside the box to improve Quality & Patient Satisfaction

• Transforming Data: Collect Accurate, Timely, and Meaningful Data• Leading the Transformation of the Patient Experience • Transforming your Staff: Customer Service Experts• Transforming (Telehealth) Patient Satisfaction:

Telehealth Clinical Etiquette & Demonstration• Transforming Payment Models: Transitional Care Management

Live ITC Meeting

Not Yet Registered?

Register here!http://www.hometownhealthonline.com/event/iowa‐small‐hospital‐improvement‐conference/?instance_id=3777

Hotel reservations must be made by February 20th!

Conference Transformation Panel

We are looking for a few more individuals to join the panel on transformation ‐‐ someone willing to share special stories about the transformation work in their organizations.

Do you have:1. A “best practice” that you have identified and either fully or partially implemented?2. Essential learnings you experienced along the way that you can share with your colleagues?....what worked and what didn’t?3. New competencies and capabilities required and how you got there?

If you'd be interested in sharing with others some successes from your hospital in the area of Quality or HCAHPS improvement, please contact Jennie [email protected]



Watch for Information

One‐On‐One Hospital Consultations/ Coaching

Calls have started!

To be scheduled with HMA’s IQTC Team

(To occur over February, March, & April)

Upcoming Education

April 20, 2017 2:00pm EST/ 1:00pm Central

Quality: Improving Data Collection & Analysis&HCAHPS: Individual Measures (Cleanliness of Hospital Environment (Q8) & Quietness of Hospital Environment (Q9))

May 18, 2017 at 2:00pm EST/ 1:00pm Central

Closing Webinar #8:∙ Setting Goals for Improvement &∙HCAHPS: Becoming a 5 Star Hospital: Overall Hospital Rating (Q21) & Recommend the Hospital (Q22)

Program Dashboard

www.hthu.net/iqtc*password protected*

Password supplied in your “Next Steps…” Email Sent in August

(or contact the HTH team!)



IQTC Program Goal

The goal of the Iowa Quality Transformation Consortium (IQTC) is to build a group of hospitals and other stakeholders that work together to provide support and reduce barriers for small rural hospitals participating in HCAHPS.

This will be accomplished by providing education and resources in:

▪ Value-Based Purchasing (VBP) data collection, quality reporting, and improvement

▪ Accountable Care Organizations (ACO) or Shared Savings investment efficiency and quality improvement

▪ HCAHPS best practices, management and staff development

POLL QUESTION

On a scale of 1 to 5, to what extent areCare Transitions a challenge at yourfacility?

POLL QUESTION

Which aspect of Care Transitions are you most concerned about? (Mark all that apply)

Patient ExperienceAccountabilityCommunication between providersCare coordinationCare giver issues



Disclosure of Proprietary Interest

HMA does not have any proprietary interest in any product, instrument, device, service, or material discussed during this learning event.

The education offered by HMA in this program is compensated by the Iowa Department of Public Health Small Hospital Improvement Program (SHIP) under grant number 5887SH01

Suzanne Mitchell, MD Principal at HMA

Expertise in policy, financing and clinical delivery system solutions to improve healthcare delivery

A practicing, board certified palliative care and family physician, health services researcher, and medical educator

20 years of experience in medical and health professional education

HMA is a leading independent, national health care consulting firm providing technical and analytical services.

Our strength is our people and the proven expertise and experience they bring to the most complex issues, challenges, and opportunities.

Quality: Improving the Transitions of Care

Presented by: Suzanne Mitchell, MD Health Management Associates

Learning Outcome Standards: Based upon quality standards and guidelines from the Agency for Healthcare Research and Quality (AHRQ) an agency of the U.S. Department of Health and Human Services (HHS), CMS Hospital Compare, and other

healthcare industry quality best practices.

Quality Transformation Series




Quality Transformation Series: Improving the Transitions of Care

Learning OutcomesAt the end of this session, you should be able to:

1. Describe common challenges health systems face with care transitions;

2. Identify best-practice protocols for care transitions;

3. Describe the role payment reform plays in care transition program implementation;

4. Identify key focus areas for care transition programs;

Care Transitions: Hazardous, Fragmented, Inefficient

LTSS and Post‐acute Care• Home Health• Rehab• Hospice

Care transition is the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. (Coleman EA.) www.caretransitions.org

“Care Transition is a Perfect Storm" of Patient Safety Hazard

▪ Poor Quality Info

▪ Communication

▪ Poor Preparation

▪ Lots of Loose Ends

▪ Fragmentation

▪ Great Variability

▪ Post-hospital syndrome?

The hospital discharge is non-standardized and frequently marked with poor quality.



Why manage Transitions of Care (TOC)?

“Patients are especially vulnerable to adverse events in the period immediately following discharge, and they need immediate access to a trusted clinician who can answer questions, provide advice, and help ensure that their clinical condition remains stable…..”

http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideImprovingTransitionsHospitaltoOfficePracticeReduceRehospitalizations.aspx

The Patient Experience

▪ “The biggest surprise in my patient experiences: how fast the acute phase of my care was over! I was out on the street with a sheaf of discharge papers in my hand….within 24 hours of waking up from surgery.” Jeff Goldsmith

Fragmented Healthcare System –No Care Zone

50% of hospitals refer patients to 18 or more post‐acute providers at up to 40 different facilities.



Value‐Based Purchasing

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Provider Financial R

isk

Provider Integration and Accountability

Fee For Service

Full Capitatio

n

Upside Shared Savings

Two‐way Shared Savings

Partial Capitatio

n

Bundled/Episodic

P4P

Incentive Payment

s

How do you measure value?

Bundle Payments

▪ Paying a fixed price for an episode of care, or bundling.

▪ BPCI and CJR - A 90-day episode of care includes the hospital stay, physician services, outpatient care, home health, post-acute facility services and readmissions.

▪ Increased attention on care coordination and delivering a complete clinical solution to a complex medical problem.

▪ Hospitals and others accepting bundled payments are at risk.

▪ Requires a network of HHAs/SNFs available to patients that has adequate capacity, high quality, geographic coverage, special services and the willingness to accept hard-to-place patients.

Long Term Services and Supports (LTSS)

▪ 67,000 paid, LTC providers served ~9M people

▪ 4,800 adult day services centers

▪ 12,400 home health agencies

▪ 4,000 hospices

▪ 15,600 nursing homes

▪ 30,200 assisted living and similar residential care communities

Favreault & Dey (2015), Table 1



Medicaid & Out of Pocket Cover Most Lifetime Average LTC Spending

Note: The estimated remainder of spending (Other) includes a combination of private LTC insurance and MedicareFavreault & Dey (2015), Table 3A

Best Practice Models are out there…

▪ Project – RED – Re-Engineered Discharge

▪ Project BOOST – Better outcomes by Optimizing Safe Transitions

▪ RARE Campaign – Reducing Avoidable Readmissions Events

▪ Coleman’s Care Transitions

▪ STAAR – State Action on Avoidable Rehospitalizations initiative (IHI launched in 2009)

32

Getting started: Building TOC processes

▪ Identify hospital providers most likely to be significant providers of care to patients (ACO members)

▪ Meet with main hospital partners to forge solid relationships and bridge fragmentation

▪ Do you have an existing TOC committee that you could join?

▪ Work to develop joint processes for hospitals to identify high risk patients and routine communications to PCP about those in ED, admissions or discharges from hospital

▪ Create internal process triggering CM and PCP follow-ups

33



Evaluating Partners▪ Compliance with federal and state regulations

▪ Meets or exceeds median for federal quality standards

▪ 30-day hospital readmissions rate at or below national/state norms

▪ Patient satisfaction ratings

▪ Patient and family engagement: data and tools

▪ Attending SNF physicians include primary care physicians and extenders that are part of health system's physician network

▪ RNs in the SNF 24/7

▪ Appropriate nursing hours per patient day for subacute care (4.25)

▪ Average length of stay for Medicare patients at or less than national average (<30 days)

▪ Discharge at least 60% to the community following subacute care

▪ Use of tools for SNFs to reduce rehospitalizations

▪ Ability to share information electronically

▪ Willingness to take hard to place patients

▪ Agreements regarding bed availability

Source: Health Dimensions Group, 2012

Focus Areas for TOC Best Practices

35

Comprehensive discharge planning

Patient and Family

Engagement

Transition Care Support

Transition Communication

Medication Management

• Examine Discharge Process• Medication Reconciliation• Engage Pharmacist• Ensure Accountability

• Collaborative discharge plan• Prepare and Train caregivers• Navigators for Follow‐up• Engaged Partners

Next Steps

▪ What progress have you made thus far in development of TOC processes?

▪ What questions do you have or help do you need?

36



Summary

▪ Greater integration and cooperation is need between care settings and health professionals through care transitions.

▪ Much uncertainty regarding how to best match need to service delivery and payment.

▪ Examine existing processes and conduct root cause analyses

▪ Engage stakeholders/leadership

▪ Think sustainability!

Quality Transformation Series:Improving the Transitions of Care


1. Describe common challenges health systems face with care transitions;

2. Identify best-practice protocols for care transitions;

3. Describe the role payment reform plays in care transition program implementation;

4. Identify key focus areas for care transition programs.

Jeanine Davis, RN, BAAS, CMCN

Principal at HMA

A nurse with years of experience in Quality Improvement, Integrated Care Management/ Care Coordination, Utilization Management, and Models of care (PCMH’s and P4P programs

Specializing in safety-net programs: Medicaid, Medicare and Medicare/Medicaid Programs (MMPs)

HMA is a leading independent, national health care consulting firm providing technical and analytical services.

Our strength is our people and the proven expertise and experience they bring to the most complex issues, challenges, and opportunities.



HCAHPS: Discharge Information (Q19, Q20)Care Transition (Q23, Q24, Q25)

Presented by: Jeanine DavisHealth Management Associates

Learning Outcome Standards: Based upon quality standards and guidelines from the Agency for Healthcare Research and Quality (AHRQ) an agency of the U.S. Department of Health and Human Services (HHS), CMS Hospital Compare, and other

healthcare industry quality best practices.

Patient ExperienceTransformation Series


Discharge Information (Q19, Q20) and Care Transition (Q23, Q24, Q25)


1. Identify three best practices to Boost Hospitals' HCAHPS Scores on Discharge Information (Q19, Q20).

2. Describe the concept behind Patient-Centered Discharge Instructions.

3. Identify the purpose of Discharge Phone Calls.4. Identify three best practices to Boost Hospitals'

HCAHPS Scores on Care Transition (Q23, Q24, Q25)

5. Describe why seamless transitions are important.

HCAHPS: Discharge Information (Q19, Q20)





Discharge Information (Q19, Q20)

Question Details:

▪ During this hospital stay, did doctors, nurses or other hospital staff talk with you about whether you would have the help you needed when you left the hospital?

▪ During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?

The scale for rating these questions is a “Yes” or “No.”


▪ Discharge planning helps address the medical, psychosocial and community resource needs.

▪ Many patients and their families end up being briefed on the discharge plan on their way out the door– little opportunity to assimilate the information– ask questions– have their questions answered.

▪ Even when the material is covered during a hospital stay, patients are sometimes:– Foggy in recall– Timid to ask questions– Or too overwhelmed to manage care post-discharge

Discharge Information (Q19, Q20)Best Practices

▪ Discharge Planning Begins at Pre-admission. • The common wisdom of starting at the beginning is true with hospitals as well.

• The beginning is prior to a patient being admitted when ever possible.

• Facilitate conversations with admitting physicians and their practice staff to help in providing education before a stay begins.

▪ Explain the Why

▪ Teachable Moments

▪ Assessment Never Stops

▪ Assess Knowledge, Skill and Attitude

▪ Standardize Discharge Forms and Instructions



Discharge Information (Q19, Q20)Cover the Bases and Review your current instructions to see if they are:

– Patient-centered, Concise and Comprehensive

Medication list include:– Dosage, Times, Frequency

– Possible side effects

Home care instructions such as:– Activity level and types

– When the patient can return to work or school, or resume driving, etc.

– Diet

– Restrictions on bathing

– Wound care

– Signs of infection or worsening condition, such as pain, fever, bleeding, difficulty breathing, or vomiting

– Normal symptoms to expect once at home and length of time to expect them

– When to see the primary care physician for a follow-up appointment

– Post-discharge services such as home health and contact information


Teach Backs– Simply asking questions of patients and families to

require them to restate follow-up care instructions, using their own words.

– An assessment of knowledge – Assess remaining knowledge gaps

Patient-Centered Discharge Instructions– Tailor your discharge instructions to the patient– Consider health literacy and social circumstances– Concentrate on high-value and high volume areas


Listen, Write, Ask, Learn– Provide written discharge instructions

– Have the patient and family write on the materials

– Encourage them to ask questions

– The final discharge instruction is a personal account by the patient and family of what should happen post discharge.

Annual Discharge Planning Competencies should include:– Refreshers and audits

– Consider incorporating this aspect of clinical care in job descriptions

– And performance appraisals

– linking clinical and service excellence to individual performance expectations.




Discharge Phone Calls

– Allay patients concerns about how well they are able to perform self-care instructions

– Provides a mechanism to review any test results

– Serves as a reminder of any follow-up appointments

– Provides an opportunity to ask questions

– Provide a final act of service, checking that everything went well, offering amends if there was an issue, and offering well wishes and thanks

Formalize and Document Callbacks

– Set a threshold goal and stretch goal for contacting patients after their hospital stay.

– Adds accountability and measurement for this process goal.

HCAHPS: Care Transition (Q23, Q24, Q25)



Care Transition (Q23, Q24, Q25)

Question Details:

▪ During this hospital stay, staff took my preferencesand those of my family or caregiver into account in

deciding what my health care needs would be whenI left.

▪ When I left the hospital, I had a good understandingof the things I was responsible for in managing my health.

The scale for rating these questions is “Strongly disagree”, “Disagree”, “Agree”, “Strongly agree”.

• When I left the hospital, I clearly understood the purpose for taking each of my medications.

The scale for rating these questions is “Strongly disagree”, “Disagree”, “Agree”, “Strongly agree”, “I was not given any medication when I left the hospital”.



Best Practices are Rooted in COMMUNICATION – before, during and after care transitions

▪ Important to discover patient and family preferences early in the process and integrate them into the plan

▪ Include Family in Creating the Care Transition Plan

▪ Use Bedside shift report to confirm patient preferences

▪ Implement Post Visit Phone Calls



Communication, Coordination, & Collaboration- Brainstorm top 3 concerns about leaving hospital- Create a list of 3 individuals (other than primary care giver) to contact - Identify 3 constrictions or obstacles that might prevent the transition to

home from being a success - Discuss warning signs and symptoms- Develop a checklist - Collaborate with the patient and caregivers

Formalize nurse assessment of discharge readiness- Post-discharge support services- Contact lists/Community resources- Provide basic tools needed at home- Pharmacy involvement- Transportation- Financial considerations

Be conscientious of culture/own expectations; caution your own biases


Use key words related to:- Personal Care - Household care - Healthcare - Emotional care - Referrals

Factors of Engagement- Active listening- Non-multitasking (one thing at a time, focus)- Eye contact- Tone of voice- Appropriate speed of speech- Appropriate use of touch- Appropriate use of humor/emotion- Physical positioning (sit)- Energy mirrors the needs of the patient




Why are seamless transitions important?- It’s the right thing to do for our patients!- Create better outcomes- Reduce unnecessary readmissions- Reduce unnecessary Emergency Department visits- Reduce risk of potential reimbursement impacts- Improve or maintain positive relationship with our

“consumers of care”- Partners for ACOs/ Bundled payment contracting and

referrals


To achieve successful transitions of care, the National Transitions of Care Coalition recommend:

- Improve communication- Implement electronic health records that include

standardized medication reconciliation elements- Expand the role of the pharmacists- Establish points of accountability- Increase the use of case management and professional

care coordination- Implement payment systems that align incentives- Develop performance measures to encourage better

transitions of care


To Do- Create a standardized system that never discharges our

patient but cares for them across the continuum- THE key is to establish a clear known process for care

transition each and every time- Create a CARE TRANSITION team- From admission gather patient-specific information and

weave into the daily plan of care- Two-way communication (inclusion and collaboration)




Use CARE when explaining and/or teaching

C-Control

A-Active

R-Relevant

E-Experience

Discharge Information (Q19, Q20) and Care Transition (Q23, Q24, Q25)Learning Outcomes

At the end of this session, you should be able to:1. Identify three best practices to Boost Hospitals'

HCAHPS Scores on Discharge Information (Q19, Q20).

2. Describe the concept behind Patient-Centered Discharge Instructions.

3. Identify the purpose of Discharge Phone Calls.4. Identify three best practices to Boost Hospitals'

HCAHPS Scores on Care Transition (Q23, Q24, Q25)5. Describe why seamless transitions are important.

Referenceshttp://www.hcahpsonline.org Centers for Medicare & Medicaid Services, Baltimore, MD. 11,22,2016.

http://www.setma.com/Letters/pdfs/HCAHPS-Discharge-Instructions.pdf

“PDF] Improving Care Transition and HCAHPS Scores https://www.ruralcenter.org/sites/default/files/Care Transition...

[PDF]Improving Care Transition and HCAHPS Scores https://www.ruralcenter.org/sites/default/files/Care Transition...Improving Care Transition and HCAHPS Scores Part 1: ...

Merlino, J. (2014). Service fanatics: How to build superior patient experience the Cleveland Clinic way(1st ed.). McGraw-Hill Education.

Ketelsen, L., Cook, K., & Kennedy, B. (2014). The HCAHPS handbook 2: Tactics to improve quality and the patient experience(2nd ed.). Fire Starter Publishing LLC.

http://www.hcahpsonline.org/Files/Bibliography_April_2015.pdf

www.ahrq.gov

www.healthcarecomm.org

www.peacehealth.org/system/news/sharedcareplan061306.htm



How to contact us

Suzanne Mitchell, MD MS

[email protected]

Jeanine Davis

[email protected]

Office Phone (404) 522-0442

HMA

Health Management Associates

https://www.healthmanagement.com

Questions?

The HCAHPS Manager Toolkit

For Primary IQTC Hospitals:

• Toolkit & Poster for each HCAHPS area discussed today on your Dashboard:

‐Discharge Information

‐Care Transitions



Support Courses this Month

Continuum of Care/Discharge Planning

Preventing Falls: Keeping Patients Safe

Explore and utilize any course in the HTHU.net School of Clinical/Staff

Compliance or School of Long Term Care!

Access the Certifications and Courses

Available for your entire hospital staff ‐ clinical and non‐clinical ‐ unlimited access!

If you’d like assistance settingup a group of individuals forparticular courses, pleasecontact Jennie Price [email protected]

Contact the Team

[email protected]



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Welcome to the HOMETOWN HEALTH...Hospitals and others accepting bundled payments are at risk. Requires a network of HHAs/SNFs available to patients that has adequate capacity, high

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