ihi expeditionapp.ihi.org/events/attachments/event-2736/document-5219/session_5_slides.pdfcare, and...
TRANSCRIPT
3/31/2016
1
IHI ExpeditionImproving Care Transitions To Reduce Readmissions
Session 5: Executing on an Ideal Outcome in the Transition: Right time, Right Place, Right level of care at the Right Cost
March 31, 2016
These presenters have
nothing to disclose
Peg Bradke, RN, MAJill 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.
3/31/2016
2
Phone Connection (Preferred)3
To join by phone:
1) Click on the “Participants”
and “Chat” icon in the top,
right hand side of your
screen to open the
necessary panels
2) Click the button on
the right hand side of the
screen.
3) A pop-up box will appear
with the option “I will call
in.” Click that option.
4) Please dial the phone
number, the event
number and your attendee
ID to connect correctly .
WebEx Quick Reference
• Please use chat to
“All Participants”
for questions
• For technology
issues only, please
chat to “Host”
4
Enter Text
Select Chat recipient
Raise your hand
3/31/2016
3
Chat
Name and Something you learned during
this Expedition
5
5 Please send your message to All Participants
Expedition Director
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.
6
3/31/2016
4
Expedition Objectives
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.
7
Expedition Sessions8
Session 1Building 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
3/31/2016
5
Faculty9
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.
Session Agenda
Action period review
Discuss the different levels of care with regards to:
Patient in the right place, at the right time, with the right
services and the right cost.
Summarize and put the Expedition learnings into an
orchestrated action plan
Share progress and barriers with implementing
transitions.
10
3/31/2016
6
Looking Back: A Wordle
Please take a moment to chat in one word that
describes how you were feeling about your
readmissions work prior to the Expedition
Action Period Review
Be prepared to share one best practice from your
organization related to transitions.
12
3/31/2016
7
Executing on an Ideal Outcome in the Transition: Right time, Right Place, Right level of care at the Right Cost Session 5
13
Looking Back: A Wordle
Please take a moment to chat in one word that
describes how you were feeling about your
readmissions work prior to the Expedition
3/31/2016
8
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
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
16
3/31/2016
9
2014 Year End Management Group Retreat
Role of Social Determinants
IMPACT Act of 2014
Requesting Health Human Services (HHS) to develop a
report on the impact of socioeconomic status (SES) on
quality of care and Resource Utilization Methods to account
for these factors in Medicare Payment program as they
affect the Medicare Beneficiaries health outcome
Remington Report March 2016
3/31/2016
10
Initial List
Socioeconomic position
– Low income, low education,
Race, ethnicity, cultural context
Gender
Social Relationships
– Married have decrease admissions
Residential Community context
– Low poverty neighborhood
19
Building the Will, Ideas and Execution
for Successful Transitions
Session 1:
– Model of Improvement
– Cross Continuum Team
– Importance of Building the Patient Story through
Assessment
– Diagnostic Review
20
3/31/2016
11
Achieving Desired Results
“Results”
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.
3/31/2016
12
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
Fostering Cross Continuum Teamwork
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
3/31/2016
13
Rules of Engagement
1. Throw out your old attitudes about work
2. Don’t think of reasons Why it Won’t Work, Think of Ways to Make the New Ideas Work
3. Don’t Make excuses, and Don’t Accept Excuses. Don’t say, “ We can’t”
4. Don’t wait for perfection; 50% ,is fine for starters
5. Correct Problems Immediately
6. Wisdom Arises from Difficulties
7. Ask “Why” at least 5 times until you find the root cause.
8. Better the “Wisdom” of Ten people then the “Knowledge” of One.
9. Improvements are Unlimited. Don’t Substitute Money for Brains.
10. Improvement is Made at the Workplace NOT from the Office.
Opportunities
Keys to reducing re-admissions include:
– Not focusing on the hospital alone
– Aligning financial incentives
– Addressing systematic barriers
Determine which actions are have the highest
leverage and are scalable
3/31/2016
14
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?”
Determinants of Preventable
Readmissions
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
3/31/2016
15
Establish & Implement a Person
Centered Transition Plan to Meet the
Identified Post Acute Needs
Session 2
– Comprehensive Plan of Care
– Telephone follow up and triage
– Community Care Workers
– Assessing transition encounters across all sites of
care
29
“….effectively communicate the
plan of care (based on the
assessed needs and capabilities)
to the patient/caregiver and
community-based providers of
care?”
How Might We….
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.
30
3/31/2016
16
Simply
What do we know about the patient/caregiver
that will help the next level provide the needed
care in the transitions?
How will we communicate that?
Sender Role vs Receiver Role
Develop one comprehensive assessment and
plan for the patients post-acute care needs that
integrates input from all members of the care
team
31
Risk32
Is the answer in the
Patient’s
Story?
What did the
Comprehensive
Assessment tell us?
What are the Patient
and Caregiver telling
us?
3/31/2016
17
Include the Patient’s Perspective
Ask patient/caregiver:
What matter most to you during this transition?
What are your concerns or worries about going
home or to the next care setting?”
Who do you want involved in your transition
(your Support person)
33
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.
Customized Plan of Care
Develop one comprehensive assessment and plan of
patients post-acute care needs that integrates input from
all members of the care team
– Make sure each member of the care team is clear about what
information they must bring to the assessment and plan
Consider:
– Patients Preferences
– Patient Capabilities
– Activation Level
Develop Bidirectional dialogue and collaboration
between sender and receivers
34
3/31/2016
18
How much coordination do you have?
How many services are wrapped around the patient/
caregiver?
– Are all the services communicating? Do they all understand the
Plan of Care?
– If there are multiple services involved is a “lead person” identified
and communicated to the patient/caregiver and the care team?
How many phone calls is that patient/caregiver receiving
after they get home?
– What are each of the calls purposes?
35
Transitional Care Models
Session 3:
– Coleman Model
– Naylor Model
– Advanced Care Planning
– The Conversation Project
– Gunderson Respecting Choices
– Transition to Skilled nursing facilities
– Community Agency on Aging (AAA)
– Assignment: Become more aware of Community
Programs/Agency that could be working with you
36
3/31/2016
19
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 and Better Models of Care
Supplemental Care for High-Risk Patients
The Transitional Care Model (TCM)
IHI’s Framework:
Improving Care Transitions
37
A Valued Partner in the Community: Your
Local Area Agency on Aging
Available in nearly every community in the US
AAAs work directly with the older adult’s family to
improve planning; providing additional services including
transportation, in-home care services and case
management; and providing or paying for home
modification
To find local resources please visit:
– http://www.n4a.org/caretransitions
– http://www.aoa.gov/AoA_programs/Tools_Resources/Care_Tran
sitions.aspx
38
3/31/2016
20
Home & Community Based Services
Information & Assistance
Nutrition Services
Senior Centers Meals
Home Delivered Meals
Adult Day Care
Legal Services
Benefits Counseling
Livable Communities project
Advocacy Project
Hospital Care Transitions
Nursing Home Transitions
Medication Management
Nutrition/Wellness Education
Volunteer Services
Transportation
Ombudsman
Evidence-based Health
Promotion/Education
Options Counseling
Case Management
Material Aid
From Prehospital to In-Hospital: The
Continuum for Time-Sensitive Care
Session 4:
– Design and implement a process to identify high
frequency EMS users and manage their care through
referral to external resources and the Agency medical
director
40
3/31/2016
21
Conclusions
EMS can be a partner through which we can improve
care
There are traditional and non-traditional roles to evaluate
One size solutions will not fit all
So many other areas that could have been
discussed in regards to Transitions…
Teachback
Goal Setting
Motivational Interviewing
Health Literacy
Timing of the transition
Patient Activation Levels
The important Role of the Caregiver
Addressing the Unique needs of our Geriatric Population
Chronic Disease Management Interventions/Programs
Staff engagement in the work
42
3/31/2016
22
What did you learn?
Did you have any “a-ha” moments?
What surprised you?
Did you identify any opportunities for improvement?
Share one best practice from your organization related to
creating a successful and safe transition for your
patients.
43
Looking Forward: Another Wordle
Please take a moment to chat in one word that
describes how you were feeling about your
readmissions work moving forward.
3/31/2016
23
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
46
Questions?
Comments?
Discussion?
3/31/2016
24
Expedition Communications
All sessions are recorded
Materials are sent one day in advance
Listserv address for session communications:
IHI Improvement Blog
End of Expedition Evaluation
CE Surveys for accreditation
47
Upcoming Expeditions
Facing the Care Coordination Challenge– Begins March 15, 2016
Build Joy in Work and Prevent Burnout– Begins March 29, 2016
Patient Reported Measures – A Key to High-Value Health Systems
– Begins April 6, 2016
Advancing Safer Maternal and Newborn Care– Begins April 14, 2016
Improving Community Health – Population Management in the Safety Net
– Begins April 14, 2016
Is Your Organization Conversation Ready?– Begins April 19, 2016
Preventing Clostridium Difficile Infection– Begins May 11, 2016
11
3/31/2016
25
Thank You!49
Jill Duncan
Colby Champagne
Please let us know if you have any questions or
feedback following today’s Expedition webinar.