medicaid accelerated exchange (max)...
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MEDICAID ACCELERATED EXCHANGE (MAX) SERIES ACCELERATE TRANSFORMATION AND LASTING CHANGE
Presented by:
Linda Efferen, MD, MBA
Medical Director
Suffolk Care Collaborative
19
THE MAX SERIES SUPPORTS AN INTERDISCIPLINARY CARE TEAM
AT A SPECIFIC LOCATION TO IMPROVE PATIENT CARE
The MAX Series Program focuses on local process improvement for a specific patient population to
impact overall DSRIP measures and improve patient health.
The DSRIP program focuses on statewide system reform to improve population health.
H
DSRIP GOALReduce avoidable hospital admissions and ED use by 25%
over the next 5 years
Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.
Composition of the MAX Action TeamThe MAX Series Program impacts change at the local hospital/provider level.
The Action Team is an interdisciplinary front-line team comprised of 8 – 10 individuals that are directly involved in meeting the target population’s diverse medical, behavioral and social needs.
Source: Emergency Department Super Utilizer Programs, Rural Health Value
Mental Health Centers
Urgent Care / ED Clinics
Primary Care Clinics
Other Care Coordination
Programs
Community Paramedics
Homeless Shelters
Community Health
H
• Patient or Family Member*
• ED Physician
• Primary Care Physician
• Nurses
• Care Managers
• Social Worker
• Behavioral Health Counsellor / Psychiatry Liaison
• Manager
• Other representatives that can be key to providing care for this patient population
*Required
Sample List of Action Team Members
Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.
Topic 1 Topic 2 Topic 3
Super Utilizers:Meeting Complex
Patient Needs
Integrating Behavioral Health And Primary
Care Services
Super Utilizers:Meeting Complex
Patient Needs
Reduce avoidable hospital use by 25% over 5 years (better care, better health, lower costs)
Care system redesign to better meet
complex and high-cost patient needs
Ensure care coordination to
improve outcomes for patients with
Behavioral Health diagnoses
Care system redesign to better meet
complex and high-cost patient needs
October 2015(pilot – limited availability!)
February 2016 March 2016
MAX Series Program Topics
Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.
FOR EACH TOPIC, THE MAX SERIES PROGRAM IS DELIVERED IN THREE PHASES
Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015.
MAX SeriesMedicaid Accelerated eXchange
Assessment Call with PPS: Discuss questions about the program and confirm
interest in topics
Enrollment Call with PPS: MAX Team calls with
Executive Sponsor, PPS Leads and Champions to
confirm enrollment
PPS Baseline Assessment Process (including: surveys,
site visit, etc.)
Phase 1: Assessment and Preparation
Phase 2: Clinics and Improvement Cycles
Phase 3: Reporting
Action Period support: Weekly 30 min telephone status update (between
Coach and Team Lead) On-site visit mid-PDSA cycle (during 1st or 2nd PDSA
cycle) Emergency/Troubleshooting on-site visit by Coach
(based on PPS need) Teleconference attendance during presentation of
results after each PDSA cycle
MAXWorkshop 1
MAXWorkshop 2
MAXWorkshop 3
A JOURNEY TO REDUCE PREVENTABLE COPD ED VISITS
Presented by:
Julie Vinod, DNP, MS, ANP-C, RN
Assistant Director of Nursing Operations
Brookhaven Memorial Hospital Medical Center
24
A Journey to Reduce Preventable COPD ED visits
Presented by: Julie Vinod DNP, MS, ANP-C,RN
Date: June 17, 2016
MAX Series Team
Sponsors: Keisha Wisdom, V.P.CNO and Dr. Zeyneloglu, CQMO
Administrative Lead: Karen Shaughness, LCSW
Dr. Julie Vinod DNP, MS, ANP–C, RN Asst. Director of Nursing (Team Lead)
Stanley John MHA, BS, RT, RRT-NPS Director Respiratory Care & Support Services
Tameka Squire BSN Clinical Instructor
Samuel Beckles RN Nurse Manager, COPD Unit
Elfriede Weiss-Paquette LCSW Coordinator Collaborative Care, PCMH
Dr. S. DeAngelis Medical Director of ED
Brianne Rizzo Director, Care Management
Monica Schlie Social Worker in the ED
Jessica Philius Care Manager, COPD Unit
Bernadette Peters Care Manager POE RN
Jody Felice, RN Home Care Nurse
Steven Sanderson Decision Support Analyst
Problem Statement:
Does the implementation of COPD bundle
reduce the ED visits by 10% among
patients with primary and secondary
diagnosis of COPD for a period of one
year?
Objective
To reduce the number of
COPD Super Utilizer ED visits
by 10% in one year
Sample
Individuals with primary and
secondary diagnosis of COPD
who had ≥3 ED visits and/or >1
readmissions from Jan 2015 to
Sept 2015
Sample Size
Total number of COPD ED visits/patients from
Jan 2015 to Sept 2015
432 COPD ED visits (62 patients)
71 COPD readmissions( 27 patients)
Our Accomplished Action Plans
Created COPD Super Utilizer List
Created a Flagging System
Created 62 patient profiles
Opened a COPD Unit
Created a secured shared drive to document
and communicate within the action team
Our Accomplished Action Plans
Educated the frontline staff
Created a multidisciplinary COPD Plan of Care
Created a workflow for COPD patients
Created a care coordinated note template
Our Accomplished Action Plans
Created a Home Assessment tool
Created a Graduation Protocol
Created Health Home enrollment spread sheet
Established a Brookhaven Better Breathers Club
Flagging System
Body Copy here:
Patient Profile
Stake Holders
Executive Team/Leadership Team
Nursing
Physician
Primary Care Provider
Respiratory
Stake Holders
Care Management
Education Department
IT
Pharmacy
Coordinator Collaborative Care
Home Care and Health Homes
Team Strategy
Body Copy hereBrookhaven Team
Meeting Every Wednesday from
230pm to 4pm
Team Lead Meeting Every Friday from 10am
to 1030 am
Contact via email as needed
(Max Series Group)
Contact with Expert on MIX IT website
COPD Journey…
Priority Reasons for ED utilization
Medications
Pain
Comfort/ Security
Substance Abuse/ Mental Illness
Social Needs
Common Attributes
Majority lived alone
Over 80% have concurrent Behavioral Health
diagnosis
All met criteria for Health Home
Some for Home Care
Improved Process
Changed the ED and Inpatient Unit culture of
treating super utilizers via education of staff, EMR
flagging of cohorts; sharing of patient success
stories with staff
Created in depth Assessment process in ED and
referral to HH and PCP immediately
Utilized motivational interviewing techniques
Improved Process
Began true Care coordination with external
agencies, such as OP providers, Health Homes,
Home Care, residential providers, Inpatient and ED
staff
Conducted Case Conferences on patient to change
their pattern of behavior Care, residential providers,
Inpatient and ED staff
Key Elements of Success
Diverse and Integrated Team who commits
several hours a week to project
Strong administrative support and Team lead
Desire to embrace change
Accurate Data
Timely Communication
Collaboration with community agencies
Our Dashboard
Metrics TargetBaseline
Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16
1. Percentage of Super Utilizer Cohort with a completed patient profile
100% 0% 0% 22% 69% 85% 85% 85% 85%
2. TBD: Patient Engagement (e.g. Correct Responses to Ask-Teach Moments)
100% n/a 0% 16% 40% 54% 70% 75% 83%
3. Percentage of Super Utilizer Cohort enrolled in Health Home
n/a n/a n/a n/a n/a 21% 70% 70% 73%
4. Number of admissions among Super Utilizer Cohort per month
0 12 7 8 14 12 10 8 10
5. Number of ED Visits by defined Super Utilizer Cohort per month
0 46 35 29 35 29 24 20 26
Our Dashboard
020406080
100
Baseline
Nov
Dec
Jan
Feb
March
April
May
Our Impact
Total Cohort
(61patients)Before After Result (%)
ED VISITS 65.1/month 36.3/month -44%
ED IPADMISSIONS
15.5/month 8.5/month -45%
ED READMISSIONS
5.3/month 3.75/month -29%
Our Impact
0
20
40
60
80
Before
After
Health Home Data
75% of patients are enrolled in a Health
Home
Engaged Health Home to educate care
managers of their benefit and application
process
Case Study
DD is a 57 year old female with multiple chronic
conditions, including depression. She has,
14 hospital visits in a 6 month period including,
5 admissions and 3 readmissions.
As the first patient of the program, DD received a needs
assessment which uncovered a need for frequent
education and support for follow-up appointments.
Case Study contd.
She is now receiving care coordination services,
which have helped connect her to primary care,
Medicaid transportation, and alternatives to the ED
Ms. DD has been engaged to a Adult Day Care center
DD has not returned to the ED since
DD graduated in MAY
Future Steps
Continue to identify new super utilizers
Maintain Integrated care approach to assessment and
treatment
Replication of project with new cohort of patients who
have AMI and CHF
THANK YOU
QUESTIONS???