Transcript URAC PRESENTATION

Chaos and The Second Law of
Thermodynamics -
How They Impact the Practice of Case
Management
Cheri Lattimer, RN, BSN
Executive Director Case Management Society of America (CMSA)
Executive Director National Transitions of Care Coalition (NTOCC)
Second Law of Thermodynamics
States that "in all energy exchanges, if no energy enters or
leaves the system, the potential energy of the state will
always be less than that of the initial state." This is also
commonly referred to as entropy.
Example: A watchspring-driven watch will run until the
potential energy in the spring is converted, and not again
until energy is reapplied to the spring to rewind it.
A car that has run out of gas will not run again until you
walk 10 miles to a gas station and refuel the car
A healthcare system drained of energy cannot
reengineer by itself – SO WHAT WILL IT TAKE?
http://www2.estrellamountain.edu/faculty/farabee/biobk/biobookener1.html
Current Approaches Are Not Working
Problem Identification,
Education and Logistical Support
Critical
Business
Issues ?
Needs
“To provide health care services
and support to all Americans
including health prevention,
care coordination, and
appropriate resource utilization.
To promote quality of care to
improve quality of life for our
citizens. A commitment to
processes that focus on
education, consumer advocacy,
clinical optimization of
resources, patient safety, and
technology to achieve superior
clinical and financial outcomes
with positive member and
provider satisfaction”
Optimum Health
Fragmentation of Care
Growing Cost of Chronic Care
Access to Care Options (24x7)
Inconsistent Approach
Collaborative Practice
Whole Person Care Approach
Transitions of Care Facilitation
Rising Costs of Drugs
Regulatory/Gov’t Imperatives
Premium Increases, MLRs and
Health Plan Assessments
Gaps
3
Our healthcare system operates in
“silos” and information queues
– incapable of reciprocal operation with other related
management systems & different departments of organizations
Complicated & Uncoordinated
© Eric A. Coleman, MD, MPH
Key Driver:
The National Quality Agenda
3 Aims:
1. Better Care
2. Healthy People
3. Affordable Care
6 Priorities:
• Making care safer
• Ensuring person- and family-centered care
• Promoting effective
communication/coordination of care
• Promoting prevention/treatment of top
mortality causes
• Working with communities to enable
healthy living
• Making quality care more affordable
The National Quality Strategy is available at www.ahrq.gov/workingforquality
With Permission: Susan Dentzer
Costs to the System
• Heart Conditions -- MI, Rhythm dysfunctions,
heart failure. CAD, valve disorders
• Trauma -- Fracture, sprains, open wounds,
joint disorders and bruising
• Cancer
• Behavioral health -- Alzheimer’s and dementia,
schizophrenia and attention deficit hyperactivity
• Hypertension
• Arthritis and Joint Disorders
• Diabetes
• Back Problems
$63 B
$56 B
$48 B
$48 B
$32.5 B
$32 B
$28 B
$23 B
Waves of Change
• New models of health care delivery and
reimbursement are quickly evolving
 Their success is
contingent on effective
care coordination
 This in turn requires
interprofessional and
transdisciplinary
collaboration
Emerging Models Across the Healthcare Landscape
New Models of Healthcare
Delivery and Reimbursement
Patient-Centered Medical Home (PCMH) Primary Care Practices
Accountable Care Organizations (ACOs)
Integrated Health Delivery Systems
Population Health Management
Outcomes-Based Reimbursement With Shared Risk
Value Based Purchasing of Health Care Services
Goals Of These New Models
• Minimize fragmentation & improve transitions of care
• Focus on patient safety and quality of care
• Improve the patient’s experience with care
• Expand access to care
• Reduce the cost of effective care
• Payment that recognizes value of patient-centered care
What These New Models Require
Processes to promote evidence-based
medicine, patient engagement, and care
coordination, including:
• Patient-centered philosophy and operations
• Coordinated and integrated care
• Use of evidence-informed medicine
• Use of health information technology for data
sharing/reporting capabilities
• Continuous quality improvement processes
What Causes Poor Care Coordination
& Often Hospital Readmissions?
Transition Issues Dramatically Impact
Patients & Their Family Caregivers
Patient &
Caregiver
ER
ICU
OUTPATIENT:
• Home
• Home Care
• PCP
• Specialty
• Pharmacy
• Case Mgr.
• Caregiver
• Hospice
In-Patient
SNF
Patient &
Caregiver
ALF
Transition Issues Dramatically Impact
Patients & Their Family Caregivers & Providers
NO
Discharge
Care Plan
Patient &
Caregiver
ER
NO
Medication
Reconciliation
OUTPATIENT:
• Home
•
•
•
•
•
•
•
ICU
Home Care
PCP
Specialty
Pharmacy
Case Mgr.
Caregiver
Hospice
NO
Coordinated
Care Plan
NO Medication
Reconciliation
NO Personal
Medicine List
In-Patient
SNF
ALF
Patient &
NO
Personal
Medicine List
NO
Care Plan
Caregiver
NO
Care Plan
NO Medication
Reconciliation
NO Personal
Medicine List
The Care Transitions Intervention
Does encouraging
older patients and
their caregivers to
assert a more active
role in their care
transition reduce
rates of
rehospitalization?
17. Coleman EA et al. Arch Intern Med 2006
Seven Essential Intervention
Categories
1
Medications Management
2
Transition Planning
3
Patient and Family Engagement / Education
4
Information Transfer
5
Follow-Up Care
6
Healthcare Providers Engagement
7
Shared Accountability across Providers and Organizations
Source:
http://www.NTOCC.org/compe
ndium (2011)
http://www.ntocc.org/Toolbox/browse/
Strategies to Reduce
Preventable Readmissions
During Hospitalization
At Discharge/Transitions
 Risk screen patients and
tailor care
 Establish communication
with PCP, family and home
care
 Use teach-back to educate
patient about diagnosis
and care
 Use
interdisciplinary/multidisci
plinary clinical team
 Discuss end-of-life
treatment wishes
• Implement comprehensive
discharge planning
• Educate patient/caregiver using
teach-back
• Schedule and prepare for followup appointment
• Help patient manage medications
• Facilitate discharge to nursing
homes with detailed instructions
and partnerships with nursing
home practitioners
Facilitating A Safe Transition
–
–
–
–
Recognize high-risk nature of transitions
It is a Team Effort!
And, each member of the team is personally
accountability for their individual role in the
transition of care process
Actively involve patients early in the discharge
process
Care Coordination Begins at or
before Admission
Moving Towards A Collaborative Care Model
Source: Robert Wood Johnson Foundation (November 2011). Implementing the IOM Future of Nursing
Report—Part II: The Potential of Interprofessional Collaborative Care to Improve Safety and Quality.
Accessed at www.rwjf.org/humancapital
The Golden Age of Case Management
“New models of health care
delivery and reimbursement,
and a laser-sharp focus on
improving the quality and
experience of health care,
have put case management at
the crossroads of a changing
landscape in healthcare.”
~ MBNewman
Case Manager Skills Are Required For
Success in These New Models!
Knowledge and experience with
care coordination
Focus on patient-centered processes
Assessment, planning, facilitation
across care continuum
Knowledge of population-based care
management strategies
Meaningful communication with
patient, family, care team
Case Management Philosophy and
Guiding Principals
Client-centered, comprehensive, and holistic
Collaboration, coordination, communication
Facilitate self-determination through advocacy and education
Promote evidence-based care, safety, wellness
Integrate behavioral change principles and cultural competency
Assist with navigating health care system
Pursue professional competence and excellence
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The Integrated Team
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•
•
•
•
•
•
Patient
Physicians
Wellness or Health Coaches
Lab and Radiology Professionals
Rehab
Front Office Staff
Case Managers
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•
•
•
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Medical Assistant
Pharmacist
Specialists
Hospitalist
Nurses
Therapists
Social Workers
A Different Level of Physician Engagement
• Todays Health System transformation call for a
different level of physician engagement
– organizing care around the patient
– means working together in teams
– Embracing the bigger mission of the organization
“An engaged physician workforce
is also linked to enhanced patient
care, greater efficiency and lower
cost and improved quality and
patient safety.”
http://www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Magazine/2014/Apr/gatefoldmedsynergies
The Pharmacy Opportunity
• Leadership role in interdisciplinary efforts
to establish accurate and complete
medication lists
– Hospital admission and discharge
– Any change in level of care
• Encourage community-based providers and
health care systems to collaborate in
medication reconciliation efforts
• Educating patients and their caregivers on
their role in retaining a current list of
medications
• Assisting patients and caregivers through
the provision of a personal medication list
ASHP. Medication Therapy and Patient Care: Organization and Delivery
of Services–Positions. 2009.
Defining Patient Engagement
“Actions individuals must take to obtain the
greatest benefit from the health care services
available to them”
This definition focuses on behaviors of individuals relative to their
health care that are critical and proximal to health outcomes,
rather than the actions of professionals or policies of institutions.
Engagement is not synonymous with compliance.
www.NTOCC.o rg
http://www.cfah.org/pdfs/CFAH_Engagement_Behavior_Framework_current.pdf
Compliance means an individual obeys a directive from a
health care provider.
Engagement signifies that a person is involved in a process
through which he harmonizes robust information and
professional advice with his own needs, preferences and
abilities in order to prevent, manage and cure disease.
The definition is agnostic about the many factors that have been shown
to influence these behaviors, although we recognize that they are
complex and many and include individual characteristics (e.g., age,
self-efficacy, literacy), disease characteristics (e.g., acuity, comorbidities, treatment demands), characteristics of the setting (e.g.,
type of provider; information availability) and cultural norms.
To Make
It All Work,
We Must Learn
How to
Communicate
with Each
Other.
Improving Communication
NTOCC Measures Work Group, 2008
“The biggest problem
with communication
is the illusion that
it has been
accomplished.”
George Bernard Shaw
Effective Communication =
Effective Engagement
Open and honest conversations are critical to promote
interprofessional approach to patient care
Bring active listening skills into everyday conversations
Need to be fully in the moment for
meaningful communication to
occur
Connect on a personal level to
build trusting relationships
Continued Support for Case Management, Care
Management & Care Coordination
Medicare Physician Fee Schedule 2012
Beginning January 1 2013 payment for
Transitional Care Management post-discharge
from acute care facilities:
– Transitional Care Management Services (TCM)
– Complex Chronic Care Coordination (CCCC)
These codes are important because we are acknowledging the
importance of care coordination and transitions of care at the point of
the patient leaving one provider/facility and moving to another.
Transitional Care Codes - 2012
National Average $142.96
National Average $231.11
• 99495: Transitional Care
Management Services with the
following required elements:
• Communication (direct contact,
telephone, electronic) with the
patient and/or caregiver within 2
business days of discharge
• Medical decision making of at
least moderate complexity during
the service period
• Face-to-face visit, within 14
calendar days of discharge.
• 99496: Transitional Care
Management Services with the
following required elements:
• Communication (direct contact,
telephone, electronic) with the
patient and/or caregiver within 2
business days of discharge
• Medical decision making of at
least high complexity during the
service period
• Face-to-face visit, within 7
calendar days of discharge.
Physician or other qualified clinician
• Obtain and review discharge information,
• review need of or follow-up on pending testing or
treatment,
• interact with other clinicians who will assume or
resume care of the patient’s system-specific conditions,
• educate the patient and/or caregiver,
• establish or re-establish referrals for specialized care,
and
• assist in scheduling follow-up with other health
services.
Clinical Staff
(under supervision of a physician or other qualified
clinician)
• Communicate with the patient or caregiver (by phone, email, or in person),
• communicate with a home health agency or other
community service that the patient needs,
• educate the patient and/or caregiver to support selfmanagement and activities of daily living,
• provide assessment and support for treatment adherence
and medication management,
• identify available community and health resources, and
• facilitate access to services needed by the patient and/or
caregivers.
Wyden Bill S. 1932
Better Care Program
• Provides for integrated care for Medicare beneficiaries with
chronic conditions through the full continuum of care
• Encourages specialized team-based care from health
professionals acting as part of a multidisciplinary team
• Individualized patient assessment , patient-centered care
plans and patient/family caregiver engagement
• Supports the use technology that enhance communication
between providers, patients and family caregivers such as
telehealth, remote patient monitoring, smartphone
applications
• Financial incentives aligned with patients outcomes not FFS
• Includes vital case management services proven to increase
medical adherence
• Bill provides for changes to medical school curricula
Wyden-Isakson-Paulsen-Welch Better Care, Lower Cost Act
Moving Forward in 2014
• Medicare Transitional Care Act – reintroduce May 29th 2014
NTOCC Recommended changes incorporated into bill:
– “Findings” which include multiple care transition models and references NTOCC’s
work on care transitions issues
– An expanded definition of “eligible entities and providers” (physician, physician
assistant, nurse, case managers, pharmacists, social workers etc. are eligible to
provide services)
– Broadens the definition of “Transitional Care Services” to support evidence-based
care transition models which align with NTOCC’s seven essential elements.
– Includes language to require the documentation of a family caregiver during the
plan-of-care process.
– Requires the development of measures to address and hold accountable both the
sending and receiving side of the transition.
• Encouraging the expansion of payment codes supporting multidisciplinary
care coordination and transitions of care
• Bringing greater awareness to legislators and regulatory bodies on the value
of case/care management (pharmacist, nurses, social workers) and the
important role they play in care coordination
• Continued focus on aligning the payment incentives with performance
outcomes
Case/Care Managers Worked Across the
Healthcare Landscape
PCP/Medical
Home
LTC
Advocate
Motivational
Interventions
Community
Health Center
Assessment
Care Plan
Patient
TOC CM
Health
Promotion
Health Plan
Pharmacy
Hospice
Employer
Hospital
Specialist
Case Management
Can Promote Safe, Effective Care Transitions &
Coordination
• Patient-centered care — patient’s goals and preferences
• Patient (or caregiver) education to increase activation and
self-care skills
• Accurate communication and information exchange during
handovers
• Medication reconciliation and safe medication practices
• Procurement and timely delivery of services
• Ensuring “sender” maintains responsibility for patient until
“receiver” confirms assumes responsibility
• Follow-up with patient/caregiver within 48 hours after a
transition from a setting or service
Collaboration
“To work together with others to achieve a common goal”
Multidisciplinary Teams:
“Communication and Care
Coordination is a
collaborative process . . .”
Lies At The Heart Of Successful
Practice
Without collaboration, there is
little hope for positive change or
successful outcomes
Waves of Change
• Changing is like Breathing – And we all know
what happens when we stop Breathing
Questions
Cheri Lattimer RN, BSN
[email protected]
Case Management, TOC & Care Coordination
Resources
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NFCA - National Family Caregiver Association - Family Caregiving Resources –
www.thefamilycaregiver.org
CAPS - Consumers Advancing Patient Safety – Toolkits www.patientsafety.org
NTOCC - National Transitions of Care Coalition – Provider & Consumer Tools
www.ntocc.org
CMSA - Case Management Society of America – CM Medication Adherence
Guidelines & Disease Specific Adherence Guidelines, CMSA Standards of Practice www.cmsa.org
AMDA’s (Dedicated to Long Term Care MedicineTM) Transitions of Care in the Long
Term Care Continuum practice guideline http://www.amda.com/tools/clinical/TOCCPG/index.html
ACC and IHI – Hospital to Home – Reducing Readmissions, Improving Transitions http://www.h2hquality.org/
AHRQ – Agency for Healthcare Research and Quality - Questions Are The Answers
– www.ahrq.org
NASW – National Association for Social Workers http://www.socialworkers.org/Resources
VNAA Blue Print for Excellence – www.vnaablueprint.org