Transcript A Cross Continuum Collaborative: Working Together

November 2015
LeadingAge National
A Cross Continuum
Collaborative: Working
Together to Improve
Outcomes
www.abramsoncenter.org
Introductions
• Staci Warsaw, VP Transitional ServicesAbramson Center for Jewish Life
North Wales, PA
• Cathy Benner, Executive Director of Rehab and
Case Management-Doylestown Health
Doylestown, PA
Objectives
• Learn about an effort to create a regional cross
continuum network of acute and post-acute providers
• Consider the processes used to identify partners to
include in the collaborative and work toward mutual
goals
• Examine how mutual goals were established to improve
quality of care, patient experience, and efficiencies in
care delivery
Regional Health Care Market
• Northeastern suburbs of Philadelphia
• Population approximately 1.6 million
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5 hospital systems 15 mile radius
92 SNFs/CCRCs
58 home care agencies
3 major health insurers for seniors
Among highest cost of health care in the country
Why?
• Hospital systems were trying to collaborate through SNF
consortiums
• Care transitions/care coordination beginning to emerge
as primary contributors to quality patient care and
experience
• Hospital systems and post-acute providers sharing
patients across levels of care
The Issues
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Coordination of care
Communication
Follow-up processes post discharge
Duplication of services
Increasingly educated consumers
Changing healthcare landscape
Know your Market
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Hospital systems
Post acute providers-all levels
Role of primary care
ACOs/BCPIs
Referral patterns
Regional Health Care Market
Decide on Partners
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Location
Referral patterns
Affiliations
Star ratings
Non-profit
Decide on Participants
• COOs
• Executive Directors
• Administrators
• Business Development specialists
• VPs
• Clinical Leaders
Explanations and Invitations
• Vet your idea with colleagues
• Determine message you want to portray
as you invite partners to join
• Use the phone
• Follow with email
Eye on the Prize
• Outcome and quality reporting is done in a consistent
way that ensures that information being used to make
transition decisions is accurate and reliable
• Identify and initiate the aspects of care transitions that
contribute to the quality of the patient experience as they
travel through the health care continuum
• Create a network of providers that are focused on
providing high quality, patient-centered care transitions
First meeting
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Agenda
Ground Rules
Introductions
Organizational and personal reasons for
participating
• Potential barriers
Rules of Engagement
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Everyone has to answer
Keep them guessing-change up the order
Follow the ground rules
Stick to the agenda
Finish in time
Outcome of first meeting
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Medication Reconciliation
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Understand what one another does (restrictions, clinical capabilities, regulations)
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Universal transfer form
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Sharing of data and essential data elements
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Measurement tools for sharing data
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Uniform definition of re-admission
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Group discussion of adverse outcomes
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Information and Referral Guide access
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Research/evaluation of best practices
Outcome of first meeting
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Improvement of chronic disease management
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ED Visit Evaluation (between SNF/hospital)
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Palliative Care discussions (POLST)
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Understanding definitions ie observation, healthcare
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Consideration of community assets
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Incorporation of physician into care continuum
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Awareness/monitoring of physician conditions
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Families Understand capabilities
Next Meeting
• One month later
• Hired a facilitator
• Each partner brought in at least one
additional person-25 people in room
• Much buzz and excitement from
participants
Next Meeting Goals
• Determine top three priority goals
• Draft action plans for top three priority goals
• Choose sub-teams for each goal
• Draft goals Draft action plans for goals
• Date of completion for goals should be within 2 – 3 months
Challenges
• Topics too big
• Team realized they did not have enough
information about how each organization
approached these things to create
effective action plans
Decisions
• Decided to carry over action planning process to next
meeting
• Goals to fine tune topics and action plans
• Intended to begin working on 2-3 topics
– Medication reconciliation
– Universal transfer form
– Communication with PCPs
In the meantime….
• QIO heard about the collaborative
• Spoke with someone from QIO
• She wanted to use the collaborative to
create a “Health Care community” focused
on decreasing re-hospitalizations
• Invited her to speak ant next meeting
Third Meeting
• QIO introduced health care community
• Group had to decide whether we wanted
to participate
• Decided against it
• Tried to work further on action plans….
Third Meeting cont
• Began to struggle
• Refined our purpose/mission statement
• Decided to reduce frequency of meetings
Next meeting
• 2 Months later
• Major changes in the regional market
– Mergers
– ACO
– MCO
– HIE
Forks in the Road
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New people at the table
New regional landscape
New issues to work through
Needed to redefine again
New Direction
• Clear communication at time of transition was
still of key importance
• Needed to decide what is included in transition
communication
• Decided we needed additional people around
the table (physician services representaives)
Now What?
• Pilot the use of the interact transfer tool for
communication between any level of care; not just
hospital and SNF.
• Develop and pilot communication process with PCPs
and/or practice/ACO based care managers when people
transition between levels of care
Lessons Learned
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Have Vision
Communicate clearly
Be flexible
Don’t let your ego get in the way
Next Steps
• Continue Quarterly meetings
• Pilot transitions projects to enhance
collaboration across different service lines
• Information sharing
• Best practice sharing
How Partnerships Benefit
Patients
• Case Study
Questions