Transcript Document
Indiana Continuity of Care Conference Nancy Meadows, RN, BS Manager, Care Management Union Hospital Terre Haute, IN September 2013 Building Community Engagement in Indiana: The Conduit to Transforming Healthcare Empowerment 2 7/16/2015 Program Objectives 1) Describe the growing importance of taking a community-team based approach to integrated care. 2) Explain why addressing the underlying of community-level health factors may provide a beneficial approach to reducing unnecessary hospitalizations and readmissions. 3) Share the experience and lessons learned from community’s team-based approaches. 3 7/16/2015 Quality and Poor Care Coordination “Today, one in five older patients who leave the hospital, thinking they are well and ready to go home, will be back in the hospital within 30days. That’s frustrating, painful, costly and most of the time, avoidable…” Source: Improving Health Care Close to Home, Rebecca Hightower, eQHealth Solutions, January 2013 http://www.eqhssmarterhealthcare.org/improving-health-careclose-to-home/ 4 7/16/2015 National Agenda (August 2011-July 2014) Three key activities shape the current direction for the Department of Health and Human Services (HHS) National Quality Strategy (NQS) Partnership for Patients (P4P) Affordable Care Act (ACA) 7/16/2015 Driving Improvement National Quality Strategy, an evolving health care guide for our nation. 1) 2) 3) 5 Strategy accomplished through three critical aims to make care better for everyone: Better patient care - Patient centered, reliable, accessible, and safe Better population health-Healthy People/Healthy Communities - Behavioral, social and environmental determinants Lower health care costs through improvement National Quality Strategy Strategy is driven by six priorities 1. safer care 2. coordinated care 3. person- and familyThree Broad Aims centered care 4. preventive care 5. community health 6. making care more affordable CMS Sensitive 7 7/16/2015 Partnership for Patients 2013 Keep patients from getting injured or sicker. • goals for the new partnership Decrease preventable hospital-acquired conditions by 40% Help patients heal without complication. • Decrease preventable complications during transitions of care so all are reduced by 20% http://www.healthcare.gov/center/programs/partnership/index.html 8 7/16/2015 Roadmap to Better Care Integration and Improved Outcomes of Care CMS is working in partnership with states, consumers and advocates, providers, and other stakeholders to create sustainable, person-driven long-term support system in which people with disabilities and chronic conditions have choice, control, and access to a full array of quality services that assure optimal outcomes, health, and quality of life. 9 7/16/2015 Evolution of Health Service Delivery Shift of accountability and financial risk (clinically and economically) across the continuum of care • • Shift to episodes of care Shift to outcomes of care 10 7/16/2015 Structure of Health Care Incentives Expansion of pay-for-performance (P4P) to value-based purchasing (VBP) Bundled payment pilots Potential avoidable admissions, readmissions, and sites of care Fixed hospital payments Increasing focus on “cost and comparative effectiveness” Present on admission (POA) and healthcareacquired conditions (HAC) 7/16/2015 Increase Healthcare Value Improve Quality Decrease Cost 11 Teamwork / Community Infrastructure CMS Sensitive Reduce Episoctic Based Payments Reducme HAC Reduce preventable Readmision VBP ACO Electronic Health Records 12 7/16/2015 Preparing for the New Era of Healthcare Economics of value-based healthcare and reimbursement reform are driving fully integrated models Individual hospitals are moving to system affiliation Health systems are partnering with other health systems Healthcare leaders are now faced with joining capital considerations with strategic planning to ready their organizations for the new era of healthcare Source: Capital Finance: Changing Structures, Health Leaders, March 2013 7/16/2015 13 7/16/2015 Preparing for the New Era of Healthcare Understanding the seriousness of the issues Reduction in potentially “Avoidable Adverse Events” if patients had access to care and community-base support Emergency Room Visits Observation and Inpatient Hospitalizations Costs of uncompensated care 14 7/16/2015 Preparing for the New Era of Healthcare Understanding the “seriousness of the issues” Numbers of persons affected in targeted at-risk populations Particularly affected persons living in poverty or reflected health disparities Availability of community-based resources to address the need” 15 7/16/2015 Preparing for the New Era of Healthcare Developing high quality care transitions Transmitting and communicating essential data elements to practitioners involved in a patient’s care across all settings Structuring organizational and community delivery systems to promote seamless transitions across care settings Reviewing coverage and limitations that affect access to care and services Helping patients and caregivers understand what should expect at the next care setting(s) 16 7/16/2015 Preparing for the New Era of Healthcare The new era of healthcare requires a “Continuum of Care Approach” focus built on understanding the population served that resides within YOUR community It’s about the move to becoming a “Patient Engagement and Activation Network” 17 7/16/2015 Preparing for the New Era of Healthcare Creating awareness and understanding the value Making it “personal” and “urgent” at a local level Create a need for change/establish the “value of working together” Create strategic partnerships Kickoff community discussion/“coalition building” Create welcoming atmosphere, earn trust 18 7/16/2015 Community Action University of Wisconsin Population Health Institute. County Health Rankings 2012. Accessible at www.countyhealthrankings.org 19 7/16/2015 Addressing the Importance of Underlying Health Risk Factors The primary component of reducing readmissions in rural settings is the ability to coordinate care and ensure the patient has access to health care services and community support. 20 7/16/2015 Addressing the Importance of Underlying Health Risk Factors Underlying risk factors that contribute to health disparities are the result of where people live, learn, work, and play. Commonly called "social determinants of health," health factors interact to impact health and contribute to health disparities. Eliminating “health disparities” will necessitate behavioral, environmental, and social-level approaches to address issues. The National Partnership for Action to End Health Disparities (NPA) http://www.minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=11 21 7/16/2015 Addressing the Importance of Underlying Health Risk Factors Differences in regional readmission rates for heart failure are more closely connected with the availability of care and socioeconomics rather than with hospital performance or a patient’s degree of illness. Communities with higher (readmission) rates were likely to have more physicians and hospital beds and their populations were likely to be poor, black, and relatively sicker. People 65 and older are also readmitted more frequently. Hospital readmission rates linked to availability of care, socioeconomics American Heart Association Meeting Report - Abstract 12, May 11, 2012 22 7/16/2015 Model of Population Health Improvement University of Wisconsin Population Health Institute. County Health Rankings 2012. Accessible at www.countyhealthrankings.org 23 7/16/2015 Current Opportunities for Communitybased Care Hospitals and Public Health collaboration part of federal Affordable Care Act requirements Community needs assessment Community-based Care Transitions Programs Centers for Medicare & Medicaid Services Innovation Programs Accountable Care Organizations/Medical Homes Moving towards “Meaningful Use” 24 7/16/2015 Realms of Integrated Care Community Individuals with chronic and progressive diagnoses live within “YOUR communities”. Requires integration of access to communitybased resources reflective to the needs of individuals and their families” 25 7/16/2015 Realms of Integrated Care Health System It’s about eliminating “discharge” mentality Integrated efforts of the clinical caregivers supported by hospital operations that deliver not only “doorto-door” care and provide seamless and smooth transitions across care settings (it’s not just acute) 26 7/16/2015 Realms of Integrated Care Clinician Transforming the care process from a transactional activity to a “relationship” among the clinical caregivers and those they care for. The human dyad there are “two human persons in relationship to each other” Clinician to clinician Clinician to patient and/or caregiver 27 7/16/2015 Realms of Integrated Care Use of evidence-based best practices“Spread” Knowing current literature Serving as “local” and homegrown experts Sharing and spreading what works Being mentors within our community 28 7/16/2015 Realms of Integrated Care Developing community support Coalition leadership Secure organizational and individual commitments/formalize goals Identify and communicate the resources 29 Realms of Integrated Care Developing strategic direction Research best practices When possible, draft your own language Understand your supporters (map out key players and roles) Understand those who will work against your success (internally/externally) 7/16/2015 30 7/16/2015 Realms of Integrated Care Developing an action plan Finding out what other community organizations are doing regarding the priority Organizing a team which includes both field professionals and representative community members Developing a work plan Critical Factor: “Establishing metrics including measurable outcomes indicators” Assuring work is coordinated with other care transitions and/or readmission implementation teams 31 7/16/2015 Realms of Integrated Care: Action Plan What do we want? Who can give it to us? What do they need to hear? Who do they need to hear it from? How can we get them to hear it? What have we got? What do we need to develop? How do we begin? How do we tell if it's working? “Sphere of Influence” Nine Questions (County Health Rankings-ROADMAPS TO HEALTH ACTION CENTER, www.countyhealthrankings.org) 32 7/16/2015 How far are you ready to go? Trust and Time Turf Wars Collaborate Coordinate Network Information Exchange Information Exchange & Harmonize Activities Cooperate Information Exchange & Harmonize Activities and Share Resources Information Exchange & Harmonize Activities & Share Resources & Enhance Partners’ Capacity 15 33 7/16/2015 Key Team-based Approaches During Hospitalization Risk screen patients and tailor care Establish communication with PCP, family, and community-based service lines Use ―teach-back to educate patient about diagnosis and care Use interdisciplinary/multidisciplinary clinical team Rounding and daily team huddles Coordinate patient care across multidisciplinary care teams; include community-based service lines as part of team Discuss end-of-life treatment wishes 34 7/16/2015 Key Approaches at Discharge Implement comprehensive discharge planning and follow-up Educate patient/caregiver using―teach-back Schedule and prepare for follow-up appointment Establish system to help patient manage medications Facilitate discharge to nursing homes with detailed discharge instructions and partnerships with nursing home practitioners 35 7/16/2015 Key Approaches Post Discharge Promote patient activation, engagement, and selfmanagement Conduct patient home visits; develop or work with community partners to develop coaching programs Follow up with patients via telephone or utilizing at home coaching programs Use personal health records to help patients and caregivers manage vital care management information and goals Establish and utilize community-based service networks and Build and utilize Telehealth programs 36 7/16/2015 Discussion & Questions What current steps has your organization and community taken to organize? What do you feel is the biggest value of a community-team based approach? What is the biggest barrier to forming a local team-based approach? What do you feel will help take it to the next level?